Apr 23, 2013

Preventing the next bomb plot

Detecting suicidal thinking can stop bomb plots like Boston’s. Like every one of our recent mass killings, this was suicide with a murderous twist. 

The minimum requirements for suicide are suicidal intent and access to a means of suicide.

If the means of suicide is a weapon, there is a possibility of harming another in the course of the suicide.

If there is also an intent to murder someone, or make a statement, or respond to another person’s influence, then someone or something may likely get attacked as the suicide plays out.

If a group is promoting suicide terrorism, or if there is social shame attached to suicide but cultural approval of suicide martyrdom, then the suicide attack can become a terror strike.

National security expert Adam Lenkford writes:
Homicidal intent often increases the severity of attacks…truly homicidal suicide terrorists are motivated to maximize enemy casualties.

A sponsoring terrorist organization may increase suicidal and homicidal intent, provide access to weapons and enemy targets, and boost social approval of suicide terrorism through its use of propaganda…
Social stigmas surrounding conventional suicide and social approval of suicide terrorism often work together. When a community strongly condemns conventional suicide as a certain path to hell, it virtually disappears as a potential escape route. And when a significant percentage of people believe that suicide terrorism is justified, a new door opens for desperate individuals.  
I believe that ordinary Americans have the best opportunity to detect suicidal thinking among our friends and family members. Saving them saves us.

In 2009, at age 22, Tamerlan Tsarnaev told his uncle he was not concerned about work or studies because God had a plan for him. He was flunking out of accounting school. His boxing career was close to over. He identified himself as a very devout Muslim. In 2013, after his trip abroad, he was effectively silenced within the community of his Boston area mosque for the way he expressed his disruptive radicalism.
When a preacher at the same mosque says slain civil rights leader Martin Luther King Jr. was a great person, Tsarnaev stands up, shouts and calls him a "non-believer," the Islamic Society of Boston said. Tsarnaev accuses the preacher of "contaminating people's mind" and calls him a hypocrite. People in the congregation shout back at Tsarnaev, telling him to "leave now." Leaders of the mosque later tell him he will no longer be welcome if he continues to interrupt sermons. At future prayers, he is quiet.
Tsarnaev had become a shunned, alienated, isolated, radicalized has-been boxer, a “loser” as described by his uncle. And an outlaw. Look at the social boundaries he is willing to violate as he challenges the authority of the preacher at his mosque, demonizing, of all people, Martin Luther King Jr.

Who was the person best placed to take this young man aside, befriend him, and find out what he was facing, what he was contemplating?

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.

Previous posts

Teach suicide prevention where people buy guns. http://redesigningmentalillness.blogspot.com/2013/02/teach-suicide-prevention-where-people.html

Dear Vice-President Biden, Here’s What It Takes to Fix Mental Health. http://redesigningmentalillness.blogspot.com/2012/12/dear-vice-president-biden-heres-what-it.html

Mass murder is the new flavor of American suicide. http://redesigningmentalillness.blogspot.com/2012/12/mass-murder-is-new-flavor-of-american.html

Lenkford, A. (2013). The Myth of Martyrdom: What really drives suicide bombers, rampage shooters, and other self-destructive killers. NY: Palgrave Macmillan.

CNN. (2013). Timeline: A look at Tamerlan Tsarnaev’s past. Downloaded April 23, 2013 from http://www.cnn.com/2013/04/21/us/tamerlan-tsarnaev-timeline/index.html

Apr 18, 2013

Is your mental health expert smarter than a second year college student?

If we took what we know about how mental illness plays out in the world and let some second-year college students work on fixing it, would we end up with something better than what people experience today?

Today’s experience of mental illness, such as it is, developed through accretion. It is a mishmash of good and bad intentions, a clump of attitudes and practices, a basket of  traditions, economic and political factors, plus choices made since time immemorial. We have “cures” that include home remedies, scripts for talking with people, and manufactured pills and potions. We have “lifestyles” that include disempowerment, isolation, poverty, broken families, unemployment, poor health, even death.

What if we told our students to start from scratch, rejigger the whole thing. Redesign it,  using standard design techniques, a reasonable budget and some consensus-based mental health practices. What might this design team come up with?

Here are some of the principles the design team would use.

Unification.  The team would pull elements of the proposed solution from everywhere, not just from one discipline, but many. Whatever the origin, the product would work cohesively, as a unit.

Diversity. Designers are known to be self-referential. Men design for men, women for women, everyone for their own home culture. A diverse team delivers results appropriate for more people.

Accessibility. Users would know how the product functioned. The technology would be evident to the user.

Safety. The designer would understand the human factors involved, making sure the technology is safe for the user.

Simplification. Reducing the number of paths, parts and processes.

Problem solving. Addressing the user’s concerns, delivering something that makes a person’s life better.

Waste reduction. Reduce the burden of the product on the environment and on society at large.

Responsiveness. Deliver what the user demands. Create what the consumer wants, respecting the consumer’s motivations, even when the designer does not agree.

Appropriateness. Don't confuse commercial products with consumer products. Commercial products are money and process-driven, whereas consumer products must address the human needs of product users.

Deep research. Designers must immerse themselves in the user’s world to ensure they are reflecting the user’s desires, not their own.

* * *
Yesterday I watched as these principles played out at the school where I teach, Cincinnati State Technical and Community College. Six industrial design technology students presented their capstone design projects, products ranging from bike racks to assistive devices to squeeze bottles to trash can bags. A group of experienced designers from Procter and Gamble, GE Aircraft and other local companies coached and mentored the students. Over the course of the four-hour event, the advisors highlighted additional opportunities to learn from users. What does the client want? How do you know what the client wants? Was the client satisfied with what you delivered? When something wasn’t safe, how might you fix it?  Would the fix be satisfactory to the client?

Needless to say, this was eye-opening for me. Mental health services are consumer products, after all. Why does no one listen to service users, people the system calls consumers?

This classroom of second-year undergraduate-level design technology students were figuring out how to solve any problem by listening to people, applying some basic prototyping and fabrication, and checking to see if the user’s needs were met.

How many of today's mental health experts can honestly say they do that?

Apr 12, 2013

Healthcare innovation and the digital madhouse gulag effect

I spent the day hanging out with healthcare innovators, entrepreneurs and investors at the Innov8forhealth Business Expo at the Northern KY University METS Center, a beautiful conference center across the river from Cincinnati. I really enjoy these events. It’s an occasion for me to improve my own work, and an opportunity to compete with other startup ventures for the attention of investors and healthcare system buyers.

As I have written before, healthcare is now a galaxy.  At the center is a black hole where everything that happens is mandatory and payment is by and large measured in bulk on a population-served basis. A little farther out is a ring of fee-for-service places, the Primary Care Zone. Out beyond that is the realm of health educators and “healthy support” people. Think of the nurse that calls from your health insurance company, or the educator that shows up at the senior center. Or folks like me, with books and programs.

The space between these layers is becoming filled in with health data transaction machines, satellites really, that people in the population hook their phones, gadgets and computers up to, so the information infrastructure of the galaxy can check in and measure what the population is doing.  Or they phone back to tell you how you are doing.

Some examples: Phone apps now connect older adults to caregivers. People can know when their elderly relative has forgotten to take her pills, because the app sends an alert to the caregiver’s phone when it’s time to call and complain. (Sorry, I mean “remind the person to do better.”)  Exercise bikes can email out gift cards when a person racks up enough miles. Smartphone sensors can work like always-on stress detectors, heart rate monitors, blood gas measuring devices. Phones can even wake people at just the right time to optimize their dreams.

Within these apps, the experience is being turned into a game. Healthcare is becoming “gamified.”  If I lose a couple pounds, my scale will report in and I will get a coupon for vegetables I probably won’t eat. The coupon will let my grocer know to report in if I bought them.

As all these trends come together, people in a position to access data profiles for employment, justice system, credit, insurance, political and other economic purposes will be able to view each of us as avatars, or data constructs. (We will all check the box on some form that says this is okay.) A job applicant’s “permanent record” might include what he buys at the grocery, the books he has downloaded, the restaurants and clubs where his face has been seen, the people he travels with, how well he sleeps and more.

Over the next few years, the gamified data incursions on personal privacy will be absolutely horrifying to people concerned about personal autonomy and freedom from intrusive monitoring.

I think this has significant implications for mental health. What algorithms will we develop to track personal growth? Will people be permitted a “fresh start” in a data-dominated ultra-competitive economy?  And what will the data profiles of people experiencing trouble of one kind or another look like?

The future madhouse will, I think, be a data-driven invisible economic gulag. People with mental health concerns will be identified easily because their data profiles will reflect their relative poverty and isolation from the main stream. Mechanized online psychological pre-employment testing has already become super-inexpensive. In the past month I learned of two people applying for jobs who were required to take psychological tests. One person was applying for a first job at Pizza Hut. He spent ten or twenty minutes answering a few dozen multiple choice questions. The other was applying for an executive level position at a healthcare system. This executive spent half a day working through a barrage of questions (many of them forbidden to standard personnel departments because they are plainly discriminatory). In the future, the very near future, job seekers will check a box and employers will just look this data up.

One consolation for me on this otherwise data-driven day was the opportunity to have a chat with my own cardiologist about his life in a very busy practice involving several patient offices across the city, as well as hospital work. We talked about the disconnect between the major layers in the healthcare system, about the difficulty doctors face getting to know the people they see every day in their office caseload, plus the logistical challenges of seeing patients when they have a hospital stay.

At some point, healthcare must confront and balance out the human element in the equation. Patient encounters make more sense to people at both ends of the stethoscope when they meet each other face-to-face. We have this primitive capacity and a need to know that what needs to be said has been heard, by a real person,  not just by some robot attached to the other guy’s phone.


Learn more about healthcare innovation in Cincinnati at http://www.innov8forhealth.com.

Apr 5, 2013

The 33 losses of modern psychiatry

What a portrait of modern psychiatry in today’s New York Times. Psychiatrists are abandoning 45-minute therapy practice for 40 brief encounters a day. Mechanized medicine. No therapy, because the system won’t pay. The featured doctor’s wife,  a licensed social worker, gave up her own therapy practice to become the full-time office manager and copay enforcer in her husband’s practice.

Here’s a list of what modern psychiatry has given up, and what a sad thing it has become, as described in the course of the article.

1. No therapy. “Hold it. I’m not your therapist.”
2. No long appointments.
3. Less intimacy
4. Less familiarity
5. Can't know patients by name
6. Lowered goals of treatment. It used to be patients leaving “happy and fulfilled”
7. Less effective treatment. Now he tries to “keep them functional.”
8. Forced disinterest in patients. He “resists helping patients to manage their lives better.”
9. Surrender of natural capacity to care. “I had to train myself not to get too interested in their problems.”
10. Therapeutic traditions abandoned.
11. Loss of practice identity
12. Industrialized practices. “very reminiscent of primary care.”
13. Loss of mystery and intrigue
14. Loss of sense of mastery
15. Hospitals now “discharge them within days with only pills”
16. Psychologists and social workers are now economic competitors.
17. Loss of “quality of treatment” edge compared to other therapists.
18. Discovery that the “craft was no longer economically viable.”
19. Economic coercion “Nobody wants to go backwards, moneywise, in their career.”
20. Loss of competitive edge for psychiatry compared to other medical specialties.
21. Providing less potent care. He dispenses pills but “it’s the relationship that gets people better.”
22. Forced to assume a more mercenary attitude, with add-on fees and charges.
23. Less opportunity to display kindness and sympathy.
24. Less adaptability
25. Living in a culture of scarcity
26. Less access for new patients.
27. Long waiting lists.
28. Interview techniques that do not follow professional training
29. Patients “frequently ignore” advice to seek therapy
30. Forced to disclaim capacity to help people with problems.
31. Recognition that he is delivering poorer care now.
32. Feelings of shame.
33. Fear for son’s future in the family profession.

After all of these losses, what is left of what people used to call the profession of psychiatry?

I was also struck by the disconnection between office-based psychiatry and the front door of the psychiatric hospital. There is no evidence of continuity whatsoever. The hospital is an isolated, separate team. Is there a minute for a phone call if the person shows up at the hospital for help? Is that phone call in anybody’s protocols?

When police become involved with people with mental health problems, they often say they are not trained therapists, but in today's economy are there therapists anywhere? Is the economy for psychologists really so poor that there is better money to be made as an office manager for the family’s designated breadwinner than as a licensed therapist?

Given that psychiatry as we used to know it is a dead thing, a zombie profession, I am more convinced than ever that the traditional power imbalances in treatment are doomed.

Psychiatrics are mechanics now, so patients already have the power. Visit the pill dispenser of your choice. Offer your $50 buck copay, let the provider roll the dice on whether insurance will kick in anything more, see what pills are on offer. If you can get an appointment.

Meanwhile, I suspect the real market for peer specialists is as mentors, unregulated people to talk to for money. Imagine: Be a life coach, charge $50 an hour, hang out, have a relationship. It's the cost of a copay. Try to be ethical in the unregulated economy. It’s better than the $12 an hour, part-time job with a mean boss at the low end of the treatment system food chain. Plus,  since it’s the talk that’s effective, you’ll be doing your client some good, without shame.

The psychiatrists in your neighborhood will envy you.