Dear Vice-President Biden, Here’s what it takes to fix mental health

Vice-President Biden,

We've had from thirty to fifty years of mental health deinstitutionalization in America. Don’t listen to people who whine about the days of yore when we locked people away in big institutions. Presidents Kennedy and Carter were right. That should not happen again.

It’s time for Americans to adjust. As disorderly and chaotic as deinstitutionalization has been, every one of our civilian institutions has had enough time to figure out some basic strategies that work. The practices outlined below are well-documented and in place today, but on a hit-and-miss basis.

Access to treatment

The problem: People have difficulty accessing care and connecting with systems.

The solution: A single point of contact telephone number for a region or a county, connecting with multi-system resources for screening, assessment, and referral. A “no wrong door” mutual aid policy within healthcare and mental health systems that includes some basic protocols for data exchange. A tiered entry into care, with an emphasis on delivering the first appointment in a timely fashion.  Neighborhood health centers and public clinics with sufficient capacity for delivering assessments and delivering basic care for depression, anxiety, bipolar disorder and first-onset schizophrenia, plus family and caregiver education. More specialized care available promptly for more complex cases.  De-couple assessment systems from resource allocation systems. Do not change standardized assessments so that they “ration care.” Use mobile crisis teams to prevent escalation to the criminal justice system.

Housing

The problem: When we had big institutions, we underfunded them, but even then they were among the largest budget items for state government. As deinstitutionalization progressed, state governments kept funding the big hospitals for many years. For the most part, when these institutions closed, their former funding did not transfer to communities. And if it did, the money generally went for mental health treatment, not housing. Deinstitutionalized people found themselves with no way to access housing, because SSI, the primary source of income for people who never had substantial work histories, did not pay enough to cover the cost of market rate housing, and Medicaid, which pays for treatment, does not pay for housing.

The solution: Subsidized housing using housing dollars, plus case management services covered by Medicaid. “Housing First” policies work because they simply deliver a housing product, and, after thirty years, the mental health system has figured out how to keep people connected to mental health care. Small scale group homes also need enough supplemental funding to permit operators to deliver realistic levels of programming for people with a high burden of disability.

Criminalization

The problem: Unruly people with mental illness are clogging our courts and jails. The most difficult population has moved from mental hospitals to jails and prisons.

The solution: Diversion programs throughout the entire criminal justice pipeline. Pre-arrest solutions that give street level officers discretion to drop people off for mental health evaluation in lower-cost settings than emergency rooms or psychiatric hospitals. Jailhouse coordination with mental health agencies to provide early release of clients already in the system. Secure mental health facilities under criminal justice jurisdiction separate from local general population jails. Social workers available at all levels of the criminal justice system, including courtrooms and probation offices. Restorative justice programs that address the needs of crime victims and offenders, but allow a way out of imprisonment. Note: This works once the housing issue is fixed.

Police killings of people with mental illness

The problem: Too many people with mental illness end up dead after encounters with police.

The solution: Training every officer to identify mental illness and use appropriate tactics that de-escalate situations. Specialized units to respond to mental health calls. These practices must be incorporated into use of force policies and firearms training protocols. Many deaths of people with mental illness occur because these training protocols and policies were designed before the era of deinstitutionalization.

Violence and suicide connected with mental illness

The problem: People with mental illness become disconnected from treatment, stop taking medication, or use drugs or alcohol, and commit violent acts or suicide. People decompensate and become violent or suicidal without being connected with treatment.

The solution: Better communication, coordination and data exchange between all levels of the mental health, general health care, education, criminal justice, and court systems. More suicide prevention training within the general population. Risk management protocols that give greater weight to leaked signals of harmful intent. Sufficient secure healthcare facilities to handle immediate needs including mandatory minimum stays in step-down facilities for medication stabilization. Protocols within treatment systems that facilitate information sharing with caregivers or family members. Protocols that integrate college counseling centers with the community’s mental health provider system. Consider “safe harbor” provisions to permit and encourage information sharing under HIPAA and professional practice systems. Increase funding for substance abuse detox and treatment.

Suicide of armed forces members and military veterans

The problem: We are losing more soldiers to suicide than to other war wounds, and the high number of veteran suicides is simply tragic.

The solution: Increase the capacity of soldiers, families, churches, community groups and employers to detect problems as they are developing. This involves having face to face conversations and perhaps following a simple script, plus the willingness to ask about suicidal intent. You can find a script in my book Defying Mental Illness, and free suicide prevention training through the QPR Institute. Every community already has a front door for treatment.

That’s a start. I think we get the rest of the way with more emphasis on what ordinary citizens can do, starting with simply talking with each other, and recognizing that mental health and mental illness are not obscure and unfathomable or disgraceful, but legitimate topics for everyone. The experts are needed too, but many ordinary people with a little more training can do a lot to keep us safe. It takes an hour or two to train anyone on the basics of mental illness.

Let me know if you need some help rolling this out.

Best regards,

--pk---

Strengths for the troubled

If you suffered a setback or a tragedy, how would you rebuild your life?

If rebuilding or recovering depended on your strengths, where would you look to find them?

A few years back, Victor Garcia, a Cincinnati Children's Hospital trauma surgeon, got fed up with seeing gun-shot children on his operating table.  He pledged to a mother who lost her child that he would lead an effort to stop the urban violence in Cincinnati. One result of his efforts is a community project called CoreChange.  I'm involved with one of the CoreChange project teams, called Strengths-Based Cincinnati. Our workgroup has been meeting every few weeks for the past ten months, looking at ways to identify strengths and put them into play, instead of wallowing in the negative energy that surrounds us.

One tool that many of us like is called the VIA Character Strengths survey. It's a positive psychology profile of personal characteristics that make people successful. I am not usually a fan of new-age style pop psych parlor games, but this one makes some sense. It offers a way past negativity, and demonstrates that everyone has strengths, even people facing tough circumstances. The VIA Institute says that this survey is the foundation of a positive approach to life.

A strengths- based approach to life:

• Is honest (acknowledges problems, but doesn't get lost in them);

• Is positive (focuses on what is best and good);

• Is empowering (encourages and advances the individual);

• Is energizing (uplifts and fuels the person);

• Is connecting (brings the person closer to others, aiding in mutual connection).

The VIA process starts with an online survey. It takes a little under half an hour for most people, so the online system has you register so you can save your work. When you're done, you can pay for a fancy analysis or choose a free version of the results. The free version was what I chose. Take a look at your top five character strengths, and have a chat about them.

How do your top five character strengths play out in your life?

What can you do that takes advantage of your strengths?

Start the VIA Strengths survey here. . https://www.viame.org/survey/Account/Register

Learn more about CoreChange.

What I am doing to respond to Sandy Hook

When Pete Earley asked what we were doing to respond to Sandy Hook, this is what I wrote.
 
Over the course of the past week, I have written several blog posts about preventing violence of this kind on my blog http://redesigningmentalillnes.... I usually write about mental health recovery, but I know a lot about the connection between mental health and violence. I have designed curricula for NAMI and I have taught crisis de-escalation in courts and jails in Ohio and Kentucky. I have been writing about research connecting violence and mental illness for quite a while. I don't subscribe to the views of either of the policy camps. The TAC offers bad policy, the mental health community wants anti-stigma more than they want to express precision about risk.

There is a realistic way to approach this. The key is that these very hard incidents look just like suicides as they roll out. You don't have to have a "by the book" case of diagnosable whatever in order to have a breakdown or become suicidal. The DSM is just a catalog, after all, and even psychiatric pros will change their mind and argue about what kind of disorder is what. For ordinary people who are not clinicians, the kind of trouble a person has is not material. It's the pattern of the breakdown in thinking that matters, and this can be interrupted. People interrupt suicides every day.A tiny fragment of these people in trouble end up attacking others.

We can interrupt these incidents if ordinary people were better at spotting suicide risk, and learned to have a serious talk or even a simple four-question script. I wrote about the parallels between the Portland shooter and Wade Page, the Sikh Temple shooter one week ago, and laid out the crisis/suicide prevention technique I published in my book Defying  Mental Illness.

http://redesigningmentalillnes...

A final note: In the NY Times yesterday there was an article about suicide bombers and rampage killers. Adam Lankford, an academic researcher has a book coming out connecting both with motivation to suicide. The article's author and I both agree that the clues and motivations of potential suicide risk are often common denominator in murder-suicides, and ordinary people really do have the best opportunity to prevent all this senseless death.

Holiday reading for a kinder, braver world

Yes we need gun control and better mental health and all that. But won't we also benefit from a kinder, braver world?

Lady Gaga's Born This Way Foundation has teamed up with Harvard University and the John D. & Catherine T. MacArthur Foundation on a series of research papers to help ordinary people in America grab hold of the future, defeat meanness and bullying, and make kindness stick. There are papers about the role of youth organizations like 4H Clubs and Girl Scouts, and what young people can do to create emotionally healthy schools.

Follow the link. Read the research. Your book report is due when school starts up in January,

The Kinder & Braver World Project: Research Series – Eight Papers on The Role of Youth Organizations and Youth Movements for Social Change
http://www.zephoria.org/thoughts/archives/2012/12/17/kinder-braver-world-youth-papers.html

Frightened moms at the instant before the trigger

Yesterday I met a mom who was frightened of what her grown-up kid might do. The kid's life focused on violent video games. Terrible mood swings. Using drugs. Talking about getting a gun. She told us she tried to get her son to treatment, but he wouldn’t go. We went through a checklist of places she might call. We are doing what we can to help, but what she really needs is a concierge or a companion, because the prospect of presenting a nightmare to another indifferent gatekeeper in a busted-up partially-funded mental health treatment system was overwhelming.

Women in tough situations like this are coming out of the closet all over America.

It is our duty to help these women. When you think about it, the people we must actually rely on for our safety are those who know and love people at high risk. They receive the first trouble signals, many times well in advance of tragedy. Public officials, health workers and law enforcement show up much later. They must receive a call or see someone being hurt.

Frightened moms exist inside and outside the world of mental illness. We can help these women if we put our minds to it. The violence on our streets is not some baffling weird mystery ordinary people can’t grapple with. Criminologists and violence prevention experts already know the patterns to violence that our society must confront.

First, there is the mental model of the trigger man. Does he consider himself to be violent? Does he express himself violently? The violent identity can even be fictional. We have seen many people put on fantasy roles plucked from their larger culture.

Then there is the action pattern of the violent incident.

Researchers who study violent prison inmates have identified three possible developments that determine whether or not a violent actor follows through to commit a violent criminal act. The first is a kind of tunnel vision around a violent interpretation of a situation, where violence becomes the path to be taken. The second is restraining judgment, an escape from the tunnel vision, that lets the perpetrator redefine the situation and decide he should not act violently. For example, a witness may show up, or the person thinks he will get caught, or the person thinks that the violent act is just not worth it. The third element is called overriding judgment, when the person who decided not to use violence returns to his original plan and uses violence anyway because the victim’s conduct or attitude was found to be intolerable.

The same action pattern happens in suicides. People develop tunnel vision. They see no way out but suicide. But they usually remain persuadable. Someone can persuade them not to act. Yet the person is still impulsive. If the person is not brought to safety and kept under observation he may still act impulsively and harm himself.

Risk of suicide and risk of violence both connect with faulty thinking. As thinking deteriorates, risk skyrockets. Bad outcomes become more likely if people get firmly stuck in tunnel vision.  People with troubled thinking are more likely to commit to bad plans. They are less likely to generate alternative ways out of trouble. They have more difficulty processing advice offered by others. They are more likely to act impulsively, even if they retain the capacity to hesitate or reconsider. They have hair triggers.

The reason most of us don’t harm each other is a basic human taboo against hurting people. We don't have violent identities. Whether genetic or cultural, people are averse to seriously harming others, let alone themselves. Soldiers must be specially trained to shoot and kill people. If they don’t practice until shooting becomes instinctive, they need to be urged by officers to pull the trigger even in the heat of battle. (Violent video games are a substitute for all of this.) Pulling the trigger is the kind of threshold that most of humanity never crosses.

Where does gun control fit in?

Guns are part of the environment. If you think of violence as a disease, then guns are the pathogen that must be eliminated. We wiped out polio and smallpox this way. But gun control isn't a complete solution to violence. We have plenty of other lethal instruments lying about. Wiping out polio did not wipe out all sickness, but our world is better for it.

---
Sources
Grossman, D. (2009). On Killing: The Psychological Cost of Learning to Kill in War and Society. New York: Little, Brown and Co.

Rhodes, R. (2000). Why They Kill: The Discoveries of a Maverick Criminologist. New York: Vintage.

Political correctness in the mental health community is killing people

Those of us who work around mental health, and particularly those of us in the recovery community, must stop whistling in the wind about risk of violence.

The one thing I trust on the Treatment Advocacy Center website is the list of murders committed by people with mental illness. Whatever we may believe about the TAC’s proposed response to this issue, it is time for the mental health recovery community to acknowledge that the list is there, and that dozens of names from shopping malls and schools were added to the list last week.

Yes, I know that people with mental illness are much more likely to be victims, not perpetrators of violence. Yes, I know that it’s important not to fuel stigma. So what. Anti-stigma’s political correctness is murder blindness. It is not compatible with anybody’s safety.

Violence denial does its own damage. It undermines the credibility of the recovery movement. It threatens the very notion of people with mental illness living in regular neighborhoods. It brings out today’s version of peasants with pitchforks, the NIMBY people who agitate against safe housing in our communities.

Recovery involves more than feeling vaguely better about our lives. As we reconstruct our lives, we must confront our real risks, including risk of violence.

I believe that the mental health recovery movement has a responsibility to build the public’s capacity to understand the violence in our society. After all, we are the mad. We own the stories of our lives, including our first-hand experience of the process of breaking down. What lessons can we teach about what it takes to interrupt our path when we are at our worst?

Messaging that gets violence right

It does not take much to get the connection between recovery and risk of violence right. Here’s what I write about recovery in my book Defying Mental Illness.

Recovery is a process of building a person's capacity, empowering the person to overcome the effects of the illness. Every person has a range of talents and abilities, a variety of vulnerabilities, a certain capacity to withstand stress, and a certain risk of causing harm when something goes wrong.

Ask four questions to help build recovery.
-- What helps you make the most of your talents?
-- How can you reduce the areas where you are vulnerable?
-- How can you improve your ability to cope with stress?
-- How can you deal with the risk of something going wrong?

The answers will inform critical choices about treatment, medication, overall health, career, housing, and family relationships.

Here’s another excerpt about crisis and violence.

ASSESSING RISK OF HARM

We usually encounter two types of violence in civilian life: instrumental violence and expressive violence. Instrumental violence is used to gain control over others. This is the violence of robbery and terrorism. Instrumental violence that is fueled by delusional thinking can be as well planned as a bank heist. The other type of violence, expressive violence, is the failure of self-control. People break down and strike out. Anger and frustration builds up to a violent outburst. For people with mental illness, handling the internally generated background noise of their symptoms is difficult enough. Stress and conflict make the internal noise level worse. The "fight or flight" response kicks in. But people usually do control their behavior, even at this point.

Most people with mental illness never become violent. People with severe mental illness but no substance abuse and no prior violence have a very low probability of becoming violent. But risk factors add up. The risk of violence increases if the person has more than one psychiatric disorder. The higher the number of co-occurring psychiatric disorders, the greater the risk of violence. The combination of substance abuse and major mental illness is more volatile. Another key predictor of future violence is past violence. Risk skyrockets after someone commits their first act of violence. For example, nearly a third of people with schizophrenia also abuse alcohol or drugs, and are, statistically speaking, twice as likely as the average person to become violent. If such a person commits a violent act, their likelihood of future violence doubles yet again.

Dangerousness involves reckoning with four factors: magnitude, likelihood, imminence, and frequency. Courts weigh these factors to determine if the facts justify involuntary treatment…

In community settings, people with paranoid delusions are more violent than people in other mental illness categories. Their violence is well-planned, aligned with their delusion, and aimed at individuals or institutions. These individuals are likely to commit the most serious crimes because they can gain access to weapons, stay relatively well-connected to reality, and maintain an ability to plan. There are many other patterns of violence connected to mental illness symptoms. People with depression can react to despair by striking out at other people. Parents may kill their children prior to a suicide, especially mothers of young children. Because everyone's experience of mental illness is so different, it is entirely appropriate to ask treatment providers what risk patterns to look out for. Everyone has a stake in safety. Talking about risk does not make violence happen.

CRISIS PREVENTION STRATEGIES

Effective long-term crisis prevention for most people with mental illness means controlling the internal noise level by managing symptoms, plus controlling the stress factors within the environment, plus building self-management skills. As the person builds impulse control and self-manages symptoms, the risk of violent action goes down.

Coping with a violent child

Note I wrote this post the day before the Newtown CT massacre. I know families who live with the daily threat of violence from children they love. The answer to Newtown lives in the home life of the shooter. This post is about what parents of violent kids go through.

Here's an episode of The Coffee Klatch on Blogtalk radio, a great interview revolving around a family trying to do the right thing for their daughter who they truly love, but who is dangerously violent.

Listen to internet radio with The Coffee Klatch on Blog Talk Radio

The family at the center of the episode is in the middle of it, fighting with school systems, mental health agencies and health insurers to get the care they need.

The episode raised compelling questions many families must reckon with.

 -- Should parents focus on helping their child, or take steps for their own health and resiliency?

-- What if the local schools can't afford to provide care your child needs?

-- What does it take to change a troubled child's life course?

Mass murder is the new flavor of American suicide

It’s time to add mass murder to the annual “means of suicide” statistics list. There’s more collateral damage when compared to hanging, bridge-jumping, self-inflicted gunshot wound, overdose, poison and wrist-slicing, and so much drama in the act itself, you don’t even need to leave a note.

The only way to stop these murders is for the general public to step up and learn to prevent suicides.

As these incidents are developing, clues and hints of distress and trouble accumulate around a person. We see problems related to how the person is thinking, failure to succeed at work or school, trouble in life, loss of a girlfriend, or other experiences of  shame and guilt. We also notice expressions of  hurt or resentment. When a critical point is reached (and sometimes after surprisingly careful planning) the person takes action. It is at the action stage that suicides and violent attacks diverge. An attacker strikes out against an institution, person or group, or even against random people. The action is a statement.

We are learning that the Portland mall shooter Jacob Tyler Roberts had a life that lately reeked of failure, depression, fantasy, drinking and more. He quit his job at a sandwich shop,  and sold all of his belongings. He gave up his dream of becoming a firefighter. He broke up with his girlfriend. He dropped out of community college. He made up a fantasy plan about buying the shop where he worked. He lied about inheriting a large sum of money.  He was supposed to move to Hawaii but didn’t, saying he missed his flight because he got drunk (if there actually was a flight). He had a Facebook cover photo that said “Cancelled.” He wrote  on his Facebook wall: "I may be young but I have lived one crazy life so far." Once easy-going and sociable, he dropped out of sight this past year. His phone was disconnected. He was evicted from his apartment in July. His Oregon driver’s license was suspended. His commercial driver’s license was suspended. He wrote that he was an adrenaline junkie who enjoyed shooting.

There are parallels between Roberts and the Sikh Temple shooter Wade Page, whose final hate drama episode took place just up the street from the restaurant where his ex-girlfriend worked. 

Page’s military career ended in 1998 when he refused treatment for his drinking. By 2000, then age 29, Page’s beliefs about an impending holy war were fixed. In 2000, Page sold everything he owned and went on a cross country trip attending festivals and shows. In 2001, he couldn’t hold a regular job because he drank so heavily that he would pass out and miss work the next day.  In 2003, Page was having trouble paying his bills, irritating his friends and evidently wearing out his welcome. He moved back to Fayetteville, where he worked at a Harley-Davidson dealership for a year and a half. The dealership fired Page because he refused to obey orders from female co-workers. According to his former boss, Page showed a volatile side when women tried to tell him what to do. He worked as a truck driver from 2006 – 2010. He was fired after a DUI offense. His home was foreclosed on in January 2011. He moved to Milwaukee in 2011, where he moved in with a girlfriend. He was hired as a temporary night shift worker in a local factory in February. Page and his girlfriend broke up in June 2012. Page stopped showing up for his job in mid-July. His landlord said he owed back rent when the attack happened in August, about a block from where Page’s ex-girlfriend worked..

What everyone can do to prevent attack-suicides

In most of these situations the only possible intervention is below the level of our formal systems. 

Prevention is the responsibility of family, friends, co-workers and neighbors. Even if reported, emergency responders can't act forcefully if the risk is not immediate and serious. Sometimes the police or a crisis team might be able to make a safety check visit to a person's home.

The best thing anyone can do is to support their friend. This helps prevent feeling isolated and helps build resiliency. You are unlikely to ever know if the steps you take to support a friend have prevented a suicide or interrupted a developing course of violence. You want the person to become more resilient and successful, so that the outcome is positive.

Try to have a brief chat in a public place but out of earshot of other people. Ask the following questions one at a time, in order. Practice the questions out loud. Yes, this is awkward. You can use your own words, but follow the pattern. Listen to the person's answer. People benefit simply by knowing they have been heard.

-- What have you accomplished since the last time we talked?

-- What are you facing?

-- Who are your allies?

-- What is your plan?

As you listen, be on the lookout for suicide risk factors. These include prior violence, substance abuse, a failure of addiction or mental health treatment, difficulty verbally expressing feelings, stress, extreme discouragement or recent shameful loss, no ability to make effective plans, trouble relating to other people's feelings, the onset of schizophrenia or another major mental illness, and lack of sources of support.

If you start to feel worried, offer to connect your friend to a more formal source of help. You may have the single most important opportunity to help your friend. If you detect tunnel vision and a sense of diminishing options, or the person talks about suicide, or expresses a lack of hope, ask the person directly about thoughts of suicide. Suicide is much more likely than violence directed against other people. Ask directly using these words: "Are you thinking about killing yourself?"

If you sense that the person is becoming suicidal, stay with the person. Try to persuade them to seek help from their doctor or visit an emergency room. Offer to help them get in contact with a crisis hotline by calling 1-800-273-8255 or dialing 911.

Effective suicide prevention training is available online through the QPR Institute at www.qprinstitute.com/ and from many community groups.

Sources

Clackamas Town Center shooting: Friends say it’s hard to imagine Jacob Roberts as a killer. (n.d.). The Oregonian - OregonLive.com. Retrieved December 13, 2012, from http://www.oregonlive.com/clackamascounty/index.ssf/2012/12/clackamas_town_center_shooting_33.html

Elias, M. (2012). Sikh Temple Killer Wade Michael Page Was Radicalized by Army Base’s “Thriving Neo-Nazi Underworld”. AlterNet. Retrieved from http://www.alternet.org/civil-liberties/sikh-temple-killer-wade-michael-page-was-radicalized-army-bases-thriving-neo-nazi?akid=9762.1076401.gyKqNM&rd=1&src=newsletter755977&t=13&paging=off

Ex-friend says temple shooter Wade Michael Page was a “loner”. (2012). Retrieved December 6, 2012, from http://piersmorgan.blogs.cnn.com/2012/08/07/ex-friend-says-temple-shooter-wade-michael-page-was-a-loner/

Lohr, D., & Lohr, D. (2012). Wade Michael Page Timeline: Key Dates To Sikh Temple Shooter Investigation. Huffington Post. Retrieved December 6, 2012, from http://www.huffingtonpost.com/2012/08/07/wade-michael-page-timelin_n_1749297.html

Motives of Portland mall gunman Jacob Tyler Roberts remain a mystery to family, friends, police. (n.d.). NY Daily News. Retrieved December 13, 2012, from http://www.nydailynews.com/news/crime/search-motive-portland-mall-shootings-article-1.1219205

Oregon mall shooting suspect not the “violent type”: ex-girlfriend. (n.d.). Chicagotribune.com. Retrieved December 13, 2012, from http://www.chicagotribune.com/news/chi-jacob-tyler-roberts-20121213,0,6711130.story

Sikh Temple Killer Wade Michael Page Radicalized in Army | Southern Poverty Law Center. (2012). Retrieved December 6, 2012, from http://www.splcenter.org/get-informed/intelligence-report/browse-all-issues/2012/winter/massacre-in-wisconsin

The Ballad of Wade Michael Page. (2012). Retrieved December 6, 2012, from http://www.ocweekly.com/2012-08-16/news/wade-michael-page-sikh-temple-shooting-intimidation-one/

US Sikh temple shooter was a white supremacist. (2012). Retrieved December 6, 2012, from http://www.firstpost.com/world/us-sikh-temple-shooter-was-a-white-supremacist-407806.html

Wade Michael Page: Excessive drinking cost Sikh temple shooter his military career, civilian job. (2012). Washington Post. Retrieved December 6, 2012, from http://articles.washingtonpost.com/2012-08-07/world/35490243_1_wade-michael-page-barr-nunn-transportation-military-exercises

What brought Wade Michael Page to Milwaukee? (2012). Retrieved December 6, 2012, from http://www.jsonline.com/news/crime/gunmans-exgirlfriend-tied-to-whitepower-group-r66djcf-165342766.html

Defending Recovery

There's a report floating around the internet these days claiming that "recovery" thinking threatens the health of people with mental illness. The report claims that the sickest among us have no capacity to recover, and if  you don't fully subscribe to the biopsychosocial/medical model of mental illness, you are depriving people of needed access to medical treatment. It's a lock-up or medicate piece along the lines of what you might read from the Treatment Advocacy Center. Pete Early reacts to it here. I wrote a comment on that post, and another to an earlier Huffington Post blog by Marvin Ross. 

The author of this report, Lembi Buchanan, deserves praise for her activism, which is grounded in support of her husband's survival from a very difficult experience of mental illness. She told Marvin Ross that her husband of 40 years would not be alive today if it hadn't been for involuntary hospitalization, medication and treatment on occasions when he has had psychotic episodes. She said that her husband is grateful for having been saved from suicide and for the support that has kept  him in good health.

What I like about Mrs. Buchanan's report is the opportunity it provides to review what we believe about recovery and the role of treatment in extremely difficult circumstances. The theoretical limits of recovery is an issue worth exploring.  I know that some people are not comfortable with the concept -- and even I have some trouble with it, which I have written about before.  What I don't like about Mrs. Buchanan's report is the way she mischaracterizes today's recovery movement by claiming that today's recovery-oriented groups and today's anti-psychiatry groups are essentially the same.

Recovery may have started out connected with anti-psychiatry, but it's a mistake to jam the two concepts together today.

Recovery literature is less than fifty years old. Authors like Judi Chamberlin, who created the language of the recovery movement, were reacting against psychiatric hospitals that operated as very coercive "total institutions."  Thomas Szasz was inventing antipsychiatry at roughly the same time. Chamberlin quoted Szasz, and even E. Fuller Torrey (who was a Szasz follower at the time) in her 1978 book On Our Own.

Recovery and anti-psychiatry are separate concepts these days. Psychiatrists, healthcare administrators and insurance companies have all signed off on recovery, with recovery being the notion that people can get better, decide what's important for them, and assert control of their lives. Recovery even has a SAMHSA-approved cousin, whose name is shared decision-making. At least on paper it seems the bad old days of one-sided, white-coated, doctor-driven psychiatry are gone. Even inside hospitals, care is meant to be person-centered.  In many hospitals today, few decisions are made without the patient's buy-in, participation or consent -- or a court order. 

Sadly, people with mental health conditions still get to the point where they're not safe. Most of the time, these are not people fully engaged in recovery. People pursuing recovery, with or without medication, usually know what they must do when they are getting into trouble. The people I worry about are those the system fails to help when they show up in emergency rooms asking for help, and those the system fails to detect or engage, the people who have disordered lives, clusters of sub-clinical trouble symptoms, who never get diagnosed until they are drugged or drunk, suicidal or psychotic, out of control, blatantly unsafe and possibly a threat. Society needs to be able to respond appropriately. Jails are no help, so we need hospitals, and community-based solutions.

As I worked through my own recovery, and later, when I ran a substance abuse treatment program that supported people who did not respond to AA, I came to realize that diagnosis and labels essentially did not matter in the lives of non-clinicians. What matters in recovery is engaging in the struggle, finding a path for moving forward. An hour or two of training lets anyone spot signs of trouble in people's lives. The real work follows, connecting people with a clinician who can do a real work-up and help create a treatment and recovery path that works for that individual.

So here's where I have ended up. Pro-recovery, pro-science, pro-therapy, pro-psychiatry, pro-choice, pro-wellness, and anti-coercion (to a point). Neutral on meds.  Unfortunately, some people need treatment, imperfect as it may be, at times when they don't want it. The anti-psychiatry folks are the experts on how offensive and distasteful involuntary treatment is. It would be great to have workable, effective alternatives that can be funded with healthcare dollars, but right now, we have what we have, and it's certainly not perfect either.

But recovery is nobody's threat.

Viewing insanity from outer space

Think about how mental illness plays out in our world. How can ordinary people affect its trajectory?

Start by thinking small.

We have some choices in our own lives. A better diet. More sleep. More exercise. Seeing the doctor. You already have the whole list.

As we move through our days, choices show up in our homes, and workplaces, and the other places of our daily lives. Can we see and hear the clues and cries for help around us? Do we know the smallest thing that we do on the spot? Do we know how to have a chat when it matters?

As people make small choices, bigger things emerge.

And in today’s world, the things we do, the actions that emerge, all generate data.

People have always known that if you find a different vantage point, you can see different things. From the top of the hill you can see a whole battle play out. If you have binoculars, you can zoom in and pay attention where it counts.

Today’s binocular lenses are made to detect data.

In fact, today’s technology gives us practically infinite zoom focus. Ordinary people, often for free, can access data from a health care landscape that ranges from the invisible micro-wavelengths of the brain, to the microscopic ecology of our bloodstreams, the intimate details of electronic health records, to the aggregate data of our census tract, our social crowd, our church group, our zip code, our region or political entity, or for that matter, all of the earth.

We can choose a data lens that lets us view insanity from space.

Healthcare experts know this. Health care used to take place in doctor’s offices or hospitals. The economics of health care worked themselves out through individual transactions and pricing by the visit or procedure. 

Our new data lenses are catalyzing the development of new economic models for health care.

These days, in fact, healthcare no longer thinks of itself as an industry. Today, healthcare is an eco-system.

Here in Cincinnati – and maybe in your town – healthcare plays out in networks that collaborate as well as compete. Transactions that happen within these networks tend to be more expensive and reimbursable within traditional brick-and-mortar medical spaces, like hospitals and doctor offices. But now you see agents of these networks venturing farther from traditional centers. Is there a parish nurse at your church? Does your pharmacist pack a stethoscope?

There might be less reimbursement away from the center, but healthcare is investing in reaching you where you are most likely to go. That’s because supercharged data lenses have connected with the economics of health care, and health care networks are now being paid for the health status of whole populations. If you doubt this, type “accountable care organization” into an internet search box.