May 24, 2012

How Indiana rigged its mental health system

Indiana might just have the worst child welfare agency leaders in America. They have figured out how to use a respected mental health evaluation tool to deprive children of the care they need.

Indiana has a “no-fault” child protection statute called CHINS 6. It is intended to allow state Division of Children’s Services (DCS) officials to provide medical care for kids at risk of harm to self or others. Unfortunately DCS refuses to use this authority, leaving children and families across Indiana to suffer. There’s money in the DCS system to provide care, but DCS does not spend it. It has returned over $300 million in “surplus funds” to the state treasury in the last three years.

“Quite simply, the system for reviewing/filing cases by the DCS is broken when it comes to CHINS 6/mental health, which begs the question whether the entire system is currently broken.” That’s what Morgan County Circuit Court Judge Matthew Hanson wrote in a court filing on May 15.

The DCS director has said that he does not believe filing CHINS 6 is good for children or parents as it “pits” them against one another. Yet the only alternative is so much worse: Parents must put themselves on the child abuse registry in order to get state help for their children. It’s the very thing the CHIN 6 statute is designed to eliminate.

And even that depressing option does not work. Parents quoted in media reports say children can’t access necessary (but expensive) residential care even with the most severe issues. Indiana DCS denies care to children who try to burn down houses and shove siblings down flights of stairs, even when terrified parents go to court and ask for a finding of neglect. DCS will not provide care even when the alternative is juvenile prison.

When questioned by the media, DCS officials say they prefer less-expensive community-based care (which of course sounds benign enough). They say they use an evidence-based tool, the CANS, to determine the level of care children need.

That’s where the system gets rigged --  in the connector, the place where the CANS assessment meets the decision about level of care.

The CANS is just a questionnaire. Clinicians rate dozens of aspects of a child’s life on a scale of zero (“no problem”) to three (“big trouble”).  Here’s the CANS question about “Danger to Others.”
This rating includes actual and threatened violence. Imagined violence, when extreme, may be rated here. A rating of 2 or 3 would indicate the need for a safety plan.
0 - Child has no evidence or history of aggressive behaviors or significant verbal aggression towards others (including people and animals).
1 -  History of aggressive behavior or verbal aggression towards others but no aggression during the past 30 days. History of fire setting (not in past year) would be rated here.
2 - Occasional or moderate level of aggression towards others including aggression during the past 30 days or more recent verbal aggression.
3 - Frequent or dangerous (significant harm) level of aggression to others. Any fire setting within the past year would be rated here. Child or youth is an immediate risk to others.
The CANS system collects all these rating numbers and reports them in a format that makes it easier for clinicians to decide what to do.

Indiana went a step further. It convened a workgroup to develop computerized algorithms to interperet CANS reports and determine the level of care workers would use in every case. That step virtually eliminated clinician discretion, and outlawed residential care. Once the algorithms were in place, rigged to eliminate residential care, the system wiped it out.

In other words, Indiana developed an app that denies sick children mental health care.


Indiana Statutes

State of Indiana, Family and Social Services Administration, Division of Mental Health and Addiction. (2007). Business Case for Adoption and Implementation of the Child and Adolescent Needs and Strengths Assessment.

In the Matter of AA, Morgan County Circuit Court, May 15, 2011.

Indiana Law Blog (2012)

Children in Peril -

CANS-MH Manual (2003)

Mentally ill kids caught in Catch-22

May 21, 2012

Are we giving too much power to mental illness stigma?

NAMI groups and others have been waging anti-stigma campaigns for decades. The stigma is said to keep people from engaging in treatment or really addressing their problems.

I think we give stigma too much credit. When we don’t go after it in a precise fashion, it becomes a shortcut for our own shortcomings, the excuse we give when we don’t engage people or an issue effectively.

Here’s the cycle: We do what we know is not effective. Or we know what might work, but we don’t do it. We make bad choices because of economics, or politics, our own shortcomings, or simple expediency. People suffer, then we claim stigma. We’re not guilty because the other person is insane.

We think we are protecting people with mental illness when we hide them from the world. That just limits their options.

We claim that only experts can solve these problems. That keeps most of society from having a role.

We train police to subdue and kill people with mental illness. We know there is a better method, but it takes more training, and takes a little more time with each incident. The limiting factor here is economics, not stigma.

May 16, 2012

Getting closer to people with mental illness in your church or community

I think that we focus too much on mental illness treatment, and not enough on friendship. America’s trained therapists amount to around 0.05 percent of the US population. There’s a lot left for the 99.95 percent of Americans who aren’t therapists to do.

The truth is that any group that can support a little training can do effective outreach to people with mental illness. Volunteers will need some modest basic training and refreshers once or twice a year. They will need modest supervision and a phone number for crisis situations they can’t handle. They need to take the same organizational precautions they would take for any other activity (work in groups of two or more, meet in public places, keep some basic records, and so on).

Training is not an obstacle. Mental illness is not that complicated. It takes two to three hours to cover basic signs and symptoms and a little bit about medication in a community college or workplace setting. It’s one or two chapters, about 25-50 pages in my book. Most of what an ordinary schoolteacher, church volunteer, or youth worker needs to know about mental illness can be covered in one or two sessions.

Use my book Defying Mental Illness to train your volunteers. It is simpler than anything else available. One minister told me that we covered everything he needed to know about any issue in two or three pages, never ten or twenty.

Create social and recreational events that build relationships and friendship. Invite your whole constituency, not just people with disabilities.

If you find yourself working with people who have little access to mental illness support, start a “mini support group.” This is not treatment, not even a real self-help group like AA. Your goal is to promote safety by providing some opportunity to check in on a friendly basis. Put two volunteers in charge. Meet on some sort of scheduled basis. Start with some small ritual to convene your group – a prayer for instance. Cover your ground rules and program for the day in one minute or less. One of the ground rules should relate to safety – you will always call out for help when needed. Then let everyone have a chance to “check in.”

Take turns covering four points.

What have you accomplished since the last time we met? At the very least, people managed to come to this event, and that’s good enough.

What are you facing? People need a chance to say what they are dealing with and also need to know that they are being heard. Resist giving advice. The point of this 4-question check-in is simply to invite people to say they are working on their own challenges.

Who are your allies? Chances are that people already have someone helping them. If someone is all alone and has no allies, people can talk about how to connect with another group or resource (but after the “meeting”).

What is your plan? Let the person say what he plans to do. Don’t jump in or interrupt. This is his plan, not yours. The minimum plan is to check in again at some future time.

You want the mini-support group to be non-stigmatizing, so everyone must be invited to join in, even the so-called “normals.” Everyone also has a right to pass on participating.

Don’t make the 4-question check-in the point of your gathering. It’s just one way of making sure everyone is okay so you can focus on the potluck and the bingo.

May 15, 2012

Mental Illness Power Trip: Flashback 1981

A collection of 1981 essays shows how mental illness stigma works today. 

In early 1981, the authors of the academic journal Community Mental Health published a special issue on citizen participation in community mental health services. For many years, community mental health centers had been required to include members of the community-at-large as well as service users (“consumers”) on their governing boards. How was that working out?  Where else could ordinary citizens participate?

The editors found that citizen participation seemed to work out in theory, but it hit its limits when it came up against the power of professionals to design and deliver services. This clearly relates to two themes of mental illness stigma that persist today – a real fear of loss of personal power and control, and a false derivative belief that only experts can help.

As one author noted “Dialogue between professionals and citizens has been hampered by the pervasive view that providers are better judges of the needs of individual clients and the community than are citizens in general or consumers in particular.” 

Another author identified a “persistent pattern of deference to professional judgment that raises a question about the ability of board members to use authority independently and to hold professionals accountable.”

A third author, a governing board member, wrote: “Nine years of representing the community as President and Treasurer of a board which went through a name change from advisory to governing has left me sad, annoyed, angry, frustrated and most of all disappointed.” Although nominally in control, this writer and her fellow board members found they could not seek greater effective power over the professionals on the board because the only penalty available to federal officials was to withhold service funding from clients. Moreover, the need to identify as a “consumer” or non-consumer” was both needless and stigmatizing. “To arbitrarily divide the non-provider citizens into two groups--consumers versus non-consumers--is to continue to perpetuate the stigma of mental illness. Perhaps I am naive; I thought one of the goals of Community Mental Health was to work to eliminate the labels and to educate the community that to use mental health services was not the same as to declare in the public square that I am a syphilis carrier.”

A center director noted just how strongly professionals resisted outside control of their practices. “The consumer/professional issue … is the one causing mental health professionals to flee to private practice where they feel they have a little more control over their own destiny.”

Power struggles over health center governance were nothing compared to obstacles to consumer participation in service delivery. 

As one physician-author noted: “This objection to independent patient-run programs rests on the fundamental question of the nature of mental illness as a disabling condition. Mental health professionals view mental disability as an illness or disorder requiring treatment from experts… Although former clients may have had direct experience in the workings of the system, their views are generally discounted.”

The “angry consumer” on the panel wrote: 

The client is thus viewed by the professional in an adversary situation as the supplicant (i.e. beggar) of the system, albeit a necessary one…

When a client chooses to direct his own life, and in so doing, “complains,” therapists often view the complaints as symptoms of illness, rather than as legitimate responses to an inadequate (and perhaps threatening) situation. This view serves to deny the client his rights as a human being to disagree or dislike, and preserves the professional’s self-image as all-competent and all-knowing. Fears of inadequacy on the part of the therapist resulting from the complaints are re-directed to the client as his own feeling of anxiety and projected as failure on the part of the client to “interact” appropriately. Fear of loss of the client by the therapist is seen as the client’s failure to accept therapy. Fear of anger is viewed as a true “symptom of illness.” Clients are denied the right to be angry, an emotion which is legitimate for “normal” persons in society.

The opinions in these articles are not the rants of anti-psychiatry radicals. These articles were compiled by Dr. Charles Windle, of the National Institute of Mental Health, and authored by community mental health center administrators, consumers and professionals. 

The takeaway for people interested in working on stigma reduction is this:

Fear of loss of power/control is one component of mental illness stigma that is based on fact. With all the power on the professional’s side of the equation, non-experts are left feeling they have no valid role to play.

The articles referenced in this post can be found in Community Mental Health Journal Vol. 17(1), Spring, 1981.

May 8, 2012

Is addiction a disease?

I once worked as Executive Director for a Cincinnati outpatient substance abuse treatment program that supported alternatives to AA, groups like Women For Sobriety, SMART Recovery, LifeRing Secular Recovery and even Rational Recovery (which isn't technically a group).

I was fascinated to learn the diversity of attitudes towards the disease concept of addiction. This diversity turned into practical issues: What would work for our client? If AA hasn't been working, what way of looking at the issue would take the client to sobriety?

Our clinicians would use a screening tool we developed, and match clients with one or another recovery self-help/support model. Nearly everyone also stopped in at AA, but there's a reasonably large pool of meetings in our area, so it was possible to find compatible meetings.

People seemed to benefit. They stopped drinking or using, and avoided relapse even if AA had not worked for them before.

My takeaway was that neuroscience and disease models have contexts where they work, but in other contexts, or for nonbelievers, they are much less useful.

What counts for me is that everyone has a path they can actually use to take them to sobriety.

Link to original comment on Psychology Today:

Sober transcends "yes or no"

May 7, 2012

Let's take mental illness away from the experts

It's time to do for mental illness what AA did for alcoholism.

The idea that ordinary people meeting in church basements could defeat killer social menaces like alcoholism was completely revolutionary, and has saved millions of lives.

If we want to be as successful with mental illness, we need a similiar approach. Something that names the problem, combined with a message focused on powerful recovery, not the details of treatment. I'm not saying that we don't need effective treatment too. But mental illness is scary, and we need to make mental illness simpler if we are to make it less scary.

Ordinary people help each other cope with difficult problems every single day in every culture on earth. Why not mental illness?

May 6, 2012

What's a risk management person expected to do?

Let's say you are a risk management person at a hospital, and you receive warning from a physician about violent threats against the institution made by a person with paranoid schizophrenia. What should you do?

Hint: You don't want the following exchange to be the result.

On March 9, the day after the shooting, Dr. Whitcomb wrote to thank Dr. Spiegel for contacting Dr. Singh about Shick.
"As you have probably heard, he was the gunman at the tragic shooting in Pittsburgh yesterday at Western Psychiatric Institute, which is directly across the street from our clinics. Everyone at the GI division is safe. Your concern is very much appreciated."
Dr. Spiegel wrote back:
"I was worried about that.
"I guess the concern here is whether risk management could have/should have done something sooner."

May 4, 2012

Empowerment means pursuing your own dreams

The participants at Starfire U in Cincinnati are heading into the larger community to pursue their own dreams. They have developed theatrical productions, fashion shows, and corporate annual meetings.

"[P]eople with disabilities are segregated and lumped together with other people with disabilities and they become associated merely by circumstance as opposed to by choice. ... Starfire mapped out a working 4 year model designed to support Starfire members as they move towards genuine integration into their communities while simultaneously discovering their passions, dreams, and talents."

 Read more here.

Mental Illness and Crime Prevention

"Not guilty by reason of insanity" cases often bring out mental illness stigma. It's just a dodge, people say. Whatever your opinion about how this is handled in criminal trials, there's a key role for mental health in crime prevention.

Ordinary people need to know more about the patterns of behavior that can indicate a person is becoming more violent. Information often becomes available in the weeks before these mass attacks. Right now, unless the attack planner is actually seeing a therapist, very few people connect the dots and phone the police as a plot begins to unfold.

This is not a binary issue like the criminal justice system tends to approach it.

Dangerousness and mental illness follow multiple pathways. For example, people with paranoid delusions can commit terrible crimes. They are motivated by their delusions, but can stay connected with the world, accumulate weapons, and plan attacks. Compare this to the more typical case of a person who is decompensating because of stressors and difficulties holding themselves together. They might become dangerous, but can very often be de-escalated, and their attacks are less well organized.

There's a good presentation about risk of violence here:

Read the news article that this opinion was posted about:
Not All Outrageous Crimes Are Linked To Mental Illness

This post originally appeared at

May 1, 2012

Claiming some violent territory for mental illness

There’s something to be said for the old Soviet way with mental illness. If what you’re thinking is wrong, then mental illness it is and you go to the hospital for some political therapy. If you take some action (commit a crime against the State) based on your incorrect thinking, you are packed off to jail or sent to a prison camp. It’s a brutally functional approach.

As we begin working through the challenge of redesigning mental illness, we should probably start from a place that is somewhat kinder. If we truly believe we are dealing with a health issue, we ought to bring our ethics around “healing the sick” and “human dignity” with us. And so let’s start with a really basic tentative working definition of mental illness.

Let’s propose that mental illness means some phenomenon that’s not benign, and is something that someone with a rudimentary level of training in counseling or psychology or related fields might be expected to identify or try to make better. This definitely includes all the phenomena that licensed professionals in today’s “behavioral health” field are currently expected to handle, like depression, mood swings, hallucinations, anxiety and the like.

The definition also takes us into some violent territory: school shooters, workplace violence, some domestic violence cases. In other words, cases of “expressive violence” (where someone breaks down under external or internal pressure and lashes out), plus cases where people act under delusions or assumed violent identities (reacting to nonexistent threats or assuming the personality of a violent fictional character, historical figure or celebrity). We expect our mental health system to prevent these sorts of incidents, yet they happen again and again.

In the aftermath of these incidents we see missed opportunities to detect, prevent or defuse these attacks. Someone could have, should have done something.

It seems obvious that our society needs a way to actually prevent mass murder. Because we are redesigning mental illness, we get to specify how that might happen, and who might participate.

How much training should it take to recognize one of these incidents as it scales up?

Shouldn’t everyone know a little bit about this?