Sep 20, 2013

Aaron Alexis and the demon delusion

There is an out-of-character vibe to the Navy Yard shootings. A good guy, but big trouble. Intentional, planned violence. It's the kind of situation that generates talk about demons. Would an exorcism have derailed this particular murderous plan?

Maybe it would -- if a concerned knowledgeable spiritual advisor knew enough about the risk factors for mass violence, and took other steps to protect the shooter and the public too.

Mental health and addiction problems are said to be "biopsychosocial" meaning they have biological, psychological and social components. If we add a spiritual component, then we have four ways to approach the problem.

Interventions gain strength when they are stacked up. Medication for the biological, therapy for the psychological, the comfort of family and friends for the social, plus prayer and spirituality. All four, not just one. Demon-blaming can't stop bullets.

What Aaron Alexis needed was a realistic face-to-face discussion about what he was experiencing, and about what he might do to alleviate his suffering and stay safe, and about what was too risky for him and for others. A positive course of action, including accompanying him to a doctor and ensuring that his true concerns were revealed to someone who can take the next steps. Suicidal people often visit doctors with minor complaints, failing to reveal suicidal thoughts to the medical team. Friends and family can help make sure the doctor gets the full story. Alexis was also taking an antidepressant, which sometimes can spark thoughts of suicide or activate a person with thoughts of causing harm.

A spiritual discussion or a prayer or an expression of sympathy is not a strong enough dose of intervention for a person in crisis who is experiencing paranoid thoughts and who has a history of violent impulsive behavior. This is a high risk issue that must be confronted powerfully.

People who work with high-risk populations in jails or community settings know that people can't be trusted to reveal their suicidal or homicidal plans. People in charge construct protocols that ensure safety even when a person hides or disguises his true intentions. This is easier in an institution than it is in community settings. It is a stigma-connected blind spot for security agencies and law enforcement. People who think mental illness is too scary, too hard, too inexplicable or too mysterious find it easy to ignore signs of trouble.

But mental illness is not that complicated. It's thinking or feelings that are out of bounds or off the scale, plus issues relating to safety and risk. Nonclinicians don't have to diagnose anyone, just do their part to provide support, connect with other resources, and help a person stay safe. Sympathy should not displace realistic approaches to safety and risk.

Sep 18, 2013

Mental illness is broken

I think the whole experience around mental illness is broken, a total systemic failure.

Systems have life cycles. They start out along a spectrum from randomly generated (through tradition, for example) to thoroughly designed.  Whichever way they start, they follow wobbly patterns ranging from controlled to out-of-control, effective to ineffective, sustained to out-of-resources.

A problem-solving system such as education or criminal justice or healthcare starts out with formal elements (schools, courthouses, hospitals), plus basic  professional structures (doctors, lawyers, teachers) plus broad policies (constitutions, degree programs, practice guidelines) to guide future action.

In the operational stages, professionals and governing bodies develop traditions or protocols, and deliver services to the people who interact with the system. These decisions pile up. They affect how the system operates as a whole in the future.

An operational system that is supplied with sufficient resources delivers a satisfactory range of outcomes, aligned with the expectations of its governing authority, professionals and service users. But when systems fail, people suffer.

Signs of system failure include:

- High numbers of poor outcomes
- Collateral damage
- Correct decisions that create harmful social consequences
- Absurd outcomes
- Bad rhetoric
- Political correctness
- Not reaching people in time
- Waiting lists
- Case processing backlogs
- Restricted access to techniques that work
- Treatment protocols corrupted by service-rationing
- Turf issues focus on avoidance of responsibility
- Resorting to primitive methods, e.g. shunning, shaming, coercion
- a professionalized environment but professionals can't do what counts
- dehumanization of service users
- Frail (non-resilient) systems
- Financial incentives for delivering poor service arrays
- Poor geographic distribution
- Corrupt practices

Whether failing or functional, no system is perfect. Systems always fail some portion of the constituency they are meant to serve. Complex dynamic systems have multiple capacities, patterns of strengths, blind spots, weak spots, clumps of capacity, and specific trouble points. After a while, all of these are noticed, but only rarely are they seen as system failures. They are usually interpreted as aberrations no matter how frequently they show up.

Fixing failed systems

For any system, it is possible to map out problems, and add non-system resources to compensate. These non-system resources, generally speaking, involve either money or people. Unfortunately, unless the logic and infrastructure of the system are actually fixed, this strategy just adds more of what  is already not working.

The most comprehensive approach assumes that everyone inside and outside systems can help, and that every aspect of the system is worth questioning.

Every option is optimal for something. We can find out what people can do, what they like to do, and what they are are willing to do, and use these capacities in the discretionary space within the system and in places where the system does not operate.

We can also try to identify techniques which are professionally designed and validated, but that can be adapted and used by non-system personnel.

If the system is broken, the most urgent questions are "What is our most helpful, least toxic, least costly option?" and "What can we do that's just as effective but not as harmful as what the system offers today?"

Sep 12, 2013

It’s time to shut down community mental health

Evidence is mounting that America’s community mental health system is just a passing phase. The system is under-designed for the task it faces, under-funded for the mission it is permitted to address, administratively fragile, locally corrupt, and too deeply connected with stigma to justify sustaining as anything other than a transitional phase in the evolution of American health care.

Under-designed. State asylums addressed both housing and health care for the populations they served. De-institutionalized system are treatment-only, and further limited because they only address the mental health component of a person’s overall health. Consequently, people with mental illness experience more homelessness and poorer overall health than other Americans, even those with other chronic health conditions.

Under-funded. Over time, managed care practices and funding decisions have resulted in a system where care is both rationed based on clinical need or other factors, and stretched out through technology. Insurance companies have focused almost exclusively on medication for outpatient care, rarely make psychotherapy available, and restrict access to family therapy and other more intensive treatments. In many areas of the country, patients wait for months to access psychotherapy delivered through a video system. This does not meet anyone's "best practice" standard.

Administratively fragile. Mental health providers are often fully-funded by Medicaid and other public dollars, and prepaid for services they contract to perform. Meanwhile, the people to be served are assigned to treatment agencies, denied the opportunity to choose their own provider. When regulators reclaim misspent funds, the result is service cutbacks that leave captive constituencies with zero recourse.

Locally corrupt. In many states, publicly-funded mental health services are no-bid contracts with no limits on executive compensation or administrative costs. This leaves new providers without opportunity to compete, as entrenched systems become self-reinforcing if not pay-to-play.

Deeply connected with stigma. In many places, mental health treatment providers continue to regard the people they serve as defective, perpetually dependent, discredited, and deserving of inherently coercive, degrading treatment approaches.

The bottom line: If what we have now is just a system of de-institutionalized asylums, we must redesign the whole thing.

Readers, what do you think? Is the community mental health system worth preserving, or should we just move on to something that's different and better? What do you think that might look like?
By the way, for some of my ideas on what it will take to fix mental health, start here.

Sep 4, 2013

Psychiatric Survivor Manifesto

Corinna West and I have been having a dialogue during 2013 about the core beliefs of the psychiatric survivor movement, and about points where her beliefs and mine are compatible. We've both had so-called "lived experience" and put the lessons of  our personal recoveries into what we write. My book Defying Mental Illness has a fair amount of content she objects to. I find much wisdom in what Corinna writes.

Corinna has just written a piece that tries to express the beliefs of the psychiatric survivor movement. It's a document in the Alternatives 2012 Facebook group page. Doesn't most of this sound, for lack of a better word, normal?
Psychiatric Survivor Manifesto
By Corinna West
   There are many reasons for extreme emotional states or biocognitive challenges. These often come directly from life situations that overwhelm a person's social supports. Increased community engagement and mental health prevention can greatly reduce costs, improve human rights, and increase recovery rates. A model that views all emotional distress adas a chemical illness which is best chemically treated has scientific limitations. This “disease model” approach, also called the “medical model,” has been shown to help some people, but it harms many others, and it may be increasing the amount of disability in our country. Instead, we want people who have completely recovered from mental health crises to share what was most effective for them. We can help our peers strengthen social supports, find someone who's been there before, and link people to their personal power.  We know how to come through the fire. We've done it.

   This is a summary compiled by people in the mental health civil rights movement. Some of us call ourselves psychiatric survivors, one who has survived psychiatric treatment, not the “illness.” Many of us have found scientific evidence and our own personal experiences showing that emotional distress is not an illness. We have found recovery using a variety of approaches and methods, but here are several concepts of hope and empowerment repeated in many of our personal stories.

6 ideas for complete mental health recovery compiled from psychiatric survivors.

1) Use prevention services instead of crisis-only services. This avoids a repeat of negative experiences based on coercion and force. Up to 40% of people admitted to a mental hospital have never received any kind of peer support or community care, which would greatly lower treatment costs. Peer support centers like nationally recognized S.I.D.E. in Kansas City, KS, have been able to increasingly carry this first contact burden through recent budget cuts.

2) Focus on recovery and wellness. Over 60% of the early mortality to people with mental health labels is due to preventable physical illness. Focusing on total body health, with choices made by each service recipient, greatly improves outcomes. The mental health center coalition in Kansas City hosted a walking challenge where agencies competed to post the most steps taken,, and many participants got to see their city in a whole new way. Also, use existing community services like sports or hobby or faith based activities. A day of community mental health center treatment is 1/16 the cost of jail treatment, and 1/40  the cost of a day in a mental hospital. But finding support and encouragement already in the community, before people are completely overwhelmed and seeking medications and diagnoses, is an even more powerful source of cost savings.

3) Let people know that emotional distress can be temporary and transformative. There are very many valid definitions of recovery, but “all this goes away,” is still the most hopeful and encouraging. Let people meet mental health care graduates and learn their methods. Poetry for Personal Power is a Missouri statewide stigma reduction program where hip hop artists and spoken-word poets share that emotional distress can come from many resolvable sources. These include trauma, lack of social connection, job fit or career goals, grief or loss of hope, spiritual unrest, drug use, nutrition or self-care habits, or brain injury. According to national advocate Duane Sherry, “Psychosis is an event, not a person.”

4) Used nuanced approaches to medication. We ask for fully informed medication use, where all people get honest information about long term efficacy, the risk of worsening a situation, the link between violence and medication use, and the difficulty of medication withdrawal.  Without a complete assessment of this data, none of the decisions made in mental health care are very accurate. Wellness Wordworks, a Mind Freedom affiliate in Kansas City, has shared extensive information about safe, supported and meticulously planned medication reduction strategies. Community mental health centers that shared this information and monitored doctors who repeatedly violated good clinical practice could greatly reduce medication costs. If a life situation caused a person's emotional distress, the solution will likely be a life situation change, not a chemical change.

5) Genetic research should have peer input and honest reporting. The vast majority of mental health research funding goes towards a “disease model” perspective. There is limited use in searching for physical causes of emotional distress in complete separation from a person's life situations. Reports should be honest that a genetic correlation report is meaningless unless both linkage and association studies can be paired. Truman's Prime Time peer support center instead has participated in research that was presented last week on a national webinar to show how all peer support centers can improve their services to promote recovery.

6) Give people in emotional distress a map out of that distress: 1) know that handling adversity is universal human experience, 2) talk to people who have been there before 3) resolve the overwhelming life situations, and 4) find what gives you Personal Power. The Common Ground program at the Wyandot Mental Health Center shares stories of personal power gathered by Patricia Deegan, a person who completely recovered from schizophrenia.
I think this approach is thoughtful and valid in many respects. Notice how much wisdom is evident after you scratch out whatever words you don't like.


Today's consumer/survivor movement of course has its roots in the experiences of the post-deinstitutionalization era. There's a history to all this. People may or may not reject the underlying medical theory around mental health issues, but there's been a long history of people seeking to create an experience of community and mutual support around mental health. Here's a video about the MPA, an organization that began in the early 1970s in Vancouver. Notice the tension between the experience of community and self-advocacy, and the necessity of an institutional framework in order to deliver services. Learn more about the film here.