Nov 17, 2012

Do-it-yourself brain repair is happening right now

What’s in humanity’s mental health toolkit?

How are ordinary folks helping people with mental illness symptoms make progress in their lives?

The one thing I know for sure is that the list I came up with is not long enough.
  • Accountability
  • Community
  • Companionship
  • Conversation
  • Courage
  • Curiosity
  • Education
  • Emotional connection
  • Employment
  • Family life
  • Friendship
  • Habit
  • Hugs
  • Journaling
  • Kindness
  • Labor
  • Love
  • Medicine
  • Mentalizing
  • Mother’s love
  • Nutrition
  • Observation
  • Physical activity
  • Planning
  • Prayer
  • Reading
  • Reflection
  • Religion
  • Responsibility
  • Ritual
  • Scaffolding
  • Scientific method
  • Scripts
  • Sex
  • Shame resilience
  • Social interaction
  • Spirituality
  • Storytelling
  • Sympathy
  • Teaching
  • Tenacity

Nov 12, 2012

Recalled to Life

Social inclusion is about rejoining all of society, not just your club of outcasts.

-- If everyone around you shares some defining characteristic, you are living in a ghetto and can be relocated at will.

-- Your weekly activity group does not get you there, no matter how great you get at performing the activity.

-- Your inspiring slogan does not help. People who don't need the slogan just pity you.

-- You are not a group of special people. You have been forced to hang out together by a system that thinks you need diversion. The system will withdraw resources once it sees you are successful.

-- If you are running a program for a special population, you should reconsider what you are doing.

The sense of exclusion, of life as an outcast, as someone less valued, is spread unthinkingly but felt intimately. Exclusion of the defective and fear of the alien are evolutionary adaptations. They are built in to people. So is the notion of dominance. People in charge inevitably dominate the folks who are at their mercy. When people in charge are denied resources, the people who are weakest suffer. Showing that the defining characteristic is permanent just reinforces the difference. Tagging more people with your outcast label seems beside the point.

So what works to fix this?

The only way social change has ever been proven to work is when life in our communities changes. It takes decades, sometimes longer. How long did it take for women to obtain the right to vote? For slavery to end? For civil rights? For marriage equality to emerge anywhere? Remember when mixed marriages were a scandal? Remember when selling condoms, let alone abortion, was illegal?

Tough social issues involve struggles, long tails, and aftermaths, and leftover partisans, and sometimes counterrevolutionaries. There's an issue spectrum that ranges from disapproval to recommendable. Issues resolve when people start acting like the formerly scandalous thing is just normal, or eccentric, or at least tolerable.

In the world of mental illness, we must have our struggles too. Right now there are rhetorical wars over compulsory treatment, the number of hospital beds we need, and over faith in pharma. I am okay with this level of conflict. Every side has its points.

But we do need to adjust what we are doing in the fight for social inclusion.

-- We must start by including ourselves. This means showing up at work and at other places that are not defined by disability. Divert people from system-driven isolation. If you are renting space for your clubhouse, give it up. Borrow a conference room at a library, church or community hospital once a week. Spend the rent money on coffee at the local diner, music lessons and on YMCA memberships. If you are looking for a social enterprise, start a conference center, a web design firm, or your own restaurant, and aim for top-of-the-line. If you want empowerment, have people join their political ward club. You can deliver support, but let your people go.

-- Disclosure is irrelevant. Nobody cares about your diagnosis. Let people get to know you. Get over your embarrassment. Everybody is hiding something. By the way, the stories we tell about ourselves are always approximations. Everybody just makes them up.

-- Confidentiality is a barrier. We say it is protecting us, but it also keeps us apart. It's okay to have barriers like these, but we need to put gates where they're needed.

-- Realize where you can't win. You have to be willing to swing with science, with capitalism, and with the two-party system. So what if scientists say the thing folks have is usually genetic. They don't know what happened to you.

-- Start talking in terms of universals. We all have our problems. Everyone has skills and talents to contribute. Everyone needs to take a break or regroup. Everyone needs a chance to socialize.

-- Embrace the sensibilities of the nonprofessional. True reform in mental health has always been instigated by non-professionals. Dorothea Dix was a housewife who expected the asylums she advocated for to be free of crushing restraints. Clifford W. Beers was a businessman who exposed cruelties in psychiatric care. In the 1940's, conscientious objectors forced to work as psychiatric orderlies took photos that revealed the scandals of the modern Bedlam. Judy Chamberlin experienced coercive 20th Century institutionalization. NAMI's founders were parents who wanted a better life for their children. Professionals speak in terms of dosages and treatment plans. Non-professionals talk about cruelty and justice.

Above all, we need narratives that work and build power. Recovery works like the parable of the prodigal son. We all have our struggles. We rebuild with our strengths and the help of our allies. We love our sisters even when they need some support. We want people to be different. We want people to get better. We are all alike. Everyone deserves to be safe. We want to find each other and make our way in the world.

We must own our powerful stories of redemption, of rescue, of being recalled to life -- and show up everywhere..

Nov 9, 2012


What can we do to counter the "medical horror" component of mental illness stigma? We say that people with symptoms need treatment, but we know that is not completely true.

People fear treatment, and for good reason.

Even SAMHSA publications recognize that the treatments currently available are not fully satisfactory. Here's a quote from a May 2012 SAMHSA "Recovery to Practice" article.
First, the treatments that are currently available are extremely limited in their effectiveness in treating serious mental health and substance use conditions. While some treatments may be effective for many people in reducing the more active aspects of these conditions (such as in reducing psychiatric symptoms or substance use), they typically do not address the more disabling elements (such as neurocognitive difficulties, deeply entrenched patterns of behavior, and social and interpersonal contexts that impede, rather than facilitate, improvement). Should medications be developed that were as effective in treating mental illness and substance use as antibiotics have been in treating certain infections, then we might not find it necessary to change the ways in which we plan and deliver care. Such a day, however, seems far off, should it be achievable at all.

Second, the vast majority of the challenges people face in recovery occur outside of, and beyond the scope of, traditional health care settings such as hospitals, clinics, day programs, or intensive outpatient programs. These challenges occur, and must be dealt with, within the context of the person's everyday life in the community.
If people have reason to believe that what the medical system has to offer are medications with long lists of side effects that dope you up, or electroshock jolts to the brain, or hospitals that steal your freedom, is that stigma or is that the truth?

I am a firm believer in mental illness recovery, but the story I see playing out is not fundamentally a victory of medical science. Recovery happens with the kindness of ordinary people and the support of family and friends. Medication and other treatment may help, but the essence of recovery is a steady focus on making the most of one's talents and capacities, and committing to the struggle of regaining one's life.

Nov 4, 2012

That hug from your mom is an evidence-based practice

Seriously, when things got difficult for you as a child, that hug, the attentiveness and comfort you received from your mother or another caregiver helped create the success you have today. This is one of the lessons from Paul Tough’s new book How Children Succeed: Grit, Curiosity and the Hidden Power Of Character, a book that updates our understanding of the dynamics of creating successful people.

Those hugs helped calibrate your developing stress response system. The body’s stress response system works best in short bursts, with long rests in between. Too much activation and the stress reaction becomes self-reinforcing,  inefficient, always set to trigger. Think of a car with an alarm so sensitive that you can’t walk past without starting it blasting.

Stress hormones put additional wear and tear on the body, affecting infant growth patterns and eventual life functioning. A mother's fast response to an infant’s experience of stress allows the stress reaction system to turn off when it needs to. And, as the child learns that his mother will respond to help him overcome his stress, that understanding produces what’s called “secure attachment,”  a close emotional bond between the infant and his mother or other caregiver. Large data sets accumulated over the course of decades show that some sixty percent of US children experience secure attachment, which connects with greater resilience throughout life. Careful analysis of decades of data reveals that stress and resilience are the common hidden factors within the many studies that show children in poverty have less satisfactory life outcomes.

Exposure to trauma, so-called “adverse childhood events” (which happens more frequently to children experiencing poverty) also impacts brain function. The child’s stress system gets overloaded through the same mechanism that causes post-traumatic stress disorder.  Anxiety and depression are the emotional impacts. Decreased executive function (the ability to deal with confusing and unpredictable situations) is the cognitive impact.

People need both emotional and cognitive capacities to function effectively. According to How Children Succeed, kindergarten teachers say the most difficult children to teach are those who can't manage their tempers or control their emotions. According to Tough, “When you’re overwhelmed by uncontrollable impulses and distracted by negative feelings, it’s hard to learn the alphabet.”

Researchers have found that secure attachment is a key precursor of life success. Statistically speaking, it accounts for those children raised in poverty who do succeed, and those children in so-called “good homes” who don’t. Stressed-out moms living in difficult circumstances are more likely to get overwhelmed, less likely to respond as attentively or effectively to their own children. It’s no wonder that kids in families who have experienced poverty over the course of generations face particularly difficult challenges.

From a public policy point of view, if we want more people to succeed, what needs to happen?

One strategy being used across the US is parenting support for new mothers, usually delivered during brief home visits by public health workers. New mothers are learning what works, and building strong attachment with their children.

Another set of strategies aimed at young families works on reducing the number of adverse life events children experience. We have a series of publicly funded programs to reduce children’s exposure to violence.

Other strategies apply later in the life course, in child care, youth programs and schools. Here, the work is always harder. The most effective strategies build "noncognitive skills" together with cognitive skills. Many of the educators highlighted in How Children Succeed refer to these "noncognitive skills" as "character strengths." Educators build curricula around characteristics like grit, integrity, and perseverence --markers of capacity to complete a task, postpone a reward, find one's way through difficulty, and stick with a plan.

The problem with the character strengths label is that it can end up sounding vague, preachy and political. That’s the criticism leveled at some of the charter schools that favor a character strengths approach. Nonetheless, programs with this focus do show improved outcomes for children who otherwise face significant life challenges.

I've seen other methods aimed at building these same capacities that use more neutral terminology. One example is the so-called "developmental asset" strategy. Developmental assets are things children have in their lives that are associated with better life outcomes. The research behind them, conducted by the Search Institute, supports the work of the YMCA, the Boys and Girls Club, and 4H Clubs. Equally well-researched, developmental assets have the advantage of being somewhat more concrete. Attending church, doing homework, playing a musical instrument, having positive friends are all developmental assets, and there are thirty-six more as well. Most of them can be supported by the efforts of community members. There's a lot of overlap wth character, so the language of character strengths is compatible, and gives people multiple ways of explaining why taking your time and following through is important.

Another set of strategies comes from Ruby K. Payne, whose work focuses on the effects of generational poverty on child achievement. The strategy she recommends encourages students to generate several alternatives before taking action. She also recommends using relationships to motivate children to do better.

For me, the lesson is that it's ordinary life, and interventions based on kindness, relationships and stability that really create success. And here’s another lesson: The solutions for our children’s most difficult challenges are, for the most part, already known. They are variations on themes that everyone can understand.

Nov 1, 2012

Colleges refuse to learn Virginia Tech's mental health lessons

Five years after the 2007 Virginia Tech shootings, colleges still haven't learned to help students with mental illness.

Nearly two out of three college students who encounter mental health problems end up withdrawing from school, according to a new NAMI survey. Read NAMI's press release here.

According to the survey, students in trouble don't use counseling services, even if they are available. Disability services offices don't help them. Worst of all, faculty members still have not been trained to recognize or respond properly to mental health issues.

Apart from the violent consequences, and the routine academic failure of students who might succeed if they were accommodated, we are now sending thousands of veterans, many with post-traumatic stress disorder, to every college in the US, doomed to fail because campuses won't step up.

This is an outrage, a display of deliberate ignorance -- but there's a practical solution.

It takes a couple of hours to do basic mental health training, maybe half a day if you include suicide prevention. Every college campus has someone qualified to teach Psychology 101, plus someone who runs campus security.

If these two people can't put together an effective training program for your campus, call me.