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Most Y’all Missed This ’13 Reasons Why’ Detail & It Sheds Insight Into Alex’s Story

If you haven’t finished 13 Reasons Why, exit out of this post right now because I am about to end all debates about the last episode.

Based on the best-selling novel of the same name, 13 Reasons Why is proving to be one of the best and most socially aware young adult series in recent memory. It accurately shows what high school parties are like, using the kind of language high schoolers truly use (yes, F-bombs come out in droves), and not pulling any punches on more sensitive material. From almost everyone who has seen the show (many critics excluded), it is a poignant, incredibly well-done series that hits home pretty hard.

Seeing as it’s been several weeks since the show aired, you’ve probably either finished the series or got most of the way through it, which is what brought you here. It was a compelling show that made you want to get to the end just because of what it was talking about. For the same reasons, you probably had a hard time finishing it. However, if you weren’t paying enough attention while watching, you’ll not have noticed this one moment that changes the show’s entire narrative completely.

'13 Reasons Why' [Credit: Netflix]
’13 Reasons Why’ [Credit: Netflix]

It’s All In The Little Details

Unlike Clay Jensen, I’m not going to drag this out and make you wait 13 hours to know the whole story of what happened to Hannah Baker. During the 13th and final episode of the series, the Baker family finally has their deposition against the school. Several of the students from the tapes are called in and we get to see a few of their recordings as they’re sitting there being interviewed.

If you look to the bottom left corner of the screen, you’ll see the date that the tapes were recorded. Taking into account that the show was released on March 31st, 2017, this date changes everything about the show.

Zach Dempsey's deposition. '13 Reasons Why' [Credit: Netflix]
Zach Dempsey’s deposition. ’13 Reasons Why’ [Credit: Netflix]

November 10th, 2017: None of this has happened yet. OK, well some of it has.

The Story So Far

Hannah went to the park with Justin Foley, sparking that ill-fated picture of her on the slide. Hannah met Jessica Davis and Alex Standall; they started going to Monet’s every day to get hot chocolate and whatever the hell Alex was drinking. The three of them had their falling out due to Alex’s stupid list. Hannah and Courtney Crimson found out that Tyler Down was Hannah’s stalker. Courtney painted Hannah as a lesbian to salvage her own reputation. Hannah went on a pretty crummy date with Marcus Cole, after which Zach tried to make things better, but it ended poorly for both Hannah and him.

The rest of it probably hasn’t happened yet, however. Now, I’m not entirely sure about whether Ryan Shaver’s tape happened, but the rest of it certainly hasn’t.

This means that Bryce Walker hadn’t raped Jessica, Sheri Holland hadn’t knocked over the stop sign that led to Jeff Atkins’s fatal car crash, Clay and Hannah hadn’t hooked up — resulting in Hannah being unable to show her true feelings for him out of past traumas, Bryce hadn’t raped Hannah yet, and Mr. Porter hadn’t told Hannah to just let go of what happened to her and act like it never happened.

Giving life one last chance. '13 Reasons Why' [Credit: Netflix]
Giving life one last chance. ’13 Reasons Why’ [Credit: Netflix]

But the biggest, most important takeaway from knowing this is that Hannah is still here. We still have the chance to help her and prevent this from happening. We can still save Hannah. There is still time.

When it comes to suicide, at any age, those closest to the victim wished they had seen the signs and had the time to stop it. This theme is very evident throughout the series, as every character wishes they had only known what could cause Hannah to want to end her life. As the show points out, it can be obvious that someone is depressed and looking to find a way to put an end to their pain (evident from both Hannah and Alex). However, it is difficult to see it in those closest to you, which is why everyone was so blindsided by what had happened.

The biggest message that the show is trying to push is that we don’t know what’s going on in each other’s lives. We just have to be there for each other and support each other not matter what rumors we hear. There’s too much hate in the world, especially in high school. We need to overcome it and learn to appreciate each other for who we are.

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We often don’t know if someone is depressed, no matter how evident the signs may be. However, if we can be there for each other, we can prevent something like this from happening again. And, in the case of Hannah Baker, we can prevent it from happening altogether.

With this in mind, it’s interesting to note that Jay Asher’s original ending included Hannah Baker actually surviving her suicide attempt. This original ending was actually included in the 10th anniversary edition of the novel released last December. Which was coincidentally released mere months before the Netflix series aired.

Now I’m not saying that’s suspicious or anything, but maybe, just maybe, it was released around the same time as the Netflix series with the intent to continue the series for a second season – or maybe in another format altogether. Assuming the series does well (as most Netflix series do) and with this small little detail snuck in the finale, the creators could easily turn around and say that Hannah never did kill herself and instead give us a sequel following Hannah and company in a plotline in which she’s still alive.

Congress listened

Throughout the  year, we’ve asked Congress to stop health reform efforts that would hurt Americans with mental illness—and we’ve urged them to forge bipartisan solutions to stabilize the health insurance markets.

We have good news: Congress listened.

Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) announced a bipartisan agreement to help keep insurance markets sound and more affordable. If this bill passes, it will help protect mental health coverage for Americans with mental illness.

The Alexander-Murray bill will also keep vital patient protections in place, including stopping health plans from:
Dropping coverage of mental health and substance use
Charging higher premiums if an individual has a preexisting condition, like depression or anxiety
Charging more simply because a person has a mental health or substance use condition

The Alexander-Murray bill will strengthen and stabilize the health care system, reducing the risk of sharp premium increases and lack of insurance options. It maintains important cost-sharing reduction (CSR) subsidies and financial assistance, which help low- and middle-income people pay for out-of-pocket costs and insurance premiums.

Your continued advocacy matters.

Contact your senators and tell them to support this bipartisan effort and protect mental health coverage for million of American Students.

 

Griffin Ambitions Ltd is nonpartisan. We support policies that help people with mental health conditions and their families.

Griffin Ambitions is here for you.

 

Misintent : Hazing Students | Mental Health

Notice:  This piece was selected for publishing as an open opinion piece by an unaffiliated contributor.


How is what YOU do, in any way similar to fraternity/sorority HAZING? Before you say “in NO way!”…stop and reflect a little.

I know, not all fraternity “hazing” ends in death, though it is now illegal in California. But no matter how benign it seems, having to jump a lot of hurdles in order to GAIN ACCESS, is a problem for people seeking mental health treatment…or even getting the listening ear of a friend or parent.

Can we prevent the emotional/social pain sometimes inflicted on someone SEEKING ACCESS? Getting access to faith-based or mental health services, to school counselors, to peers or even distracted parents, can sometimes feel like “hazing”…the things we are asked to do, the price we are asked to pay.

How bad does someone want or need access? To what extent are hurdles placed in the way to find out “how high they will jump”? Some people “do what they are told”…are they considered fools (even by those whose services they seek) for not knowing when to stop seeking?

This Atlantic story is sad, but thought provoking.

Checkout: UNAFFILIATED ARTICLE ON THE NEWS STORY

It brings to my mind, another old story about a woman seeking help for her ill daughter, which suggests that even caregivers can learn from care seekers. Her daughter dying, the woman bowed down before the healer (as required by custom) and begged him to help her. His first response was, “It’s not good to take the children’s bread and throw it to the dogs.”, meaning…he’s only going to heal the really sick people, and those who are in my neighborhood, so to speak. To that, she said, “Yes, but even the dogs feed on the crumbs which fall from their owners’ tables.”. Comparing herself with hungry dogs seemed to make a difference. With that, he said, “Your faith is great and it shall be done for you as you wish.” And he healed her daughter at once.

I know scripture readers might argue with my interpretation here, but my point is, even Jesus felt he was only there for certain people and she had to do a little cajoling to get what SHE BELIEVED HE COULD DO. Compassionate or convicted – either way you interpret it – the healer, healed.

But why did she have to beg first? Did he know before she even started the conversation that he was going to help her? Was he “hazing” her a little? Did she have to prove her faith in him first? Or did he have to find her “worthy” of his time? Or did the “hazing” actually show him that his “treatment” was going to work on her prepared/faithful soul? Maybe there was another way to get THAT information…

In the end, she had her daughter back, healthy and whole. I wonder how SHE felt after that conversation. Of course, she felt grateful to the healer for his work. But I wonder if SHE felt healthy and whole, too.

 

“Advocate for mental health. Work to end STIGMA of mental illness.”

 

Campus Mental Health FAQs

Campus Mental Health: Frequently Asked Questions

Campus Mental Health: Frequently Asked Questions
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Many students attending colleges and universities experience anxiety, depression, and other mental health problems. According to the 2016 National College Health Assessment, almost 40% of college students reported that they felt “so depressed it was difficult to function” at some point in the prior 12 months, 19% felt overwhelming anxiety, and 10% had seriously considered suicide. If you are a college or graduate student experiencing one of these challenges or another mental health issue, you may be worried about its effect on your academic progress, disciplinary status, or ability to participate in social or other activities at your school. In this guide, we hope to answer some of your questions about your rights as a student with mental illness, as well as about the legal protections, accommodations, and resources available to you.

Which Laws Protect My Rights as a College or Graduate Student with a Disability?

Nearly all universities are subject to the Americans with Disabilities Act (ADA), either because they are publicly funded or, in the case of private universities, because they are considered public accommodations.1 Most universities and colleges also receive federal funds in some form, and will therefore be subject to Section 504 of the Rehabilitation Act of 1973 (Section 504).2 Colleges that provide housing—including dorm housing—must also comply with the Fair Housing Act (FHA).3 Many states also have anti‐discrimination laws that apply to universities.

The ADA, Section 504, and the FHA prohibit discrimination on the basis of disability, defined in the ADA as “a physical or mental impairment that substantially limits one or more major life activities of [an] individual; a record of such an impairment; or being regarded as having such an impairment.”4 Because the definition of “major life activity” is broad and includes activities such as “thinking, concentrating, sleeping and communicating,” your mental health issue will usually be considered a disability under these laws.5

Under the ADA, Section 504, and the FHA, a university may not exclude an otherwise qualified individual from a program, activity, or facility (such as a dorm or library) because that person has a disability.6 These laws also require that universities provide “reasonable accommodations” to students with disabilities that are designed to help them participate fully in university life. For more information on what constitutes a reasonable accommodation, see below(Source #1)

In addition, two laws—the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA)—protect your privacy, including the confidentiality of any disciplinary or medical records related to your disability. These laws limit the information school administrators may request from your mental health provider and usually prevent them from disclosing information related to your disability, or your academic or disciplinary record, without your permission.

What Kinds of Accommodations Are Reasonable?

The ADA and Section 504 require schools to provide students with disabilities with “reasonable accommodations.” A reasonable accommodation in the academic context is a “modification to . . . academic requirements [that is] necessary to ensure that such requirements do not discriminate or have the effect of discriminating, on the basis of [disability], against a qualified . . . applicant or student.”7 For instance, a student might need extra time to complete exams, permission to take a leave of absence, or access to assistive technology or transportation services.

Under the FHA, schools must also make reasonable accommodations to housing policies when they are necessary to provide equal access for students with disabilities.8 In this context, reasonable accommodations may include providing the student a private room or allowing the student to keep a service or emotional support animal in campus housing.

A school may refuse to provide an accommodation only if providing it would fundamentally alter the nature of its academic or residential program or would impose an undue burden on the school, which balances factors like the nature and cost of the proposed accommodation and the school’s resources.9

How and When Should I Request an Accommodation?

All schools that receive federal funding must designate a staff member or administrator as a disability services coordinator (DSC). When requesting an accommodation, the DSC and his/her office should be your first point of contact. The DSC can guide you through your school’s internal process for requesting accommodations, which may require you to disclose some information in writing related to your disability and the types of accommodations you need. You should not, however, be required to provide extensive medical documentation. Similarly, you should not be required to disclose your entire medical history or the content of sessions with a mental health provider. At most, the DSC should request a letter from your healthcare provider or counselor stating that you have a disability and explaining that disability’s relationship to your ability to function in college. The DSC should also serve as your liaison with professors, administrators, and other school officials in all matters related to your disability. If you are seeking accommodations in your dorm, it is also a good idea to speak with your school’s Dean of Students or residential advisors, who may be more familiar with the housing accommodations your school can provide.

You should request accommodations from your school’s DSC as soon as you think they are needed, regardless of whether it is the first day of your college career or the last week before graduation. A school is not expected to accommodate a need of which it is unaware. If your needs change, you can always ask that the DSC modify the accommodations provided or request additional accommodations(Source #2).

I Am Facing Discipline for Conduct Related to My Disability. What Should I Do?

A student with a disability should not be disciplined for the disability itself (for instance, a school may not discipline a student because that student complains of hallucinations). But schools may seek to discipline a student for behaviors that arise as a consequence of a disability if those behaviors violate a code of conduct or other disciplinary rules, so long as the school applies the rules in a non‐discriminatory manner. In other words, a student who hallucinates may be disciplined if these hallucinations cause him or her to disrupt a class, just as a non‐ disabled student would be disciplined for the same disruptive behavior (but note the discussion below about a school’s obligation to provide reasonable accommodations in the student disciplinary process). In addition, schools should not seek to discipline students who engage in or threaten to engage in self‐harming behaviors, which are often linked with mental illness.

If university personnel seek to discipline you for conduct related to your disability, they will most likely provide you with an opportunity to appeal their decision in writing or contest it in a hearing. Information about the various steps in the disciplinary process should be available on the school’s website. During this process, you should consider disclosing that you have a disability if you have not done so already. This will enable you to request a reasonable accommodation to the school’s discipline policies, such as a leave of absence rather than disciplinary action, or to present the disability as a mitigating circumstance. It may also be helpful to show that, with appropriate supports, you can prevent the disability‐related behavior from recurring. A letter from your mental health provider could help you do this. In general, the more evidence you have to demonstrate that the school is seeking to punish you for behavior related to your disability, the better the chances are that you may avoid disciplinary action.

If school administrators make use of information contained in your academic record to make a decision related to discipline, you have the right to request that such information be shown only to individuals with a “legitimate educational interest” in that information.10 In the case of a disciplinary determination, this might mean that members of the school’s judiciary committee or the Dean of Students can access relevant parts of your academic record, but others (including professors, other students, or your parents) have no right to do so without your express permission.

What Are My Rights Regarding Medical Leaves of Absence?

If you find yourself struggling with the academic or other demands of your educational program as a result of your disability, you may decide to take a medical leave of absence to focus on your recovery. Rarely, your school may require that you take a leave of absence if it decides you cannot safely remain on campus. In either situation, you retain the right to be treated fairly and without discrimination. You should consult your school’s polices regarding leaves of absence before making the decision to request such a leave(Source #3).

Voluntary Leave

Most schools permit students to take a voluntary leave of absence for mental health reasons. When deciding whether to take a voluntary leave of absence, you may wish to consult with your school’s counseling center or another mental health professional. The counseling center may be able to help you secure a formal leave of absence from the school.

If you choose to take a voluntary leave of absence, your school should not place any treatment‐related restrictions on your ability to return to campus, though they may ask you to wait until the beginning of the next quarter, semester, or academic year to resume taking classes. Students on voluntary leaves of absence should be permitted to attend campus events, visit friends on campus, and access campus facilities.

Involuntary Leave

The decision to impose an involuntary leave of absence on a student should only be made in extraordinary circumstances. Imposing a leave of absence is justified only if a student cannot safely remain at a university or meet its academic standards, and the risk cannot be reduced to an acceptable level with accommodations. Similarly, a student may only be barred from university housing if he/she cannot safely remain there, even with accommodations.

Schools use different procedures to make decisions concerning involuntary leave, but they must conduct an individualized assessment, based on objective evidence, that considers the nature, severity, and likelihood of the risk, and whether the risk can be reduced through reasonable accommodations.11 In conducting this inquiry, most schools will consult with or ask for an assessment by mental health professionals. In most cases, a student faced with an involuntary leave will be given basic procedural protections. For example, the school will typically notify the student or his/her representative of the action under consideration and may provide a written explanation of that action. The school will also usually give the student or his/her representative an opportunity to respond and explain why he/she should not be required to leave. In framing your response, it may be helpful to seek the advice of a psychiatrist or other mental health professional, who can provide an independent evaluation of your mental health and suggest ways to address the school’s safety concerns. If you are ultimately required to withdraw, your school should provide the same arrangements for withdrawing from classes and obtaining a tuition refund as it would for a student withdrawing for another reason (e.g., a physical injury related to an accident).

A school has the right to access limited medical information about your mental health status and disability when it is considering imposing a leave of absence. Your school may therefore request recent mental health records to determine whether you may safely remain on campus, and it may inquire into your current mental health condition. But your school may not request unlimited access to your health or medical records, and you may limit the release of confidential medical information to specific dates. You also have the right to review all records your school requests before access is granted(Source #4).

Conditions on Returning from Involuntary Leave

A school has the right to impose limited conditions on your ability to return, particularly in the case of an involuntary leave. Even so, a school may not impose more onerous requirements on students returning from a leave of absence for mental health reasons than on other students returning from other types of leaves.12 Your school cannot require that your mental illness be cured, but it is allowed to ask you to demonstrate that the risk that motivated your initial removal no longer exists or has been sufficiently mitigated. Some schools will request that you have your mental health provider send a report stating that you attended treatment and are ready to return to school. They may also request that you sign a behavioral contract, stipulating (for example) that you will abide by the terms of the university’s code of conduct, and in some circumstances may ask that you commit to taking certain steps to preserve your mental health. You have the right to decline this contract and/or negotiate its terms, though it is possible you will not be allowed to return without signing the contract. Ultimately, decisions about whether your mental health permits you to return to campus, including the determination that it is safe for you to return, should be made by a mental health professional rather than by the school administration.

My School Is Denying the Accommodations I Requested and/or Imposing Discriminatory Disciplinary Procedures. What Can I Do?

If your school is refusing to accommodate you, denying you access to certain parts of its academic or residential program, or subjecting you to discriminatory disciplinary procedures, you should first follow your school’s internal grievance or appeal process. Information about these processes should be available on the school’s website.

If that fails to resolve your issue—or you feel the process was itself discriminatory— you have the right to file a complaint with the Department of Education’s Office for Civil Rights (OCR). If OCR determines that your complaint has merit, it will take action against your school and require it to rectify the situation. Complaints must be filed within 180 days of the event you believe to have been discriminatory.

Before filing a complaint, it may be useful to seek legal advice. In addition to helping you draft your complaint, a lawyer will advise you on state and federal law applicable to your situation. Your lawyer can also help you decide whether to consider a lawsuit against the school.

Resources

If you have difficulty getting the accommodations you need from your school or need assistance requesting a reasonable accommodation, try contacting the National Alliance on Mental Illness, Active Minds or NAMI on Campus, your state Protection and Advocacy organization (P&A), or a local legal aid organization(Source#5).

If you believe your school has discriminated against you, you can file a complaint with the Department of Education’s Office for Civil Rights (OCR) at: https://www2.ed.gov/about/offices/list/ocr/complaintintro.html.

If you believe university administrators have made inappropriate use of your medical information, you can file a complaint at: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf (select the HIPAA option).

If you believe your right to privacy has been violated, you can file a complaint with the Department of Education, Family Compliance Office, at: http://familypolicy.ed.gov/sites/fpco.ed.gov/files/EComplaint%20form%20FERPA_052217.pdf.

1 See 42 U.S.C. § 12131(1)(A); 42 U.S.C. § 12181(7). Note that the ADA does not cover “religious organizations or entities controlled by religious organizations,” a category that may include some religiously affiliated colleges. 42 U.S.C. § 12187.
2 29 U.S.C. § 794(a) (“No otherwise qualified individual with a disability . . . shall, solely by reason of her or his disability, be excluded from participation in…any program receiving Federal financial assistance”). Universities that accept students benefitting from Pell Grants or other federal financial aid programs are considered to be “programs receiving federal financial assistance.”

3 42 U.S.C. §§ 3601 et seq.4 42 U.S.C. § 12102(1).
5 Id. at § 12102(2).

6 If you have been accepted to a university, you are considered to be “qualified” to attend. See, e.g., Resolution Letter to Spring Arbor University from the Office for Civil Rights, OCR Complaint No. 15‐10‐2098 at 10 (Dec. 16, 2010) (because the complainant had been accepted into the academic program and had not been subsequently disqualified as a result of academic or disciplinary factors, he remained a qualified individual).

7 34 C.F.R. § 104.44(a).
8 42 U.S.C. § 3604(f)(3)(B); see also 34 C.F.R. § 104.45(a) (university housing for students with disabilities must be “comparable, convenient and accessible . . . at the same cost as to others”).
9 42 U.S.C. § 12182(b)(2)(A)(iii); see also 34 C.F.R. § 104.44 (“requirements . . . essential to instruction pursued by each student [or] directly related to licensing requirements will not be regarded as discriminatory”).
10 20 U.S.C. § 1232g(b).
11 See 28 C.F.R. § 36.208(b).
12 See Resolution Letter to Spring Arbor University from the Office for Civil Rights, OCR Complaint No. 15‐10‐2098 at 10‐11 (Dec. 16, 2010).

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Focusing on Mental Health Policy Issues

The recent spate of high-profile mass shootings has inspired yet another “national conversation” about mental illness, with everyone agreeing that the country has a problem. Unfortunately, isolated instances of violence are how the subject typically ends up in the news cycle. But the more mundane social repercussions of mental illness, while perhaps not as headline-worthy, are pervasive and acutely felt nonetheless.

On any given day, one in five people in jail or prison has a severe mental illness. This means that people with serious mental illness are ten times more likely to inhabit a jail cell than a hospital bed. Besides contributing to jail and prison over-crowding, mentally ill people are especially vulnerable to victimization by fellow prisoners, spend more time in solitary confinement, and become suicidal behind bars at higher rates than non-mentally ill inmates. They also cost the correctional system considerably more than otherwise healthy prisoners.

The challenge facing prisons is just one consequence of decades of de-institutionalization policies. From a nationwide peak of around 560,000 psychiatric beds in 1955, the census has been whittled down to about 35,000 today — about half of what experts estimate is actually needed. In the absence of such beds, patients will continue to be warehoused behind bars, lie on emergency-room gurneys for days, and languish in nursing homes. One-third of the nations homeless will still be comprised of the untreated mentally ill, who are at far greater risk of being preyed upon than of harming someone else.

The lesson of downsizing state psychiatric facilities — no less powerful for being familiar — is that good intentions are not enough. Too many sick people are now caught in a pernicious cycle, rotating in and out of emergency rooms, crisis hospitalization, incarceration, homelessness, and back again. Its no wonder some of the strongest supporters of mental-health reform are police, district attorneys, corrections officials, and emergency-room physicians.

These problems afflict roughly 10 million Americans, or just over 4% of the population. Mainly diagnosed with schizophrenia, bipolar (manic-depressive illness), or major depression, such individuals are chronically or periodically unable to care for themselves or are suicidal. At times, they may be dangerous to the public. Relative to other psychiatric patients, those with severe mental illness are far more likely to need medication, intensive supervision, and even involuntary treatment at some point in their lives. But they arent getting the help they need, and the governments good intentions are often the very thing preventing their getting appropriate treatment.

To understand a key source of the problem, we should compare severe mental illness to “mental health.” The Centers for Disease Control describes mental health as a composite of “emotional well-being,” “psychological well-being,” and “social well-being.” According to government statistics, only about 17% of adults are considered to be in a state of optimal mental health — the rest, apparently, need some kind of professional assistance to achieve optimal “wellness.”

Sandwiched between mental health and severe mental illness is a clinical category called mental illness. One recent national survey estimates that nearly 18% of those individuals older than 18, or about 43.7 million people annually, are mentally ill — meaning they fulfill diagnostic criteria for any condition listed in psychiatrys official diagnostic handbook, ranging from attention deficit disorder to panic attacks to anorexia. The severity and chronicity of these conditions varies dramatically, with most conditions resolving on their own, while others are best served with time-limited psychiatric care; some may require hospitalization and long-term medication and therapy.

The distinction between mental health, mental illness, and severe mental illness is crucial, because it leads us to different clinical and policy prescriptions. The vague boundaries of “mental health” enabled a variety of advocates whose true agenda is grievance and social reform to claim that their concerns fell under its rubric, as historian of psychiatry Gerald Grob has observed. As a result, he writes, “persons with serious and persistent mental illnesses…[are] forced to compete, often unsuccessfully, with other groups that now [define] their needs in terms of mental health.”

The problem we have today is that the system is geared more toward mental health than severe mental illness. In fact, the federal governments lead agency on mental health, the Substance Abuse and Mental Health Services Administration, part of the Department of Health and Human Services, has explicitly stated this as its goal. Rather than focusing on reducing homelessness, hospitalization, or incarceration among people with serious mental illness, it concentrates federal and state efforts on delivering amorphous “behavioral health” to everyone else.

This is profoundly misguided. But it may not be surprising after a half-century of inept leadership, Medicaids financial incentives gone awry, and clashing ideas about the nature of the forces (psychological, biological, and social) that lead to psychopathology — and that, in turn, point toward the best possible therapeutic strategies. Ours is a problem-ridden system that could be markedly improved with strong political leadership.

We need a mental-illness system in which care for the sickest of the sick is a priority. If the federal government intends to take mental illness seriously, Congress and the next administration must be keenly responsive to the most vulnerable patients.

a troubled legacy

To understand what should be done, a review of the dynamics that led to the current state of disarray is in order. Four key elements are to blame.

The first emerged in the late 1950s, as officials emptied state hospitals of even the most debilitated patients without adequately planning for their continued treatment. The second contributing factor came with the creation of Medicare and Medicaid in 1965, as new policies limited access to community hospital beds. The third factor is the growing complexity of competing ideas about the causal and remedial factors involved in mental illness, and the resulting complications in policymaking. And fourth is the disproportionate leverage wielded by anti-psychiatry forces in an era of victim politics. This last influence builds upon a longstanding debate regarding the civil liberties of individuals whose capacity to manage their freedom is badly compromised by dysfunction in their brains.

Until half a century ago, the care of people with mental illness had been the responsibility of the states. This changed in 1963 when President John Kennedy ushered in the era of federal support by championing the Mental Retardation Facilities and Community Mental Health Centers Construction Act. The new law mandated the creation of a user-friendly archipelago of 1,500 federally funded community clinics nationwide to supplant the large state asylums and to allow patients to live in their communities while receiving treatment. “When carried out,” Kennedy said of the act, “reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.” The presidents interest was personal, stemming from the tragic experience of his sister Rosemary, who was born with mild mental retardation and eventually underwent a frontal lobotomy for schizophrenia.

The nation was primed for the change the president sought. Two decades earlier, Life magazine had run “Bedlam 1946,” a searing photo-journalistic exposé of Pennsylvanias Philadelphia State Hospital at Byberry and Ohios Cleveland State Hospital. Books like Albert Deutschs The Shame of the States and popular entertainments like the movie The Snake Pit, both of which appeared in 1948, exposed shocking conditions of filth and abuse in state facilities.

State-initiated efforts improved the conditions at state hospitals in the mid-1950s, and, thanks to the availability of Thorazine, an anti-psychotic medication introduced in 1954, some patients were successfully moved into the community. But with Kennedys community centers under construction in the mid-60s, the campaign to empty out state facilities took on new urgency. Some patients did well upon discharge, but the sickest were caught in a revolving door: Without closely supervised treatment, many failed in the community and went back to whatever institutions were left. Others ended up in a kind of limbo, neither institutionalized nor embedded in a community.

The state-hospital population was further eroded by legal decisions issued in the 1960s and 70s that made it hard for judges to order necessary treatments for patients who were wildly psychotic or immobilized by depression but were refusing care. A convergence of strange bedfellows — fiscally conservative state officials, progressive reformers, former patients, and politically liberal civil-rights lawyers — formed a strong advocacy coalition for deinstitutionalization policies.

In 1965, as the exodus from state hospitals was well underway, Congress passed legislation establishing Medicare and Medicaid. The new law included a provision that unwittingly planted the seeds of the current shortage of public hospital beds. It did so by prohibiting Medicaid from paying for care delivered to patients between the ages of 22 and 64 if that care was provided in an “institution for the treatment of mental diseases,” or IMD. An IMD is defined as a treatment facility with more than 16 beds of which at least half are dedicated to mentally ill patients. The so-called “IMD exclusion” was intended to spur momentum for community treatment by barring the doors to the asylum, which Congress saw more as a warehouse than a treatment facility anyway.

The IMD exclusion did not affect general hospitals and nursing homes. They remained eligible for Medicaid reimbursement. Thus, states had a strong incentive to shift patients from state psychiatric hospitals to Medicaid-eligible institutions, even if those venues were more costly or less effective. With fewer and fewer psychiatric beds available, emergency rooms became holding areas for those who needed inpatient treatment; others spilled out onto the streets and into run-down, questionable boarding houses and jails.

It did not have to be this way, which is clear given how well Medicaid has worked for people with intellectual and developmental disabilities. They, too, could be found living in state hospitals in the mid-20th century, but Medicaid treated them differently. If they still needed residential or intermediate care, Medicaid reimbursed the state for their stay. Then when these patients were discharged into the community, Medicaid covered wraparound services such as vocational assessments, family counseling, medication management, and transportation. Today, these services are provided under a “community options” waiver that “swaps” a Medicaid-covered inpatient bed for a similarly covered, community-based slot.

Unfortunately, no such waiver exists for individuals with serious mental illness, because the IMD exclusion prohibits federal coverage for adults. The ensuing problem of fragmented services is formidable. Between orchestrating disability entitlements, housing, and treatment of medical problems, case management can require organizational skills that are beyond most of us, let alone people who are also overwhelmed by depression, difficulty concentrating, or jumbled thoughts. Even when there are quality services covered by Medicaid, such as nursing-home placement, funds are not always tailored to young or middle-aged able-bodied psychiatric patients. Meanwhile, entire subpopulations of poor, young men are not covered at all in many states.

Thus, as Harold Pollack of the School of Social Service Administration at the University of Chicago explains, “Deinstitutionalization has, on the whole, worked well for the intellectually disabled because they and their supporters could crank the political valves required to make it work. Equally worthy claimants who lacked the same political muscle or public embrace fared much worse. Thats one key lesson of the deinstitutionalization fight.”

The next major step toward our current dysfunctional approach to treating mental illness seems at first glance to have begun with a semantic, rather than a policy, decision. When Jimmy and Rosalynn Carter entered the White House in 1977, they already had an interest in mental illness. President Carter wasted no time in establishing the Commission on Mental Health. According to historian of psychiatry Gerald Grob, “the [commissions] decision in 1977 to use mental health rather than mental illness…was based on the application of a public health model that emphasized the role of the environment, social services, and prevention rather than the traditional psychiatric focus on the diagnosis and treatment of severe and persistent mental disorders.”

The dubious notion that external influences, such as stress, social problems, traumatic experiences, and even coercive psychiatric care itself are the primary causes of severe mental illness still thrives today in influential quarters, as we will see.

the recovery model

A quarter-century after the Carter commission, in 2002, President George W. Bush revisited the problem of public mental-health care by appointing a commission of his own, called the New Freedom Commission on Mental Health. The commission was charged with conducting a “comprehensive study” of the existing system and advising President Bush on improvements. The 2003 report issued some positive suggestions regarding, for example, the need for an increased number of psychiatric beds and better programs to help disabled patients participate in the workforce. But the Bush commission, like Carters before it, elided the distinction between mental health and mental illness and failed to grapple with approaches to patients with severe mental illness who refused to take medication and had a potential for violence.

Instead, the Bush commission promoted an overly optimistic treatment philosophy that came to be called the “recovery model.” It held that with sufficient therapy, housing options, and employment programs, patients with schizophrenia or manic-depressive illness would be able to take charge of their lives. To be sure, a lot of patients are indeed able to do this, especially young people with recent onset of illness. But the recovery models unrealistic one-size-fits-all approach ignored the toughest cases, which often require heavy doses of paternalism because the patients dont acknowledge their own illness — a symptom of being psychotic in and of itself, in many instances. In an un-medicated state, an individuals symptoms remain unabated, behavior remains menacing or erratic, and the risk of violence, particularly if alcohol or cocaine is involved, is increased.

The recovery agenda was inspired by the patients rights movement of the 1960s. This campaign for enlightened care, which included better quality of treatment, collaboration with physicians, and assurance of privacy of health information, was a sensible reaction to the heavy strain of paternalism that marked the medical field at one time. Psychiatry, in particular, attracted the animus of patients rights activists; after all, it is a field whose very nature requires professionals to make fraught judgments about the normal or abnormal thoughts, behaviors, and identities of their patients. Whats more, for better or worse, psychiatrists may impose tacit or actual control over their patients.

Consequently, the psychiatric patients rights movement took on a radical tenor. Spurred by a 1960s ethos of social justice, activists saw themselves as a class of social dissidents and psychiatry as an agent of social control. The Insane Liberation Front was founded in 1970 in Portland, Oregon. In 1971, the Mental Patients Liberation Project and the Mental Patients Liberation Front appeared in New York and Boston, respectively. The next year, former patients in San Francisco organized the Network Against Psychiatric Assault and the Madness News Network. They have championed the rights of severely ill patients to refuse treatment, representing the expressed wishes of their clients (patients) even when they are delusional, and they have campaigned against involuntary commitment, as well as electroshock therapy, which is one of the safest and most effective treatments for severe depression. So what do these activists prescribe as an alternative? Political empowerment.

By the 1980s, the movement had spawned a new identity known as the “consumer-survivor,” which persists to this day. In this iteration of the psychiatric patients rights movement, dynamics such as identity politics (with the mentally ill playing the role of minority population), disability status, and a sense of entitlement to public services play a larger role than they did in the 60s and 70s. Compared to their earlier counterparts who saw themselves as dissenters, not patients, these consumer-survivors actually do see themselves as ill. “Consumer” is the politically correct word for patient, and “survivor” refers to one who has survived psychiatric care. The most vocal anti-psychiatry consumer-survivor groups are the National Empowerment Center near Boston and the Nation Mental Health Consumers Self-Help Clearinghouse in southeastern Pennsylvania. Funded in part by the federal government and state mental-health agencies, these groups lobby against involuntary treatment and electroconvulsive therapy, and they discourage patients from taking medication.

As with the anti-vaccine movement, such trends always have the capacity to be damaging, but vocal, misguided fringe groups are not a rare occurrence in the United States, especially when it comes to health care. The difference is that these groups have the financial support of the U.S. government; thus, taxpayer money is being used to make things worse.

failing the most vulnerable

The Substance Abuse and Mental Health Services Administration, an agency within the Department of Health and Human Services known by its acronym, SAMHSA, bolsters the consumer-survivor agenda ideologically, programmatically, and financially. It is a striking example of government working at cross-purposes to the best interests of its most desperate constituents.

The agencys entire budget for mental health is around $1.1 billion. (The remainder of its full budget of $3.6 billion is earmarked for prevention and treatment of substance abuse.) Of the $1.1 billion mental-health budget, $482 million goes into block grants to the states for mental-health services, and the remainder goes to other programs for adults and children, the homeless, and Protection and Advocacy (described further below). Given that federal mental-health expenditures total $130 billion annually, mostly in the form of Medicaid, the SAMHSA budget seems modest. But the agency manages to leverage its funds in ways that not only shortchange but actively undermine the welfare of the sickest patients.

For one thing, SAMHSA claims to receive much of its policy input from groups of consumers that it occasionally convenes. These people may have psychiatric problems but generally need only low-levels of support, and many do not take medication. They do not represent the most impaired patients — the ones who are languishing in jails, in emergency rooms, or on the streets. Such people are too lost in their psychosis to show up for a focus group or to embrace the “recovery agenda.” Indeed, approximately half of all untreated people with a psychotic disorder do not acknowledge they are ill, which is itself a neurological condition called anosognosia.

There is a vital role for benign paternalism toward this highly vulnerable set of patients, but the culture of mental health as practiced by SAMHSA effectively denies their existence, let alone their needs. To be sure, the psychiatric profession was once dismissive and too pessimistic about many people who were indeed capable of greater independence, but there is no denying that now a subset of the mentally ill needs much more oversight and, at times, even benign coercion.

SAMHSAs worldview is reflected in the nature of its discretionary grants and programs, some of which completely undermine the best interests of patients with severe mental illness. For example, the agency is a major funder of groups that are overtly opposed to medically accepted psychiatric care. The National Empowerment Center, based in Lawrence, Massachusetts, is one beneficiary of SAMHSA funds. Its mission is “to carry a message of recovery, empowerment, hope and healing to people with lived experience with mental health issues, trauma, and/or extreme states.” The NECs Chief Operating Officer has been a long-time critic of the use of psychiatric medications.

The Washington, D.C.-based National Coalition for Mental Health Recovery is a trade group for recipients of agency largesse. Its mission is to ensure “consumer/survivors have a major voice in…policies at the state and national levels.” The coalition and its smaller, composite organizations oppose the type of services — civil commitment, increased hospital capacity — that target the most impaired. Another example is the Alternatives Conference, which is funded by SAMHSA each year. Among other things, attendees with mental illness are taught how to go off their psychiatric medications. In 2011, SAMHSA gave one of its annual “Voice Awards” to an activist who believes that “[p]sychiatry is not medical because it is not scientific. It does not diagnose or treat actual conditions. It is complete fiction. Voodoo witch doctors have a better cure rate.”

Apart from awarding grants, SAMHSA runs its own programs, perhaps the most painfully misguided of which is the Protection and Advocacy program. Established by Congress, the original, benign intent of the Protection and Advocacy for Individuals with Mental Illness Act of 1986, or P&A, was to investigate allegations of patient abuse, neglect, and rights violations in hospital wards or in residential facilities. Mission creep soon set in, however. As Rael Jean Isaac and Virginia Armat documented in their 1990 book Madness in the Streets, P&A quickly devolved into “playgrounds for anti-psychiatric activists.”

The P&A program operates with $39 million, distributed among the states. The local P&A agencies routinely flout congressional intent by lobbying state legislatures against adopting sensible treatment policies and against strengthening their civil-commitment laws. Making matters worse, they do so at the expense of conducting investigations into the mistreatment of patients. Amanda Peters of South Texas College of Law has closely examined P&A programs, and has found that their lawyers and personnel are so preoccupied with fighting civil-commitment policies and trying to liberate undeniably psychotic patients from hospitals that glaring violations of abuse and neglect go unchecked.

Many P&A lawyers are against hospitalization at any cost, to sometimes tragic result. Consider the story of Joe Bruce of Caratunk, Maine, whose psychotic son is now a murderer because of Maines P&A agency. In 2006, 24-year-old William Bruce was a patient at Riverview Psychiatric Center, where he had been committed after assaulting his father. His parents were afraid of their son and begged the hospital to medicate him with the antipsychotic that had previously quelled his paranoia and aggression. Williams psychiatrists, who had observed him for weeks as an inpatient, fought against Williams pleas for release because he remained paranoid and agitated. Nonetheless, the P&A legal advocates insisted that William was “competent” for discharge and openly coached him — as any lawyer would his client — on how to placate the doctors so theyd let him go. William and his lawyers somehow prevailed over his doctors and parents objections, and Riverview discharged him. Two months later, he killed his mother with a hatchet. The Bruce familys story is one of the most dramatic, but by no means one of the only, examples of the reckless “liberation” of dangerous or debilitated patients at the hands of a P&A agency.

For decades, HHS and SAMHSA have mismanaged the mental-illness resources of the federal government, focusing increasingly on “recovery agendas” instead of on the severely mentally ill. Our most vulnerable citizens are slipping through the cracks. It is long past time for a better, more serious mental-illness agenda.

prescriptions for mental health

Like Presidents Kennedy, Carter, and Bush, the next president could do a great deal to improve the nations mental-health system. The most radical, most effective approach might be to propose legislation to abolish SAMHSA altogether, holding on to those pieces worth saving, such as the collection of statistics, by assigning them to the Centers for Disease Control and Prevention, the National Institutes of Mental Health, or other appropriate government agencies. Charges of abuse (such as excessive use of physical restraints) and neglect could be handled by the Department of Justice. The block grants could be distributed by the Human Resources and Services Administration.

Whether or not SAMHSA is shut down, it is imperative that the next director of federal mental-health initiatives, perhaps working directly out of HHS, be a psychiatrist or psychologist with extensive experience treating and managing systems that target severely and persistently ill patients. (Currently, SAMHSA does not employ a single psychiatrist among its staff of 570, let alone in a leadership or key advisory position.) In 2013, an experienced psychiatrist joined as medical director, but she quit two years later because of what she described as “an open hostility toward psychiatric medicine by those at the helm of the agency. The concept of mental disorders as diseases was rejected.”

A SAMHSA leader who understands the clinical needs of the sickest patients and prioritizes these demands — and who is backed by the secretary of HHS — would instinctively make profound changes. He would cease grant-making to advocacy organizations whose members deliberately undermine the validity of professional help and medications and those who lobby against commitment policies at the state and federal levels. The medical-director slot would be filled by a psychiatrist who endorses mainstream views on the value of medication, the importance of promoting tested programs over a feel-good “wellness” and “empowerment” agenda, and the need for inpatient services. An enlightened agency leader would invest in research aimed at the sickest patients and accept the notion that paternalistic strategies are legitimate and necessary for some of them. Finally, such a leader would contain P&As mission creep and ensure that program funds go solely to the investigation of abuse and neglect, as was the programs original congressional mandate.

Medicaid needs improvements, too. To address the bed shortage, for example, Congress could base eligibility for Medicaid reimbursement solely upon an individuals need for care, rather than upon the location in which it is delivered. Another option is raising the limit on the number of psychiatric beds for which Medicaid will pay, to allow larger facilities already specializing in mental illness to fall outside of the scope of the IMD exclusion. Alternatively, more states could be allowed to use Medicaid Section 1115 waivers — as some already are — to draw down reimbursement for services provided in IMDs. Not surprisingly, some advocates argue against these ideas, concerned that they will re-open the door to institutionalization.

Some policymakers suggest simply expanding the number of psychiatric beds in general hospitals, but economies of scale (a benefit of larger psychiatric institutions) would be lost. Nor would general hospital units be able to reproduce the therapeutic milieu that characterizes a quality inpatient unit. Whats more, general hospitals are reluctant to admit the sickest psychiatric patients, who are often disruptive, sometimes violent, and difficult to treat and require additional nursing.

To inform lawmakers debating this complicated issue, the federal Centers for Medicare & Medicaid Services is funding the Medicaid Emergency Psychiatric Demonstration, mandated by the Affordable Care Act. Eleven states and the District of Columbia are using Medicaid funds to pay for inpatient emergency psychiatric care in psychiatric hospitals for patients aged 21 to 65 without the 16-bed restriction. By focusing on psychiatric emergencies, the three-year demonstration, which began in 2012, also attempts to explore a potential remedy to alleviate burdens placed on general-hospital emergency rooms by psychiatric patients for whom no bed is available.

Medicaid administrators also need more flexibility to cover the unique kinds of help, beyond standard fee-for-service visits for medication and therapy, which enable mentally ill individuals to thrive in the community. These may include Fountain House-type clubhouses (private, non-profit community centers that provide job training, socialization opportunities, and computer access) and various other types of assistance with staying in school or holding down a job. Assertive Community Treatment teams — intensive 24-hour outpatient supervision by clinical teams linking patients to needed medical and social services — would save money and reduce days in the hospital, but they currently have no reliable source of public funding. The same is true of Forensic Assertive Community Treatment, an adaptation of the ACT model that has been shown to reduce criminal recidivism through criminal-justice collaborations.

The good news is that there is active experimentation. In addition to emergency-room demonstrations now underway, Congress authorized a $1.1 billion, eight-state demonstration program in 2014 for a new type of community-based clinic focused on behavioral health. The Excellence in Mental Health Act, spearheaded by Democratic senator Debbie Stabenow of Michigan and signed into law in April 2014, created criteria for facilities to become “certified community behavioral health clinics.” (In 2016, Stabenow and Republican senator Roy Blunt of Missouri introduced a bill expanding the law to provide additional funding for 24 states to launch a demonstration program to tackle payment reform in behavioral health.)

These clinics are required to provide a wide range of services, such as the kinds provided by ACT teams. States will apply to develop a prospective-payment arrangement with clinics to cover all necessary treatment, a so-called flexible funding stream that supplants service-by-service reimbursement. After two years, these pilot programs may be replicated nationwide. Ultimately, certified clinics will be eligible for Medicaid reimbursement as the sole source of payment for patients.

Flexible funding streams will figure prominently in approaches to treating young people, generally in their late teens and early 20s, who are in the early stages of schizophrenia. Psychiatrists now know that the amount of time between the onset of psychotic symptoms and the beginning of treatment is very important in determining response to care. An especially promising study, Recovery After an Initial Schizophrenia Episode, just completed its first wave of trials in the fall of 2015 and attests to the value of aggressive intervention for first-episode psychosis. These data, derived from research funded by the National Institutes of Mental Health, show that a tightly coordinated team approach, including the patient, professionals, and family members, led to greater symptom control and more involvement in work and school than experienced by patients receiving treatment as usual. The team provides medication (at the lowest dose necessary), therapy for coping with stress, education for loved ones about the disease, supported employment or education for the patient once symptoms are under control, and personalized case management. Currently, these teams are in the research stage, but when they become standard practice, payment systems will need to accommodate wrap-around services en bloc instead of traditional fee-for-service arrangements.

Some additional relief has come with the Affordable Care Act of 2010, which included a provision to expand Medicaid. Currently, 31 states plus the District of Columbia have opted in to the Medicaid expansion, which means the federal government — rather than those states — will pay for the great bulk of the outpatient and hospital treatment of newly qualified low-income people. This has the potential to help individuals who are mentally ill or in the early stages of serious illness, especially young men, who are not yet designated disabled. (The IMD exclusion remains in place.) The laws requirement that young adults up to age 26 be able to stay on their parents insurance plans is also helpful in this regard, as it preserves access to psychiatric care right at the moment some will first be developing psychosis.

These encouraging developments are tempered, unfortunately, by a looming crisis in public-sector psychiatry, especially in inner-city and rural areas and especially for patients on Medicaid. While the number of all physicians in the United States rose by 45% from 1995 to today, the number of psychiatrists increased by only 12% — and over half are aged 55 or older and will soon retire. Medical students choosing the field of psychiatry are fewer in number than in decades past, in part because many graduates face huge debt burdens, and psychiatry is among the lowest-paid of the medical specialties — especially in clinics and public hospitals where psychiatrists are needed the most.

benign paternalism versus jail time

Even if these reforms were successfully undertaken and the mentally ill were granted broader access to care, however, it would not be enough to ensure that the sickest individuals received the care they needed. One of the hallmarks of severe mental illness is that patients often deny that anything is wrong with them. So for many patients with severe mental illness, a strong dose of paternalism is often required to keep them from descending further into psychosis, self-neglect, and disruptive behavior, which can range from public disturbance or destruction of property to outright violence.

Assisted outpatient treatment, or AOT, a cost-saving and effective form of civil-court-ordered community treatment, is aimed at individuals who have a well-established pattern of falling into a spiral of self-neglect, self-harm, or dangerousness when off medication. AOT allows judges to order these individuals into mandated and monitored treatment while they continue to live in the community. In some states, violation of the court-ordered conditions can result in the individual being hospitalized for further treatment. According to a review of studies by the Virginia-based Treatment Advocacy Center, AOT has reliably reduced homelessness, re-arrest, incarceration, hospitalization, and suicide by half to 74%, thereby cutting long-term health-care costs in half.

The main problem with AOT is that it is too rarely used. Forty-five states permit the use of AOT, also called “outpatient commitment,” but, due to a lack of funding and unfamiliarity with the AOT process or philosophy (which is constantly denounced by activist “consumers” in state houses), it is not applied as robustly as it should be.

In addition to AOT, which is a civil remedy, entities known as Mental Health Courts exist for those charged with criminal offenses. These courts embrace a therapeutic rather than a punitive approach, but use the power of the court to enforce ordered treatment. Defendants who agree to participate receive a treatment plan and other community-supervision conditions. Those who adhere to their treatment plan for the agreed-upon period of time see either their cases dismissed or their sentences greatly reduced. If the defendant does not comply with the conditions of the court, or decides to leave the program, his case returns to the original criminal calendar where prosecution proceeds as normal.

As a rule, most Mental Health Courts use a variety of intermediate sanctions in response to non-compliance before ending a defendants participation. At present, there is only a modest number of courts, but a 2012 Urban Institute evaluation yielded promising results: Participants in two New York City Mental Health Courts were significantly less likely to re-offend than similar offenders whose cases were handled in the traditional court system.

Law enforcement has a large role to play as well. Increasingly, emergency 911 calls for “mental disturbance” are being met by law-enforcement officials who have received crisis intervention training, or CIT. Not only do they learn how to defuse tense, potentially violent situations, but police are also taught to distinguish criminal acts from erratic behaviors due to psychosis. The first CIT program was established in Memphis in 1988, after a police officer shot a man with a serious mental illness. The program came to be known as the “Memphis Model,” and it is now a popular, 40-hour curriculum, developed in collaboration with local academics, family members of ill individuals, and the Memphis police department. It teaches police how to respond safely to a person in crisis, and includes information about the local mental-health system and laws, and about how to recognize mental illness and link people with appropriate treatment, as well as guidelines for interacting with disturbed people who are extremely agitated or aggressive. CIT can reduce arrests, injuries to police, and the need for SWAT intervention. Unfortunately, however, fewer than 20% of law-enforcement agencies train their officers, according to the National Alliance for the Mentally Ill, an advocacy group representing concerned family members.

Finally, individuals who are dangerous to others, suicidal, or unable to care for themselves may need to be hospitalized, regardless of their cooperation. Coerced care has long been a fraught issue. It pits an individuals liberty against societys safety. It also creates a tension between an ill persons “freedom” to act afoul of his own best interests and his potential to benefit from therapeutic intervention. Each case requires courts and lawyers to balance these interests as fairly and delicately as possible. The majority of states have a “grave disability” standard, an explicit and broad designation that focuses on a persons ability to feed, clothe, and protect himself. But the freedom to be psychotic and endangered is not a meaningful freedom at all. More states should adopt the “need for treatment” standard. This approach, which is in effect in about half the states, allows a court to intervene in a crisis. These standards are particularly relevant for individuals who lack insight into their illnesses.

These approaches — AOT, Mental Health Courts, crisis-trained law enforcement, and sensible commitment laws — can help divert mentally ill people from the correctional system. Though states determine their own investments in these options, the federal government could incentivize their use through extra resources or tie block-grant funding to the existence and smooth operation of AOT laws, Mental Health Courts, and need-for-treatment statutes.

the politics of mental-illness reform

Some of these solutions are currently under consideration on Capitol Hill, and constructive changes may be afoot. The furthest-reaching of the proposed mental-health bills introduced in the 114th Congress is the bipartisan Helping Families in Mental Health Crisis Act of 2015, championed by Pennsylvania congressman Tim Murphy, a child psychologist, and Texas congresswoman Eddie Bernice Johnson, a former psychiatric nurse. The cornerstone of the bill is new executive leadership in the form of an assistant secretary for Mental Health and Substance Abuse; this individual would be appointed by the secretary of HHS and subject to Senate confirmation. Funding and authority over SAMHSA would be brought under the assistant secretary who would be required to focus on both severe mental illness — thereby ensuring that adequate resources are targeted at reducing homelessness, arrest, incarceration, hospitalization, suicide, and violence among people with untreated illness — and coordinating the federal governments larger response.

The Murphy-Johnson bill would also rein in the Protection and Advocacy program, mandating an exclusive focus on safeguarding patients rights to be free from abuse and neglect. It also forbids P&A offices from lobbying federal, state, or local governmental entities and prohibits their efforts to secure discharge of patients “with a serious mental illness who [lack] insight into their condition on refusing medical treatment.” In addition, the bill encourages states to develop assisted outpatient treatment capacity and provides a financial bonus when they set up such programs. Murphy-Johnson also clarifies mental-health information privacy standards under the long-contested Health Insurance Portability and Accountability Act, known as “HIPAA,” so that medical personnel can communicate in detail with patients families in emergency situations.

Further, the legislation mandates that Medicaid cover inpatient care, no matter a facilitys bed count, as long as that facility or hospital has an average length of stay of fewer than 30 days. It also allows a Medicaid patient to visit more than one health-care provider in a given day, a boon for coordinated care. Notably, Murphy-Johnson increases the demonstration authority regarding “certified community behavioral health clinics” from eight states to 10 states and lengthens the time frame from two years to four years. The legislation also expands training and educational opportunities to ensure a sufficient number of providers.

The Murphy-Johnson bill has garnered considerable bipartisan support, and a similar companion bill has been introduced in the Senate, co-sponsored by Senators Chris Murphy and Bill Cassidy. But the legislation has met resistance on several fronts. The first stumbling blocks are basic legislative barriers such as the anticipated cost of the bill, crowded committee and floor schedules, and the fact that the bill falls into several different committee jurisdictions. As of mid-February, the Murphy-Johnson bill was wending its way through the House, having been marked up by the Health Subcommittee of the Energy and Commerce Committee.

Second, advocacy groups that receive funding from SAMHSA are protesting because their financial lifeblood is being threatened. More broadly, the mental-health consumer lobby fears that the bills provisions to increase bed space, strengthen commitment laws, and restrict the advocacy system will effectively send patients back to the asylum. According to the National Coalition for Mental Health Recovery — the trade organization representing SAMHSA-funded anti-psychiatry groups — the Murphy-Johnson bill “will set back community mental health care and undermine much of what our movement has worked so hard to achieve.”

Third, despite broad bipartisan support — 185 co-sponsors as of this writing — a cohort of Democrats has lined up against Murphy-Johnson. In a letter to the chairmen of the House Energy and Commerce Committee, the lawmakers expressed their “strong” opposition to elements of the bill that, they claim, “would restrict patients civil rights.” They refer specifically to the privacy-rule clarification (which supposedly “discriminates” against people with mental illness because no other medical conditions are singled out for special privacy considerations). The opponents decry AOT as being too restrictive because it targets patients who are not in immediate danger — the strict commitment standard they endorse — rather than merely at great risk of harm to self or others when untreated. They also reject the proposed limits on the activities of the Protection and Advocacy agencies.

Fourth, the recent, high-profile shootings in Roanoke, Virginia, and Roseburg, Oregon, have jeopardized prospects for mental-health reform. The incidents re-ignited the simmering tension between political parties as to whether such violence is more aptly attributable to the availability of high-powered guns or to the broken mental-health system, whose many fault lines allow ill people who are armed to slip into classrooms, movie theaters, and college campuses. This has resulted in a stalemate: Democrats refuse to move on mental-health legislation because Republicans refuse to pass gun-control legislation.

Some have tried to find common ground, though. Last fall, Republican senator John Cornyn promoted his NRA-endorsed Mental Health and Safe Communities Act of 2015, which tried to achieve consensus by revising the background-check system to help keep guns out of the hands of the mentally ill. But the measure falls far short of what Democrats have labeled “common-sense gun-control policies,” and so the legislation is likely to go nowhere. More encouraging, Democratic senator Al Franken’s measure that provides crisis-intervention training, funding for mental-health courts, veterans-treatment courts, and training for state and federal law-enforcement officers was approved by the Senate. And the omnibus bill passed last December provides funding for assisted outpatient treatment programs, the first time Congress has fully funded these programs. (Notably, separate grants for the same kind of AOT programs remain a major stumbling block in the debate over Representative Tim Murphys mental-health legislation in the House.) Finally, in early January, President Obama announced $500 million for expanding access to mental-health treatment as part of a series of executive actions aimed at curbing gun violence, but did not elaborate on how it would be spent.

treating the american psychosis

The right reforms can reduce the suffering of people with serious mental illness — and can protect them and improve their quality of life. That prescription entails forging better connections between institutions, and providing more quality care and community support and more psychiatric beds. We should not be afraid of creating benign asylums, especially residential psychiatric entities — ideally situated in rural areas so that patients can tend to animals and farms — that are true to the spirit of asylum: places of respite and safety. We should practice humane paternalism when needed.

This last point poses the greatest challenge to creating a system that is fully responsive to the needs of the sickest patients — that small fraction of people with severe mental illness who often require containment or intensive supervision against their will for brief periods of time and sometimes for long stretches. Some cast such intervention as an inexcusable encroachment on personal freedom. But when a persons thinking is warped by hallucination or delusion, he is not able to exercise meaningful freedom and might even endanger himself or others. The very point of involuntary intervention is to improve or restore the patients power of self-determination. Failure to recognize the need for this kind of action amounts to a refusal to face clinical reality.

What is the treatment for this American Psychosis, as it has been called? In the short term, we need more evidence that paternalistic strategies can be used humanely to produce positive results. The more effective they are, the more receptive localities will become to their use. Creating tighter community safety nets and opening up more beds will make these intrusive tactics less necessary in the first place, but the need will probably never disappear — precisely because a common feature of chronic psychosis is a lack of insight into one’s own impairment. Hopefully, over the long term, we might be able to narrow the pipeline of pathology by intervening when early signs of illness appear.

We must get rid of the distractions. We should not use government largesse to bolster opponents of benign paternalism. And we must not pit guns against patients. These are separate issues, each worthy of serious attention. Mental-health reform needs all the champions it can get. Strong political leadership could make a world of difference.

Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute.

E. Fuller Torrey is a psychiatrist and founder of the Treatment Advocacy Center, a non-profit working to eliminate barriers to treatment for people with severe mental illnesses.

Facing: Tragedy in Las Vegas at Mandalay Bay

Griffin Ambitions Ltd.  joins the rest of our nation in a collective state of disbelief and heartache as we learn the details of the shooting massacre that took place last night at a music festival in Las Vegas.
So many innocent lives were taken in this heinous crime. We extend our deepest sympathies to the families, loved ones, friends and communities of the victims who were injured or perished during this tragedy. You don’t need to personally know a victim or live in Las Vegas to feel the impact of this horrific event. With the relentless media coverage, it is understandable that any of us might feel emotionally connected to the events.
In the aftermath of a mass shooting tragedy, it’s normal to feel sadness, anxiety, fear, anger or any mix of these emotions. We encourage people to reach out to family, friends or counselors to express their feelings and explore effective and healthy ways to cope with their emotions. In the next few days and weeks, it will be important to look out for each other – be particularly aware of warning signs that someone is feeling hopeless or acute distress. The signs could include withdrawing and isolating oneself, not sleeping or sleeping all the time, increased use of drugs or alcohol and talking about death or dying.
If you or someone you know is experiencing signs of distress, please reach out to a mental health professional or get anonymous, free support by texting START to Crisis Text Line at 741-741 or by contacting the National Lifeline at 1-800-273-8255 (TALK).
At a time like this, the simple things will help – don’t hold feelings in, talk to friends, family and loved ones. Turn off the TV, computer and phone. Get up and get out – tragedies can weigh so heavily on us that it makes it hard to move. Take a walk, go to the gym, run errands, spend time with friends, volunteer to help. And lastly, everyone should take care of themselves and those around them – physical health and emotional connectedness can go a long way toward making you feel like yourself again.
The Griffin Ambitions family of mental health priorities shall continue to embrace the community ideals that make humanity marvelous – connectedness, inclusion, diversity, acceptance, and compassion – it is our hope that these ideals provide the template for healing. Love is louder than violence, hate and pain.

Be well,

JMG

 

Why the NAMI + Google mashup is not the best

Why our Director Wouldn’t Take Google’s New Depression Test


At the end of August, Google decided to make available directly on its site (through a “knowledge panel”) the ability to take a depression screening quiz. We know a thing or two about online depression screening quizzes, because back in 1996 I put one of the first interactive depression screening quizzes online, long before Google even existed.

Here’s the thing… Depression screening tests — like the PHQ-9 that Google is now offering on its website — are super helpful tools to give a person a little more insight into the possibility of having a serious mental illness. 

What’s NAMI Doing Here?

I guess to make people feel better about taking a quiz that’s been available online for more than a decade, Google partnered with a non-profit that works in the area of mental illness, the National Alliance on Mental Illness (NAMI).

This is no dig on NAMI, but NAMI is not a scientific organization, nor does it have much to do with the PHQ-9. It is an organization that does great, amazing work from a family perspective of mental illness. But why only NAMI specifically? Why didn’t Google reach out to more than just one non-profit in mental illness to contribute to this effort?

There are literally hundreds of non-profits dedicated to ending the stigma of mental illness, and many who have done really great work in the past few years. For instance, Bring Change to Mind has really changed the modern conversation, in my mind, about mental illness. And Mental Health America Chapters and the Mental Illness Policy Org. has also worked very hard in this area of education and helping to reduce the stigma of mental illness. And that’s to name just two out of hundreds.

But only NAMI was chosen to help with Google’s effort, which seems a little unfair to me.

The rise in student mental health problems – ‘I thought my tutor would say: deal with it’

Students starting university face different pressures from earlier generations.
What are the potential troubles and how can young people be prepared?

It was at 3am that film student Nicola Gee finally managed to confess, in an anonymous text to Samaritans, how depressed she had become at university. “By then, I felt isolated and shut off from my friends. I had put myself under a lot of pressure to achieve, and then would get annoyed with myself for feeling low and stressed. I had this constant feeling of being a failure, like nothing I did was ever good enough.”

She started closing herself away in her room for hours to study, and stopped eating regular meals. Her sleeping pattern became disrupted and she struggled to get up in the mornings. Then she’d tell herself it was her fault she wasn’t coping: “Everyone else seemed to be managing, and meeting their deadlines.” That belief put her off from seeking help. “I thought if I went to the doctors and said I was stressed, they’d laugh at me. And if I asked my personal tutor for help, I’d be told: just deal with it, like everyone else.”

Her mother and sisters were going through a difficult time following the breakup of her parents’ marriage, and she felt guilty she wasn’t there. “Getting a first was the only way I could validate my decision to live so far away.”

Gee, who was studying at Leicester University, eventually sought help. “I was lying awake, feeling depressed and alone. I remembered hearing that Samaritans have a 24-hour number you can text.”

Writing her feelings down in a text message proved a relief and within five minutes she had a helpful reply.

Thanks to regular support from Samaritans, she worked up the courage to talk to her tutors and got extensions on her deadlines, and then began running regularly to help release stress.

“I used that time to wind down and have a break from thinking about my degree and my family. I’d come back from a run relaxed and able to sleep.” She graduated with a first and, over the past 18 months, has run 24 races to raise money for Samaritans.

Sadly, many university students like Gee will fail to get the help they need. The Higher Education Statistics Agency recently revealed the number of students who drop out of university with mental health problems has more than trebled since 2009-10, with a record 1,180 university students with mental health problems abandoning their studies in 2014-15, the most recent year for which data was available.

How can those starting university this academic year avoid this? Do today’s students find university more of a struggle than their predecessors and, if so, why?

Dr Fredrik Johansson, a consultant psychiatrist for Camden and Islington NHS Foundation Trust, thinks they do. Around 5% to 10% of his caseload at any one time are university students, studying at, for example, nearby UCL, LSE or the University of the Arts. Their numbers have significantly increased recently, he says.

“Those who would have suffered in silence may now be accessing help. However, I do think the students I see feel under a lot more pressure and they have more extreme reactions to stress. They are less resilient than in the past.” He fears that the students he treats represent “the tip of the iceberg”.

Helicopter parenting and over-monitoring are partly the reason some undergraduates struggle to cope, he thinks – “they haven’t experienced making mistakes by themselves” – but he also blames financial pressures. “They take university more seriously than we did. They are very aware they will owe a lot of money when they graduate and they feel they absolutely have to do well as a result.”

Dr Aleksej Heinze, senior lecturer at the University of Salford Business School, has noticed the vast majority of his students now have a part-time job. “They feel under immense financial pressure.” For some students he sees in his capacity as a personal tutor, this can create what he describes as the perfect storm: having to meet work commitments as assignment deadlines pile up.

“Sometimes these students are tempted to take shortcuts like plagiarism, even though our plagiarism detection rates are very high nowadays. Others will get into strange sleeping and eating patterns because they are working shifts and don’t know how to look after themselves.”

Studying and working has replaced studying and socialising. “As a result, it’s not as easy for students today to make close friendships, and some think their existing relationships on social media are enough for them. That tends to make them less resilient if things do go pear-shaped, because they don’t have a support network at university.” He typically refers at least one student a month for counselling.

Homesickness is another common reason freshers struggle, says Dr Hinnah Rafique, a lecturer in public policy at Oxford University and a director at Generation Medics, which helps young people from all backgrounds access medical and health careers. “Some students are still unprepared for university and, especially if they are the first in their family to do a degree, don’t know what to expect.”

The good news is that university pastoral staff are better trained nowadays, she says, and recognise how overwhelming homesickness can be. “It can rear its ugly head at any time, and it tends to be triggered by really small things that seem completely insignificant to someone from the outside looking in. Students should seek help early.”

Meanwhile, Dr Ewan Jones, director of studies in English at Downing College, Cambridge, has noticed many more freshers struggling to make the transition from school, where they are frequently measured and tested, to a different form of thinking, where they are encouraged to explore ideas and try them out.

Some obsessively compare themselves to their peers, especially on social media. “Our first year students are used to being big fish in small ponds. They can’t all be the smartest kid in the room at Cambridge. Many find that difficult.”

Freshers are routinely asked if they have previously experienced any mental health problems and, over the past 10 years, Jones has observed greater numbers reporting these problems, both before and after they arrive at Cambridge. He believes this may be partly because the support services for students have increased.

“We encourage our students to feel there’s no stigma in speaking out and deliberately give them personal tutors who do not teach the subject they are studying. That way, they don’t have to put on a brave face.”

Last year, just before exams started, the college also offered students meditation sessions and puppies to stroke. “The puppies in particular proved very popular.”

Statement on Trump TransBan

Griffin Ambitions Ltd. condemns in the strongest terms President Trump’s executive memo banning transgender individuals from enlisting in the United States military and denying medically necessary care for transgender individuals already serving. As a mental health organization, we are all too aware of the trauma and pain caused by this kind of discrimination and the disproportionate mental health needs of the LGBTQ community, stemming in part from this discrimination. We stand with all trans service members.   

Personality disorders

The term “Personality Disorder” implies there is something not-quite-right about someone’s personality. However, the term “personality disorder” simply refers to a diagnostic category of psychiatric disorders characterized by a chronic, inflexible, and maladaptive pattern of relating to the world. There are many subset of personalities, all identifiable by their patterns. Personality disorders in particular are subsets that use maladaptive patterns of functioning, causing distress or problems integrating into society. This maladaptive pattern is evident in the way a person thinks, feels, and behaves. The most noticeable and significant feature of these disorders is their negative effect on interpersonal relationships. A person with an untreated personality disorder is rarely able to enjoy sustained, meaningful, and rewarding relationships with others, and any relationships they do form are often fraught with problems and difficulties.

 

To be diagnosed with a “personality disorder” does not mean that someone’s personality is fatally flawed. In fact, these disorders are not that uncommon and are deeply troubling and painful to those who are diagnosed. Studies on the prevalence of personality disorders performed in different countries and amongst different populations suggest that roughly 10% of adults can be diagnosed with a personality disorder (Torgersen, 2005).

 

Many types of disorders are evidenced by a complete and total deviation from normal and healthy functioning (e.g., epilepsy). However, personality disorders cannot be understood independently from healthy personalities.  Since everyone has a personality (but not everyone has epileptic seizures), personality disorders reflect a variant form of normal, healthy personality. Thus, a personality disorder exists as a special case of a normal, healthy personality in much the same way as a square is a special case of the more general construct of a rectangle. Therefore, it is useful for us to begin our discussion of personality disorders by first discussing the broader, more general construct of personality.

Resources:

http://www.mayoclinic.org/diseases-conditions/personality-disorders/home/ovc-20247654

https://medlineplus.gov/personalitydisorders.html

https://www.psychologytoday.com/basics/personality-disorders

https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders

https://www.nami.org/Learn-More/Mental-Health-Conditions/Borderline-Personality-Disorder

Personality Disorders: Crash Course Psychology #34

https://www.mentalhealth.gov/what-to-look-for/personality-disorders/index.html

http://www.nhs.uk/conditions/personality-disorder/Pages/Definition.aspx