Feb 26, 2013

Dealing with the tyranny of one-size-fits-all systems

Sequential Intercept Model
We’re human. Nothing we do is perfect. That goes double for our formal systems, including the mental health system.

Whatever we do, however much time we spend at the drawing board, no matter how many people participate in our focus group or get engaged in the public debate, no matter what the strength of our computer models, we just can’t ever get it perfect. At least not perfect for everyone.

There is always someone for whom the Best System is not optimal. It makes them walk an extra mile, interferes with their dinner plans, forces them to move to a new town, costs them their job, lowers their property values, violates their principles, or is against their religion.

Because systems are never perfect, they are doomed to generate conflict and dissent. Trouble is inescapable, no matter how benign or well-intentioned the system tries to be. Systems have their limits and their rules and when the system reaches its limit something has to give. When people push at the limits of a system they may occasionally gain a benefit that appears to violate system rules, but more likely they will end up being coerced or hurt. The mere existence of a system impacts populations in ways the people in it can’t entirely control and often cannot even see.

Some systems are explicitly designed. Others are self-generated, developing from custom and an accumulation of habits and small decisions. Whatever the origin, every system encounters stress over time as it encounters unforeseen circumstances or reacts to conflict. The durability of the system’s formal structures, resources and operating rules defines the system’s resilience, its capacity to respond and adapt. The system holds together, or things change, sometimes radically. We might call this process of adaptation System Darwinism.

System Darwinism still does not guarantee an optimal outcome for everyone. There will always be someone for whom the system does not work.

This realization, that systems will always be imperfect, creates opportunities for innovation.

We can make decisions about priorities, starting with What Really Matters: What is the value in our hearts, the success of the system or the health of the people? All of the people? Most of the people? People like us? What is our responsibility toward the people that the system serves imperfectly?

If we care about a particular person, and the person can't get help from the system, we look outside the system for the help the person needs. That's common sense. But what if the system is mandatory? What if it's the legal system that's not working for the person?

We know how to create mechanisms for that. It's called diversion. In the legal system, cases might get sent to mediation or arbitration instead of to a jury. If that takes care of the dispute, the formal case gets dismissed. We might even create diversion systems that run parallel with the formal system. When mental health connects with criminal justice, system planners use a technique called the Sequential Intercept Model to align an array of diversion opportunities to the stages of criminal case processing. The most effective diversion keeps people from having any contact with law enforcement at all. As people move through the criminal justice process, they suffer increasingly severe consequences. An arrest record. A conviction. Potential loss of liberty or earnings. Still, diversion at any of the stages might save a person from the next full dose of consequence.

Is there room for diversion in the mental health system? Of course there is. Mental health is mostly not a mandatory system. It fills quite a bit of our civic and economic space, but participation is mostly voluntary. Only in the toughest situations is anyone really forced to participate.

We know that American mental health is not a well-designed system. Its origins lie in reactions to primitive stigma and fear. It is built from the accretions of 19th Century thinking and a committee-driven diagnostic catalog that everyone seems willing to argue about. We know the economics of the system do not work. The system is always starved of resources. Only experts seem to know what’s good for people. We know that the pills the system offers are hard to take, and work sometimes, for some people, but tend to create their own problems. We know that the mechanics of the mental health system are often coercive. The system organizes services around a mental model of permanent sickness.

How attractive is that? Would you opt to participate a system like that?

If you were a person who suffered trauma and victimization in your life, would you be likely to benefit from a system driven by labeling and coercion?

This is the same sort of issue many people who seek to attain sobriety face when confronted with the values and traditions of AA. If you have been victimized, are you motivated by the prospect of labeling yourself powerless once again? If you are not religious, are you likely to cherish opportunities to appeal to a Higher Power?

So here’s my proposal. Let’s invest in some recovery techniques that work for people who do not want to deal with the standard medical-model system. Here are some workable suggestions. Put some resources into them, focused on outcomes, not techniques. Let people choose what is compatible for them.

Or even better, let’s apply a systematic diversion model to mental health. Try the cheap benign non-medical methods first. We can put mentoring, emotional support, suicide prevention and self-help everywhere. Let people cool down and regain their composure in some safe location. Let folks work through their distress without being smacked with a diagnosis. Use the non-medical system as a buffer for the medical system. Put it in emergency rooms, after school programs, neighborhood clinics, employee assistance programs, union halls, Grange halls, 4-H Clubs, YMCAs, and church basements. And wherever guns are sold.

We should realize that our reorganized system won’t be perfect either. But it could make things better, for many more people, at lower cost, with fewer side effects, and much less conflict. It could get more people involved in caring for each other, and foster a sense of normalcy instead of sickness.

It might even wipe out stigma.

Feb 25, 2013

Mental health needs innovators more than science

In today's New York Times, Edmund S. Phelps writes about innovation. These days, the US is doing substantially less innovation. The effect is more inequality, as new wealth becomes more concentrated around established players.

What might change this state of affairs? Phelps says it's a mistake to think that science drives innovation.
There is no evidence that innovating in America is or has been tethered to scientific advances. Some historians find that innovations largely ran ahead of scientific advances in the 19th century. The myriad new products of recent decades were mostly created by new commercial ideas and tinkering, not by new scientific advances.
The implication for mental health is that if we want progress, we must expand our pool of innovators.

How can we foster an atmosphere where more people participate in mental health innovation?

Who can we invite to the table?

How can we support their work?

Feb 21, 2013

Notes on the PBS After Newtown coverage

UPDATED -- see below. I watched the Frontline show about the Newtown shooter’s family life, and the Nova show on rampage killers.

I’m not going to criticize a mother who was murdered in her sleep by the son she adored.

Yes, she made some mistakes. She chose to keep the care of her son to herself instead of exposing him to social situations. It looks like she declined support from parents who faced similar challenges. And she went target shooting with her son. None of these choices deserves a death sentence.

You have to worry about kids who are overwhelmed by anxiety whenever they encounter the world. Temple Grandin was interviewed on NPR several years back, describing the intense anxiety that plagued her as she attained young adulthood. She said she would have committed suicide years ago if it were not for the antidepressants she took. The Newtown shooter was a lot like the Virginia Tech shooter, a person overwhelmed by anxiety and fear who could not communicate with the world.

There was nothing new to readers of this blog in the Nova special. People on the path to suicide experience overwhelming pain. They fixate on a course of action. They experience tunnel vision. They might include anything in their suicide plan, including mass murder or suicide by cop.  In one suicide this past week, a singer even executed her dog.


I really liked the "path to violence" special, especially its emphasis on open communications as the key to school safety. Systematically looking for and detecting leaked signals of harmful intent is  critical for safety in schools and communities. The only way that happens is by people showing up, talking and communicating. Even the resource officers were there as part of the school community, not as the armed guards of the more paranoid pro-gun propagandists. Do we really want any of our law enforcement officers to be mere gun-toting thugs?

The other aspects of designing school security are just as important. Perhaps we do need more of a fortress mentality in our public buildings, now that mass killing of children is a contagious thinkable outcome of suicide.

The other takeaway is the disconnect between the mental health and other public safety systems. They do not work well together. The interfaces need to be improved. Many systems think in terms of units like "cases" and "incidents" -- but in the wide world we deal with "people" who can "do literally anything."

Feb 20, 2013

Teach suicide prevention where people buy guns

Suicide prevention training takes an hour or two. Why not offer this training wherever lethal weapons are sold? And in states where concealed/carry is part of the equation, why not add effective suicide prevention to the curriculum?

Firearms are involved in nearly 20,000 suicides every year, in incidents that often put others at risk.

Prevention training, also known as “gatekeeper training” helps people learn what to do when someone is breaking down and becoming unsafe. Question, Persuade and Refer – or QPR training, is available online from the QPR Institute for $30. Firearms instructors can become accredited trainers. Call 1-888-726-7926 for information about how to host and customize QPR training for your organization.

Better yet, call your local community mental health center and ask them to host prevention training at your site.

If you are a community mental health worker, why aren’t you already collaborating with the people closest to potential suicide victims? Most gun ranges have meeting rooms. Find out where they are, and get started.

My book Defying Mental Illness covers suicide prevention too. It includes a simple script to help people talk about safety issues connected with emotions and reactions to the experiences of life.

Suicide prevention is not that complicated. You may be the only person with a chance to save your friend. The ultimate answer in most cases is to talk with people directly about their feelings and intentions. If you become worried, act prudently, control the environment and stay with the person to provide support as you connect with a more formal system. The US national suicide prevention hotline is 1-800-273-8255.
The photo is from http://www.clevelandinsideoutside.com/clevelandgallery.htm

Feb 18, 2013

Mental health everywhere

Over the course of the weekend I met with mental health advocates, organizational development experts, community development experts, health care entrepreneurs and neighbors describing their vision for improving mental health throughout our communities. Here are the ideas that struck me as having the most potential for making a difference in people’s lives.

A book and a 5 step program that achieves for mental health what AA accomplished for sober recovery
Now everybody can help. The book delivers insight into what the reader is experiencing, and creates a path to recovery. It lets anyone screen for trouble, start a self-help group or deliver support when it’s needed. Frequent readers know I am talking about my own book, Defying Mental Illness. Learn more about it at www.churchbasement.net. (The blogger's privilege is to talk about his own stuff first.)

Have kids show off their ability to work through problems
Hold a class and competition for youth and young adult spoken word poets focused on the topic “what helps you get through adversity?” The answers in the poems might include exercise, spirituality, volunteering, mindfulness, gardening, music, sports and poetry. This program is already off the ground, with hundreds of YouTube videos and texts. Learn more at http://poetryforpersonalpower.com/

Build expertise around handling common difficulties
What if more people knew how to recognize and have a talk with people experiencing difficulties in their lives? They could look for
  • Past trauma experience
  • Lack of social connections
  • Job fit or career difficulty
  • Grief
  • Loss of hope
  • Disconnection with the Creator
  • Drug use
  • Nutrition, exercise or sleep habits.
The people who do the screening could have a basic chat, then connect the person to someone who has dealt with the particular situation in their own lives.

Connect people who are experiencing adversity with people who have made their way through it
People benefit from talking through problems. We can use technology to connect people who need to talk with someone who will listen and share how they made their way through it. Think of it as computer dating focused on support and achieving personal power.

These last three ideas come from Corinna West. Corinna’s programs approach mental health from a holistic and non-psychiatric perspective. A running theme is people achieving or regaining their personal power, which sounds great to me. Learn more about Corinna’s programs and her advocacy work at www.corinnawest.com. Follow her on twitter @corinnawest.

Create a home-based recovery network where visitors receive comfort and support
Skip the crowded noisy and expensive psych emergency room. Visit a neighbor, have a cup of tea, regain your composure, get back to work or school tomorrow.

This idea comes from Malaika Puffer, a Columbus-area mental health worker, advocate and blogger. Read her work at her blog Sort of Just a Person. She has a great post about existential angst. I wonder if there is a protocol for counseling for existential angst? Follow Malaika on Twitter @malaikapuffer.
I want to thank the people who helped us develop and define these ideas this past weekend.
Cincinnati organizational development Rex Lai helped us work beyond our conflicts over labels and approaches. He’s a great friend and colleague. Learn more about Rex at http://rexlai.org/ . Follow Rex on Twitter @RexyLai

Sunnie Southern is the creator of Innov8 for Health, a health care entrepreneurship expo and incubator. At this past weekend’s event over 150 ideas got pitched to judges from health care systems and venture capital firms. Learn more at www.innov8forhealth.com.

Liz Blume is the director of Xavier University’s Community Building Institute, which does asset-based community development work in the Cincinnati area. Learn more at http://www.xavier.edu/communitybuilding/
Clyde and Betty Richard have done training and job program work in Cincinnati for over four decades. Betty is the director of Winton Hills Opportunity Center. Clyde is the founder of Cincinnati Training Coalition.

Feb 15, 2013

How to smoke out a suicidal spree killer before anyone gets hurt

Hint: Help the person work through his difficulties before he commits to suicidal violence and writes a manifesto reading in part like this:
Self Preservation is no longer important to me. I do not fear death as I died long ago on 1/2/09.
Christopher Dorner was another of America's sad suicidal gun-crazy mass killers. His employment dispute wiped out his military reserve career, which triggered his attack. Apparently Mr. Dorner's mother tried unsuccessfully to help him resolve his desperate sadness. Dorner wrote:
I was told by my mother that sometimes bad things happen to good people. I refuse to accept that.
Did she realize her son was breaking down, careening  towards suicide or worse? Did she have a way to intervene? Most people in America don't know how to begin to approach that topic with someone they love. I have some suggestions about how and when to do that.

There's more. In an earlier post I referred to a new book by Adam Lankford offering clues to dealing with suicide killers.
Mass killers are suicide killers, with homicidal intent layered on. According to Adam Lankford’s new book The Myth of Martyrdom: What really drives suicide bombers, rampage shooters and other self-destructive killers, these “indirect suicidal killers” inflict damage on others to induce their own deaths. Consciously or subconsciously, the attacker is telling a story of bravado or revenge or martyrdom, in order to hide a life filled with failure and rage, and cover over the stigma and disgrace of conventional suicide.

The only effective mass murder prevention strategy is bigger than gun control, bigger than mental health. It’s suicide prevention. At a minimum, the strategy must address three elements.
  •     Suicidal intent
  •     Access to weapons
  •     Access to targets
Yet again the US has suffered injury and death at the hands of an enraged suicidal killer. At what point will Americans find it useful to learn what's needed and become accountable for keeping people safe?

Feb 12, 2013

The psychiatrist will get you if you don't watch out

The current dialogue over gun control and public safety in the wake of Sandy Hook reveals what society expects of its mental health resources.

A double mission. The primary mission is to help people make progress in their lives. The second mission is to support public safety.

In other words, the second mission of mental health is to collaborate in the exercise of state legal power. Think of the range of areas where mental health and related disciplines affect a person's legal life.

-- Criminal law: Insanity, diminished capacity
-- Family law: Custody determinations
-- Probate law: Capacity to make a will
-- Civil law: Damages related to pain, suffering, trauma
-- Administrative law: Disability determinations, payee decisions
-- School law:  Special education placement and programming

The above list is limited in one key way: These are all situations where mental health experts ADVISE a court or administrative agency about what the government should require or decide about a person. An expert might testify, but the judge or jury decides if the defendant is Not Guilty By Reason Of Insanity, according to legal standards made up by judges, legislators and other non-medical folks. The legal standards don't align with any version of the DSM. In Texas, for example, you can be executed unless you are as impaired as Lenny, the fictional character from John Steinbeck's book Of Mice and Men.

There's another list, situations where the state simply DELEGATES power to mental health professionals. The prime example is the 72-hour hold. Depending on which state you live in, a psychiatrist can write an order, have you arrested and brought to a hospital against your will for one to three days. Once you're in the hospital, you are expected to submit to the relevant protocols. (Forced medication or ECT requires a court order. That puts the mental health worker back in an advisory role. Outside the US,  you may never get a medication or hospitalization hearing before a non-medical person.)

This delegation of power to mental health professionals is one reason people fear the mentalhealth system. Your psychiatrist is your gateway to the locked ward and the surly white-suited attendant. If you think that your therapist is judging you, you're right. Are you safe enough to go back home? Are you likely to attack someone? And, at least in New York, are you safe enough to own a gun?

Power like that scares people. Patients want a kindly sort of mental health, all support, no orders, no crappy meds, no threats, an easy journey back to health, maybe a spa day, or a pill to get you going on the trip back to work. A little something to take the edge off the mood or the encounter with the boss.

But we know we can't have that. We are realists. We know state power is inherently coercive. And as kind and positive and recovery-focused as we try to make it, mental health does have that double mission.

Why not embrace it? No one wants psychiatry to be like military recruiters who talk about paying for a kid's education, but neglect to mention the war.

Psychiatry delivers value when it offers access to safety. People show up at the clinic when they are scared of their own thoughts and feelings. Why not an alliance around safety, around risk?  Around a plan to secure your weapons when you're hurting?

And in the community, in our homes and schools and churches, why not focus on support?

After all, social support is the only truly non-coercive mental health option. Delivered by amateurs. You know, those people you love, your friends, your neighbors, the folks at church. It's the low-stakes way to start that chat about how what you feel relates to your safety.

Feb 8, 2013

Cheap and effective mental health everywhere?

Where’s the mental health aspirin?

We know the home remedy answer to our moodiness and troubled thinking is not a pill. In mental health, every pill has consequences, and self-medicating is a disaster.

In mental health, the cheap and effective answer to trouble is connecting with other people, and peaceful surroundings, some guidance, some comfort. More sleep. A cup of tea. Prayer if you like. Some exercise. Less stress.

Is there a prescribed dosage for less stress?

The standard protocols for mental health do not operate in the part of the world that is capable of dosing us with less stress. Your doctor won’t tell your boss to be more kind and send you to the resort. 

And in many places, even in our modern world, there is no doctor anyway. Some of my readers say they can’t get an appointment for months. Readers send me emails about this.

You are so right that we need experts, treatment centers and ordinary people to help. I unfortunately live in an area with its collective head in the sand, where the only resource for people with mental health issues is to wait as many as three weeks before speaking to a psychiatrist on a television screen. I know of two people who had suicidal thoughts and were told they needed to wait to see a doctor, but if they really felt like killing themselves to call the suicide prevention hotline.  

* * * * *

I have a daughter and a sister who are bipolar. We live in a rural community where professional help is extremely difficult to have. Tomorrow I am taking my sister for an appointment with her psychiatrist. She can only see her ONCE every THREE months!!

Both of these readers live in civilized places.

Mental health resources are badly distributed because within our economic universe a kind of gravity forms around money and reimbursable service user populations.  This gravitational force attracts service providers and professionalized resources. In the US, the free market Big Bang of medical mental health economics created a clumpy universe of resources and institutions concentrated in densely populated areas.

What can people do if they live somewhere away from the clumps? 

What is available if professional resources are restricted or rationed or nowhere nearby?