NAMI: Challenging Mental Health Stigma In The Black Community

In the black community, there is a negative stigma surrounding mental health. Instead of seeking professional help for conditions such as depression and anxiety, many in the community resort to self-medication (drugs, opioids, alcohol, etc.) or isolation in an attempt to solve their problems on their own. This issue of masking pain is especially prevalent amongst black men.

Speaking from experience, I know how black men grow up in culture that tells us “men are not supposed to cry,” that we “should deal with problems on our own.” This only enforces the idea that it’s not okay for us to say we are hurting inside. I’ve spoken to countless friends who, out of fear of being labeled as weak or less than a man, don’t want to acknowledge or vocalize any of their pains. This is true for me as well, as there have been moments in my life when I was afraid of sharing my true emotional well-being (or lack thereof) to close family and friends.

These are topics I talked about on my show, The Roommates Podcast. Due to my openness talking about mental health challenges, I received countless emails from young adult, black listeners who shared with me their struggles in the darkness. The more I used my platform to discuss topics relating to mental health in our community, the more others felt empowered to speak up and seek help for their own issues. This led to my desire to challenge stigma and bring light to mental health in the black community.

“Help”

Last May, I wrote and directed “Help,” a film created with the intention of beginning a conversation about mental health in the black community. The film follows the fictional story of a young black man named Raheem, who appears to have it all together on the outside, but has hidden struggles within.

Raheem is a successful man living in the Houston area; he is loved and respected by his community. He has a great career as an oil broker, a supportive wife and a large community of supportive friends. Though when Raheem is alone, you see his struggle with depression.

Raheem struggles to decide whether he should seek help from a mental health professional. When he shares this with his friend Kendrick, he’s told that “black men don’t go to counseling.” This scene is powerful because not only does it reinforce Raheem’s negative perception of getting help, but it also sheds light on the attitude towards mental health in the black community.

While he is by himself, there are thoughts in his head that constantly reinforce everything negative he believes about himself. Yet, whenever someone asks him what is wrong, Raheem says: “Nothing, I’m fine,” and then redirects the conversation with a joke. Sadly, Raheem’s story is reflective of many in the black community—millions of men who are suffering on the inside, but are too afraid to reach out for help.

Lift Up Your Voice

This year alone, there have been over 6.8 million black Americans who had a diagnosable mental illness. If we are unable to remove the negative stigma surrounding mental health in the black community, we are willingly allowing another generation to grow up without access to counseling and mental health improvement resources that can help them live a happy, healthy life.

Out of my desire to create long-lasting change in the black community, I am using my voice and platform to help others. I have heard one story too many of people in the black community struggling in the darkness, and I don’t want that to continue any longer. Anyone, regardless of how strong they are or how much they appear to “have it together” may be struggling with their mental health. You are not alone in your pain and you are not “weak” or “less than” because you are hurting. It’s time we reach out and ask for or offer help—because that’s what it takes to achieve the true healing we need.

 

Hafeez Baoku is an author, director and host of The Roommates Podcast. His work has been featured on OWN Network, The Houston Chronicle, Fox News 26, Houstonia Magazine, and Houston Style Magazine. You can connect with him at roommateshtx.com

For Immediate Release: Senate Bringing College Mental Health to Focus

PRESS RELEASE
LEGISLATION SUPPORT ADVISORY

For Immediate Release
June 25, 2018

Contact: Heather Schroeder
(877) 569-MIND(6463)

Support of Bill To Improve Access To Mental Health Services in Higher Education

On June 23, 2018 The Student Mental Health Policy Alliance voted to support a Senate Bill by Bob Casey(D PA) aimed toward improving access to mental health services for students at college campuses across America. The Higher Education Mental Health Commission Act would establish a national commission focused on mental health conditions facing students at colleges and universities across the country.

Between 2010 and 2015, enrollment in colleges and universities increased by only 5 percent, yet the number of students using mental health services increased by 30 to 40 percent. Students seeking help are increasingly likely to have attempted suicide or engaged in self-harm, the same study found. More than 50 percent of students between the ages of 18 and 24 reported having a severe psychological problem or experiencing feelings of hopelessness. This bill would help address the lack of resources to support students with mental health issues.

Highly publicized campus suicides and research showing an alarming prevalence of mental illness on campuses have heightened the sense of urgency. The reality of rampant mental illness on campus shatters the notion of college as a carefree time when the biggest worries are passing finals and finding a date. For many students, dark shadows shroud the sheltered nest of academe.

More than 40 percent of US students become so depressed during their four years in college that they have trouble functioning, while 15 percent suffer clinical depression, according to a 2004 survey of 47,202 students by the American College Health Association. Suicide remains the second-leading cause of death among college students, claiming about 1,100 lives a year.

“Today, campuses are plagued with an unprecedented demand for counseling services,” said Jacob Griffin, a former on-campus advocate—disturbed by campus administrators’ lack of responsiveness in addressing these issues; pivotal to student success and retention. “It is not uncommon for a university counseling center to have a 6 to 8 week wait…with mental health—symptoms intensify quickly,” Griffin continued.
Jacob launched a national non-profit in 2016 strategically focused on helping campus counseling centers address the influx by lobbying campus leaders to increase staffing and budgetary allotments. He has said that budgets in nearly 95% of Public University centers’ in the past 10 years have not changed to match increases in enrollment numbers, let alone the increases in demand. His research has found 7 out of 10 Campus Counseling Center Directors have resigned or retired within the last several years; citing lack of administrative support and over-extension of resources as key factors.

Specialists in the field have long known that the onset of mental illness often comes during adolescence or early adulthood. Living away from home, often for the first time, compounds stress and anxiety. So, too, does pressure to succeed in an increasingly competitive climate on campus.

As the stigma of having a diagnosed mental illness subsides, demand for counseling will presumably continue to rise. Criticizing Millennials as seemingly less resilient is the most popular diatribe, but it shouldn’t be, Griffin emphasized. In fact, it undermines a decade’s worth of work by counselors, psychologists, and student advocates who have strived to not only bring mental health to the forefront of discussion, but to reassure students that there is no shame in struggling—that experiencing mental distress is actually common and not a sign of weakness. “The distinct proof of concept and need,” Griffin said, “is what compels me to continue to advocate: the fact that I’ve had boots-on-the-ground experience…having witnessed and experienced the adversity has led me to continue bringing awareness to these issues” The result of normalizing mental health in higher education is that peers, faculty and bystanders, have intentionally led sufferers to the centers that promise to help them. “There is absolutely,” Griffin, “a lack of follow-through on that commitment.”

About The Student Mental Health Policy Alliance
A subsidiary of the 501c3 charity: Griffin Ambitions Limited, The nations leading voice on increasing campus mental health services too improve the lives of millions of Students affected by mental illness. We are committed to advocating for campus support, while reviewing and improving current trends in college mental health and highlighting promising practices that contribute to student success. We employ various strategic approaches too improve mental wellbeing on campuses. We take an active role in identifying initiatives consistent with our priorities, seeking out Higher Education Institutions’ that can advance these initiatives and work alongside administrators and stakeholders. We aim to effect change at grassroots and systemic levels. Since Founder Jacob Griffin’s mental health advocacy beyond his campus began in 2015, we have distinctly established ourselves through dedication, commitment and an unceasing belief in our mission to strengthen and improve how college Counseling Centers address their influx. Through our united support for education, advocacy and awareness efforts, the Student Mental Health Policy Alliance is at the forefront of increasing campus provisions, and is a distinctly recognized force in urging new ideas and solutions to improve educational outcomes.

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Mental Health in Higher Education Starts With Griffin Ambitions and the Student Mental Health Policy Alliance

 

II

115TH CONGRESS

2D SESSION S. 3106

To authorize the Secretary of Education to establish an Advisory Commission

on Serving and Supporting Students with Mental Health Disabilities

in Institutions of Higher Education, and for other purposes.

IN THE SENATE OF THE UNITED STATES

JUNE 21, 2018

Mr. CASEY (for himself, Mr. KAINE, Mr. NELSON, Ms. HASSAN, Ms. SMITH,

Mr. BLUMENTHAL, and Ms. KLOBUCHAR) introduced the following bill;

which was read twice and referred to the Committee on Health, Education,

Labor, and Pensions

A BILL

To authorize the Secretary of Education to establish an

Advisory Commission on Serving and Supporting Students

with Mental Health Disabilities in Institutions of

Higher Education, and for other purposes.

1 Be it enacted by the Senate and House of Representa2

tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Higher Education

5 Mental Health Act of 2018’’.

6 SEC. 2. FINDINGS AND PURPOSES.

7 (a) FINDINGS.—Congress finds the following:

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2

S 3106 IS

1 (1) More than 75 percent of mental health con2

ditions begin before the age of 24.

3 (2) More than 25 percent of students between

4 the ages of 18 and 24 reported a mental health con5

cern.

6 (3) More than 50 percent of students between

7 the ages of 18 and 24 reported having a severe psy8

chological problem.

9 (4) More than 50 percent of students between

10 the ages of 18 and 24 reported feelings of hopeless11

ness.

12 (5) Higher education counseling centers are de13

voting more time to rapid-response treatment with

14 more than 25 percent of students who sought help

15 reporting they had intentionally hurt themselves.

16 (6) Over a 5-year period, counseling center uti17

lization increased by an average of 30 to 40 percent,

18 while enrollment increased by only 5 percent, forcing

19 institutions to stretch mental health services to more

20 students without increasing resources.

21 (b) PURPOSES.—The purposes of this Act are the fol22

lowing:

23 (1) To ensure States and institutions of higher

24 education are provided with accurate information on

25 the mental health concerns facing students.

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3

S 3106 IS

1 (2) To provide detailed recommendations that

2 institutions of higher education, States, and the

3 Federal Government can take to improve the mental

4 health services available to students and properly

5 treat the rising number of students with mental

6 health issues.

7 SEC. 3. ADVISORY COMMISSION ON SERVING AND SUP8

PORTING STUDENTS WITH MENTAL HEALTH

9 DISABILITIES IN INSTITUTIONS OF HIGHER

10 EDUCATION.

11 (a) IN GENERAL.—The Secretary of Education shall

12 establish a commission to be known as the Advisory Com13

mission on Serving and Supporting Students with Mental

14 Health Disabilities in Institutions of Higher Education

15 (referred to in this section as the ‘‘Commission’’).

16 (b) MEMBERSHIP.—

17 (1) TOTAL NUMBER OF MEMBERS.—The Com18

mission shall include not more than 19 members,

19 who shall be appointed by the Secretary of Edu20

cation in accordance with paragraphs (2) and (3).

21 (2) MEMBERS OF THE COMMISSION.—The

22 Commission shall include 1 representative from each

23 of the following:

24 (A) The Office of Postsecondary Education

25 of the Department of Education.

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S 3106 IS

1 (B) The Office of Special Education and

2 Rehabilitation Services of the Department of

3 Education.

4 (C) The Office of Civil Rights of the De5

partment of Education.

6 (D) The Office of Civil Rights of the De7

partment of Justice.

8 (E) The National Council on Disability.

9 (F) A membership association for adminis10

trative and personnel professionals focused on

11 creating an inclusive higher education environ12

ment for individuals with disabilities, as deter13

mined by the Secretary.

14 (G) An organization that represents the

15 Protection and Advocacy for Individuals with

16 Mental Illness program, as determined by the

17 Secretary.

18 (H) An organization operated by and rep19

resenting secondary and postsecondary edu20

cation students with mental health disabilities

21 advocating for mental health services and sui22

cide prevention, as determined by the Secretary.

23 (3) ADDITIONAL MEMBERS OF THE COMMIS24

SION.—In addition to the members included under

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5

S 3106 IS

1 paragraph (2), the Commission shall include the fol2

lowing:

3 (A) Four members from leadership of in4

stitutions of higher education who have dem5

onstrated experience in successfully supporting

6 the retention and graduation of students with

7 mental health disabilities. With respect to such

8 4 members, 1 member shall be a staff member

9 of a 2-year degree-granting institution of higher

10 education, 1 member shall be a staff member

11 from a 4-year degree granting institution of

12 higher education, 1 member shall be a member

13 of campus law enforcement, and 1 member

14 shall serve as a general counsel. Such 4 mem15

bers shall represent institutions of differing

16 sizes.

17 (B) Three members from family members

18 of individuals who are—

19 (i) enrolled in an institution of higher

20 education on the date such family member

21 is appointed to the Commission; or

22 (ii) former students with a mental

23 health disability.

24 (C) Four members from individuals with

25 mental health disabilities, including not less

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S 3106 IS

1 than 2 individuals enrolled in an institution of

2 higher education on the date of appointment to

3 the Commission. Any remaining member shall

4 be an individual with a mental health disability

5 who has attended an institution of higher edu6

cation.

7 (4) TIMING.—The Secretary of Education shall

8 establish the Commission and appoint the members

9 of the Commission not later than 60 days after the

10 date of enactment of this Act.

11 (c) CHAIRPERSON AND VICE CHAIRPERSON.—The

12 Commission shall select a chairperson and vice chair13

person from among the members of the Commission. Ei14

ther the chairperson or the vice chairperson shall be a stu15

dent or former student with a mental health disability.

16 (d) MEETINGS.—

17 (1) IN GENERAL.—The Commission shall meet

18 at the call of the chairperson, but not more often

19 than 8 times.

20 (2) FIRST MEETING.—Not later than 60 days

21 after the appointment of the members of the Com22

mission under subsection (b), the Commission shall

23 hold the Commission’s first meeting.

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S 3106 IS

1 (e) DUTIES.—The Commission shall conduct a study

2 and prepare a report for the Secretary of Education that

3 includes the following:

4 (1) Findings from stakeholders, including

5 through solicitation of public testimony, related to

6 the challenges faced by students with mental health

7 disabilities in institutions of higher education, in8

cluding—

9 (A) the services available to students with

10 mental health disabilities in institutions of high11

er education and their effectiveness in sup12

porting these students;

13 (B) the impact of policies and procedures

14 that help or hinder the goal of providing equal

15 opportunity for students with mental health dis16

abilities, such as reasonable accommodation

17 policies, mandatory and voluntary leave policies,

18 and disciplinary policies;

19 (C) the use of protected health information

20 of students with mental health disabilities by

21 institutions of higher education, including the

22 extent to which campus-based mental health

23 providers share this information with college or

24 university officials without student consent; and

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S 3106 IS

1 (D) the impact of providing mental health

2 services on a student’s academic performance,

3 well-being, and ability to complete college.

4 (2) Conclusions on the major challenges facing

5 students with mental health disabilities in institu6

tions of higher education.

7 (3) Recommendations to improve the overall

8 education, and retention and graduation, of students

9 with mental health disabilities in institutions of

10 higher education, with the goal of helping these stu11

dents access educational opportunities equal to those

12 of their non-disabled peers.

13 (f) COMMISSION PERSONNEL MATTERS.—

14 (1) TRAVEL EXPENSES.—The members of the

15 Commission shall not receive compensation for the

16 performance of services for the Commission, but

17 shall be allowed reasonable travel expenses, including

18 per diem in lieu of subsistence, at rates authorized

19 for employees of agencies under subchapter I of

20 chapter 57 of title 5, United States Code, while

21 away from their homes or regular places of business

22 in the performance of services for the Commission.

23 Notwithstanding section 1342 of title 31, United

24 States Code, the Secretary of Education may accept

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9

S 3106 IS

1 the voluntary and uncompensated services of mem2

bers of the Commission.

3 (2) STAFF.—The Secretary of Education may

4 designate such personnel as may be necessary to en5

able the Commission to perform its duties.

6 (3) DETAIL OF GOVERNMENT EMPLOYEES.—

7 Any Federal Government employee, with the ap8

proval of the head of the appropriate Federal agen9

cy, may be detailed to the Commission without reim10

bursement, and such detail shall be without inter11

ruption of loss of civil service status or privilege.

12 (4) FACILITIES, EQUIPMENT, AND SERVICES.—

13 The Secretary of Education shall make available to

14 the Commission, under such arrangements as may

15 be appropriate, necessary equipment, supplies, and

16 services.

17 (g) REPORTS.—

18 (1) INTERIM AND FINAL REPORTS.—The Com19

mission shall prepare and submit to the Secretary of

20 Education, as well as the Committee on Health,

21 Education, Labor, and Pensions of the Senate and

22 the Committee on Education and the Workforce of

23 the House of Representatives—

24 (A) an interim report that summarizes the

25 progress of the Commission, along with any in-

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S 3106 IS

1 terim findings, conclusions, and recommenda2

tion as described in subsection (e); and

3 (B) a final report that states final find4

ings, conclusions, and recommendations as de5

scribed in subsection (e).

6 (2) PREPARATION AND SUBMISSION.—The re7

ports described in paragraph (1) shall be prepared

8 and submitted—

9 (A) in the case of the interim report, not

10 later than 1 year after the date on which all the

11 members of the Commission are appointed; and

12 (B) in the case of the final report, not

13 later than 2 years after the date on which all

14 the members of the Commission are appointed.

15 (h) TERMINATION.—The Commission shall terminate

16 on the day after the date on which the Commission sub17

mits the final report under subsection (g).

Æ

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‘Grasping at straws’: Farm advocates concur more resources needed to combat high suicide rates

Psychologist Michael Rosmann said that whenever he is home at his family’s farm in western Iowa he is taking calls or answering emails from farmers asking for help or counseling.

He specializes in behavioral health for farmers and said he has received more requests for assistance in recent months than the last three decades.

“My phone and my email have just been completely filled for the last six months. I work virtually seven days a week if I’m around the phone is always going email is always coming,” he told ABC News.

The calls are part of a critical issue faced by farmers, their profession faces the highest overall rate of suicide in the nation — much higher than the number of suicides in the general population, according to the Centers for Disease Control and Prevention.

PHOTO: Debbie Weingarten and Michael Rosmann during a visit to his farm in Harlan, Iowa, September 2017. Audra Mulkern/Female Farmer Project
Debbie Weingarten and Michael Rosmann during a visit to his farm in Harlan, Iowa, September 2017.

Debbie Weingarten reached out for help four years ago when she was running a vegetable farm in Arizona. She was a first-generation farmer and said that even without the pressure of maintaining a family farm she felt depressed and anxious about the possibility that they would lose money or crops.

“I felt like the risk that farmers undertake to produce food for eaters is not spread out fairly across the food system, so that’s squarely on the backs of farmers,” she told ABC News.

She said couldn’t find anyone to talk to online who understood her situation until she found a program run by Rosmann. The website said it lost funding a few years before but she called anyway.

“I was grasping at straws,” she said.

Rosmann picked up the phone.

Weingarten said she left farming in 2014 but still writes about agriculture. She spent five years researching and reporting a story about the suicide rate among farmers that was published in The Guardian last year.

Farmers in industries that have faced falling commodity prices and international trade disputes have faced additional economic pressure in recent years and farming experts and industry leaders say the uncertainty around the nearly $400 billion dollar Farm Bill adds additional stress for farmers and their families.

“Farmers were going through a very stressful winter weather-wise, a cold and tough winter, and on top of that we are into our fourth year of low milk prices, below the cost of production, and that has been creating a lot of stress,” Robert Wellington, a senior vice president of Agri-Mark Dairy Farmer cooperative, told ABC News on the phone Thursday.

PHOTO: Dairy cows on a Iowa farm are pictured in this undated stock photo.STOCK PHOTO/Getty Images
Dairy cows on a Iowa farm are pictured in this undated stock photo.

On average, Wellington estimated, small and medium dairy farmers have struggled through four years of milk prices that are 10 to 30 percent below the cost of production.

His group sent a letter to members in January forecasting yet another year of low milk prices. In the letter, they included phone numbers for people dealing with financial and emotional stress and a suicide hotline.

The farm bill has traditionally been bipartisan legislation to maintain subsidies, crop insurance programs, and livestock disaster programs but there has been dramatic debate and delays in this year’s bill due to proposals to cut funding from food stamp programs that make up a huge portion of the money allocated by the bill every five years.

This draft of this year’s farm bill in the House would have also provided funding for crisis hotlines and other programs to provide mental health help to farmers.

“Our farmers who feed the world are feeling the weight of the world on their shoulders,” one of the sponsors of that bipartisan provision Rep. Tom Emmer, R-Minn. said on the House floor ahead of the Farm Bill vote.

The House rejected the proposed bill.

In a 2016 report, the Centers for Disease Control found that about 84 out of every 100,000 people in the farming, fishing and forestry industries died by suicide in 2012, the most recent data available. The suicide rate for the general population was about 12 out of every 100,000 people that year, according to CDC data.

PHOTO: A farm in Iowa is pictured in this undated stock photo. STOCK PHOTO/Getty Images
A farm in Iowa is pictured in this undated stock photo.

That study included data from 17 states but did not include data from states like Iowa, Texas, or California where agriculture is a major part of the economy.

The report said that the high rate among farmers could be due to the potential to lose money in the business, as well as social isolation, lack of mental health services, or access to lethal means.

Rosmann is a psychologist and adjunct professor at the University of Iowa who specializes in behavioral health for farmers. He said farming is physically and emotionally stressful but that the current health system does not deal with all of the physical and mental risks for farmers.

“The bigger picture is that we have not attended to the behavioral well being of the agricultural population the way we have to the general population’s need for behavioral health,” Rosmann told ABC News.

He said that farmers have a unique psychology that drives them to work hard but that some factors are out of their control, like policy, weather, or commodity prices, resulting in a very stressful situation, adding that there has been increased economic stress on farmers in recent years and that they think they’re being economically marginalized.

Rosmann said farmers have a strong bond to their land and their farming operation and that on a psychological scale the stress of a life event like losing a family’s farm can be just as traumatic as losing a child.

“It’s almost always because of the loss of livelihood that people do such dramatic things as taking their lives,” he said.

Rosmann said he strongly supports a provision in the farm bill sponsored by Rep. Tom Emmer, R-Minn., to provide more money for states to provide mental health services like crisis hotlines for farmers and ranchers.

He said that some states offer resources like a crisis hotline but they need a stronger network of resources and a national center to help with the problem. In Minnesota the state employs one rural mental health counselor to help roughly 100,000 farmers, according to MinnPost.com.

Earlier in May the president of the National Farmers Union, Roger Johnson, wrote to Agriculture Secretary Sonny Perdue urging him to proactively address what he called “the farmer suicide crisis.”

PHOTO: The U.S. House of Representatives votes down a farm bill, 198-213, on May 18, 2018.C-SPAN
The U.S. House of Representatives votes down a farm bill, 198-213, on May 18, 2018.

“Farming is a high-stress occupation,” Johnson wrote in his letter. “Due to the prolonged downturn in the farm economy, many farmers are facing even greater stress. USDA’s national reach uniquely positions the Department to assist farmers and ranchers during times of crisis. We urge you to leverage your vision for collaboration across USDA and the entire federal government to develop a response to the farm suicide crisis.”

Sen. Tammy Baldwin, D-Wis., and Sen. Joni Ernst, R-Iowa, introduced a bipartisan bill on the issue of farmer suicide that would mandate more spending on mental health resources in rural areas. Rep. Tom Emmer, R-Minn., also introduced a bipartisan bill earlier this year to provide mental health services for farmers and ranchers.

Emmer’s bill was included in the version of the farm bill that was voted down in the House. The Senate’s farm bill has not yet been released.

The current farm bill is set to expire in September the most recent Farm Bill failed 198-213.

The National Suicide Prevention Lifeline provides 24/7 free, confidential support. The organization Farm Aid also offers a hotline for farmers in need of emergency help and a directory of local resources.

App Culture: Set on Mindfulness of Mental Health

Never before have we seen such a surge in apps focused specifically on mental health, mindfulness, and stress reduction.
The popular meditation app Headspace and our Apples App of the Year, Calm, both had major updates this year that expanded their breadth considerably, taking on topics such as mindfulness for children and better sleep. The creators of the new app Lake: Artists’ Coloring Books tackle destressing a bit more actively. It offers an ever-changing selection of drawings, created by burgeoning illustrators and artists, that you can color in—which is perhaps the most accessible meditation of all.
Several apps leverage the latest research on cognitive behavioral therapy to help address larger issues. Although the apps are not a substitute for professional treatment, they do put a host of resources at your fingertips. Pacifica provides a self-help toolkit and access to a support group whenever you need it, while Joyable lets you work with a trained coach via text, email, or phone.

 

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.

Racism’s Emotional Toll on Student Minds

Our screens and feeds are filled with news and images of black Americans dying or being brutalized. A brief and yet still-too-long list: Trayvon MartinTamir RiceWalter ScottEric GarnerRenisha McBride. The image of a white police officer straddling a black teenager on a lawn in McKinney, Tex., had barely faded before we were forced to grapple with the racially motivated shooting in Charleston, S.C.

I’ve had numerous conversations with friends and colleagues who are stressed out by the recent string of events; our anxiety and fear is palpable. A few days ago, a friend sent a text message that read, “I’m honestly terrified this will happen to us or someone we know.” Twitter and Facebook are teeming with anguish, and within my own social network (which admittedly consists largely of writers, academics and activists), I’ve seen several ad hoc databases of clinics and counselors crop up to help those struggling to cope. Instagram and Twitter have become a means to circulate information about yoga, meditation and holistic treatment services for African-Americans worn down by the barrage of reports about black deaths and police brutality, and I’ve been invited to several small gatherings dedicated to discussing these events. A handful of friends recently took off for Morocco for a few months with the explicit goal of escaping the psychic weight of life in America.

It was against this backdrop that I first encountered the research of Monnica Williams, a psychologist, professor and the director of the University of Louisville’s Center for Mental Health Disparities. Several years ago, Williams treated a “high-functioning patient, with two master’s degrees and a job at a company that anyone would recognize.” The woman, who was African-American, had been devastated by racial harassment by a director within her company. Williams recalls being stunned by how drastically her patient’s condition deteriorated as a result of the treatment. “She completely withdrew and was suffering from extreme emotional anxiety,” she told me. “And that’s what made me say, ‘Wow, we have to focus on this.’ ”

In a 2013 Psychology Today article, Williams wrote that “much research has been conducted on the social, economic and political effects of racism, but little research recognizes the psychological effects of racism on people of color.” Williams now studies the link between racism and post-traumatic stress disorder, which is known as race-based traumatic stress injury, or the emotional distress a person may feel after encountering racial harassment or hostility. Although much of Williams’s work focuses on individuals who have been directly targeted by racial discrimination or aggression, she says race-based stress reactions can be triggered by events that are experienced vicariously, or externally, through a third party — like social media or national news events. She argues that racism should be included as a cause of PTSD in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (D.S.M.).

Williams is in the process of opening a clinical program that will exclusively treat race-based stress and trauma, in a predominantly black neighborhood in Louisville. Shortly after the Charleston shooting, I called Williams to discuss her work; what follows is a lightly edited and condensed transcript of our conversation.

What is race-based stress and trauma?

It’s a natural byproduct of the types of experiences that minorities have to deal with on a regular basis. I would argue that it is pathological, which means it is a disorder that we can assess and treat. To me, that means these are symptoms that are a diagnosable disorder that require a clinical intervention. It goes largely unrecognized in most people, and that’s based on my experience as a clinician.

What are the symptoms?

Depression, intrusion (the inability to get the thoughts about what happened out of one’s mind), vigilance (an inability to sleep, out of fear of danger), anger, loss of appetite, apathy and avoidance symptoms and emotional numbing. My training and study has been on post-traumatic stress disorder for a long time, and the two look very much alike.

Over the weekend, I received several distressing emails and texts from friends who were suffering from feelings of anxiety and depression. Do you think we should all be in treatment?

I think everyone could benefit from psychotherapy, but I think just talking to someone and processing the feelings can be very effective. It doesn’t have to be with a therapist; it could be with a pastor, family, friends and people who understand it and aren’t going to make it worse by telling you to stop complaining.

What do you think about the #selfcare hashtags on social media and the role of “Black Twitter” as resources for people who may not have the resources they need to help process this? Are online interactions like that more meaningful than they initially might seem?

Online communities such as VitalStudentMinds.com — can be a great source of support, of course — with the caveat that even just one hater can be stressful for everyone, and that’s the danger of it. But if you don’t have a friend or a family member, just find someone who is sensitive and understanding and can deal with racial issues.

In our initial email about the ripple effects of the murders in Charleston, you used the phrase “vicarious trauma.” What does that mean?

Because the African-American community has such a long history of pervasive discrimination, something that impacts someone many miles away can sometimes impact all of us. That’s what I mean by vicarious traumatization.

Is racial trauma widely recognized as a legitimate disorder?

The trauma of events like this is not formally recognized in the D.S.M. It talks about different types of trauma and stress-related ailments, but it doesn’t say that race trauma can be a factor or a trigger for these problems. Psychiatrists, unless they’ve had some training or personal experience with this, are not going to know to look for it and aren’t going to understand it when they see it. In order for it to be recognized, we have to get a good body of scientific research, a lot of publications in reputable peer-reviewed journals. Right now, there’s only been a few. And we need to produce more.

On your blog, you chronicled the experience of a woman who encounters a therapist who dismisses her fears about racism. Is one barrier to treatment getting the medical community to acknowledge that racism exists?

Yes. A lot of people in the medical community live very privileged lives, so racism isn’t a reality to them. When someone comes in and talks to them, it might sound like a fairy tale, rather than a real daily struggle that people are dealing with. Research shows that African-Americans, for example, are optimistic when they start therapy, but within a few sessions feel less optimistic and have high early dropout rates. It could be that clinicians don’t know how to address their problems, or they may even be saying things that are subtly racist that may drive their clients away. If the patient feels misunderstood or even insulted by the therapist and they don’t go back and get help, they end up suffering for years or even the rest of their lives for something that is very treatable.

Is there a recommended model for treatment?

We have great treatments that are empirically supported for trauma, but the racial piece hasn’t really been studied very well. That’s no easy task, because when we write these articles, they go to journals, where an editor looks at it and decides if it’s worthy and applicable to go in the journal. And then it goes to reviewers who decide if it’s a worthy and applicable topic.

Why has it taken so long to get momentum?

If you think about it, they weren’t even letting black people get Ph.D.s 30 years ago in a lot of places. Ethnic minority researchers are the ones who are carrying the torch, by and large. We’re only to the place now where we have enough researchers to do the work. And there’s so much work that needs to be done.

Checkout our handout for more information on coping with trauma. 

13 Reasons Why: Pyscotherapist Reflection

Reposted with permission

I am a mom. And I am a psychotherapist. I have actually been a psychotherapist longer than I have been a mom. That’s originally why I picked up the book 13 Reasons Why. I was intrigued by its premise: a teen takes her life, then leaves behind a record of who contributed to her decision, and how. Intrigued is one word I have used — but if I am being intellectually honest with myself and you, I was put off by the premise. I was scared. As a mom of two daughters, 12 and 16, facing this book seemed daunting. I put it down. Even therapists have their limits….
I buried this book, along with its premise, for a couple of years. But like all things that scare us and bring out our vulnerabilities, this stuff comes back. This time, it came back in the form of a Netflix series that my 12 year old daughter began begging to watch. “All of my friends are watching it”, “They are going to spoil the ending for me!” (umm……that’s already been revealed!), and the ever-famous, “You are too overprotective…”.
Was I overprotective? I don’t want to shield my younger daughter from how devastating mental illness can be, especially because it is my life’s work to help people combat these demons. However, the premise still scared me. 
I made her an offer. We would watch the series together, and have frank discussions. This idea was rejected based on the fact that my daughter felt “uncomfortable” talking to her therapist mother about the subject matter. My answer was that if she couldn’t talk about it, she was not allowed to watch it. Case was closed.
Well, the case was closed for her. I decided to watch the series. But this time, as a mental health provider, not as a mother. Here is what I learned: 13 Reasons Why is irresponsible and disturbing. I will make this an easy read, and put this into bullet points.
Nobody else is responsible for our mental health. The premise of Thirteen Reasons Why disturbed me. I understand that the author was attempting to illustrate the point that our actions have an impact on people and at times, that impact can be severe. Small sins add up, and create a cumulative effect that can sometimes have dire consequences. I agree with these assertions. However, as a mental health provider, I work with people to find their power, and their voice. And yes, I work with teens to do this as well. We need to own and name our feelings as well as our actions. I believe we should teach our children to dig deep and find resilience, not point fingers at others and hold them responsible for our feelings and actions. 

Thirteen Reasons Why is a suicide revenge fantasy. Hannah received everything in death that she was hoping for: sympathy, deep regret, guilt, and ultimately — love. However, what the teen brain cannot process is the fact that Hannah is dead – permanently, and never coming back. The concept of the permanence of death is not solidified for a teen at this point in development. This makes suicide seem like an actual option if this can be achieved.

Mental health issues — and the help that’s available — are barely discussed. Depression, anxiety, and post-traumatic stress disorder are very real things that Hannah and other characters in the series struggle with. However, the opportunity to model both the struggle with the issues and the options that are available for addressing them — whether that means talking with a trusted adult who actually listens, to pursuing the right kind of mental health support — is missed. Instead, the focus is on suicide as a revenge act.

Girls are depicted as disempowered. I read a great article in New York Magazine by Anna Silman that discusses Thirteen Reasons Why, and the culture of misogyny our teenage girls face. While this could have been a very powerful message in the book, it gets overshadowed by the revenge fantasy that Hannah’s suicide provides. How about addressing the boys’ terrible behavior head-on? How about calling attention to sexual assault and what we can do to change it? I would have liked to see more outrage, and less disempowerment, from this show.

The suicide scene is cause for outrage. I am not for censorship. I am not Tipper Gore from the 80’s. But this scene was, plain and simple, a tutorial on how to complete the act of ending your life. It was graphic, It was bloody, and it was unnecessary. The book ended with a pill overdose, and yet the series ended with razor blades. Why? What purpose did changing Hannah’s method — and graphically depicting the suicide — serve?

13 Reasons Why glamorizes suicide. The series, and the book, go against best practices for addressing suicide responsibly. ReportingOnSuicide.org created recommendations as a guideline for the media on how to safely report on suicide. Research shows us that how suicide is reported has an impact on the public health of society. According to ReportingOnSuicide.org:

Don’t sensationalize the suicide

Don’t talk about the contents of the suicide note, if there is one

Don’t describe the suicide method

Report suicide as a public health issue

Don’t speculate why the person might have done it

Don’t quote or interview police or first responders about the causes of suicide

Describe the suicide as “died by suicide” or “completed” or “killed him/herself” rather than “committed suicide”

Don’t glamorize suicide

13 Reasons Why breaks all of these rules. Violating these guidelines puts our teens at risk. Romanticizing the act of suicide in a medium that teens hold near and dear to their heart is dangerous and irresponsible. 
These are my two cents as a psychotherapist, not a mother. My purpose of sharing my point of view was not to judge. The decision on whether or not a parent should let their child watch is a personal one. If you do let your children watch, please heed this advice: watch it with them. Talk to them. Assure them that you are here for them, that they are loved and empowered, and that suicide is never an option.
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Brooke Fox, LCSW, is a co-owner of Fox, Levine and Associates, Learn more about Brooke here.
Thirteen Reasons Why is a Netflix series (rated TV-MA: Mature Audience Only, “specifically designed to be viewed by adults and therefore may be unsuitable for children under 17”) based on the original YA novel of the same name by Jay Asher.

Insight on College Students Turning to Self-Medication 

Next month is is mental health awareness month. Which means, in my experience, that it is still, to some extent at least, alcohol awareness month. Many people who suffer with undiagnosed depression or anxiety reach for alcohol or drugs to calm their nerves or relieve them of emotional pain. In other words, they self-medicate. Rather than seek out some help in managing depression, anxiety or chronic resentment, they seek their own solution — a solution which, while it works pretty well for a while, eventually complicates the issues and leads to more pain. It’s the same sort of premise as having access to your own morphine drip: You administer your own dose whenever you begin to feel pain.

Hiding in Plain Sight

Many people can get rid of temporary pain by having a couple of drinks and calming down in the evening, say, or by knocking back some “liquid courage” before facing a social event. For some, there’s no more to it than this, and their use of alcohol remains fairly benign. But for another group, a group that is larger than any one cares to admit, the solution slips into a dependency, and the dependency slips into an addiction. Slowly, this group becomes trapped in their own solution. Not only can they not quite face an evening without some “help,” but their own healthy coping strategies begin to atrophy through lack of use. And as they increasingly depend more and more on a substance to change their mood, their relationship with that substance comes to have a life of its own. Pretty soon you aren’t really sure who you are talking to at dinner: Is it the person you remember or that person “under the influence”? Is it the “booze talking” expansively, angrily, or overly confidently, or is it them?

The connection between alcohol/drugs and mental health is not made enough and cannot be made too often. Once a using pattern begins, often innocently enough, it can come to have a life of its own. No longer is the person downing a drink — now the drink is downing the person.

And then there is the rest of the family, the people who don’t make it to the front page of any tabloid because they are not the ones with the “problem,” but for every one one person alcohol and drugs take, there are seven or eight others in the wings, seven or eight others who lives are profoundly affected by living with another person’s addiction, another person’s mysterious medicated depression or their strange anxiety that liquor turns into something else, something much harder to recognize, accept or reason with. The addict’s disease becomes disguised, hidden beneath the ritual of cocktails. Their long dinners lingering over bottles of wine, their diatribes on politics, their strange and singular possession of a subject that they cannot seem to let go of and have to remain in control of lest the pain they are seeping out through it, leaking slowly onto everyone else, break loose somehow and get all over everything. Their addiction is morphing into odd behavior, twisted thinking, lack of empathy for those around them. It is so strange being around someone who uses alcohol or drugs to manage inner pain, resentment or anxiety because they, more than anyone, are convinced of their own rightness. They are brittle on the subject of their increasing use, on any subject for that matter. They take over the dinner conversation, drive delicate points way too hard, go on long and tedious harangues about which they appear to have unduly strong feelings. Their eyes slowly glaze over and you know that they do not fully see you, or care to see you. But the person they really do not see is themselves. They are hiding in plain sight. Caught on a wheel of self-medication that rolls its way through the person, across the dinner table and along the path of the next generation.
The Endless Cycle

When alcohol or drugs are used as our “go to” for getting through difficult moments, managing social or interpersonal anxiety or managing real, emotional pain, a self-destructive cycle gets going that looks something like this.
1. There is something that is bothering us, a down mood we can’t shake, a social or personal anxiety that keeps us anxious or a depressed/angry feeling we don’t know how to manage.
2. We discover that 1-3 drinks or maybe some pot or even a drug really takes the edge off. We feel lighter, less self-conscious, more confident and able to cope. We’re less anxious, worried or down.
3. The more we use these “solutions” to cope, the less we learn to cope on our own, we become dependent on a substance to manage our inner world and less able to manage it on our own.
4. Our dependency nags at the corners of our mind. We’re not ready to admit to it, so we develop little ways of hiding it, first from ourselves and then, of course, from others. The more silently anxious we become, the greater our need for our drink or drug (or behavior, sex or money addiction, for example) to cope.
5. Our dependency deepens, our anxiety about our dependency deepens, our wish to hide it deepens. We live further and further away from our own inner truth. The further we are away from self-honestly, the less likely we are to admit we have a problem. And the more we rely on alcohol or drugs to hide our growing shame. And the more we look for excuses under which to hide our behavior.
6. Life complications. About this time other people are noticing that something isn’t right. Others become preoccupied with the “problem that cannot be talked about.” Now we not only have the initial anxiety or depression that was driving the wish for self medication, but we have a growing dependency on a substance or behavior.
7. Addicts’ inner pain, shame and loss of self honestly becomes more painful to them, consequently their need to self medicate to drown that inner pain increases. Their use and abuse increases, their pain and shame increases, their hiding and projecting increases.
8. Addiction takes hold and this cycle is repeated over and over and over again. And the more pain, the more projection.
About this time, the addict (and too often the spouse of the addict, who can be very invested in keeping the growing problem hidden) start looking for scapegoats. They may throw the hot potato a generation forward onto kids. Couples can unite and choose a child as a scapegoat, they make more than necessary of a kid’s problems and project the “hot potato” onto them. Or they may throw it a generation back into their family of origin, getting unduly preoccupied with their parents or siblings problems. Or the addict has subjects that come to be more soap box rants than interests or discussions — they project their inner angst at the world at large, anything to get rid of the pain inside of them, any port in a storm. All of this is silently designed to keep the microscope away from them. To keep people from looking at what is really going on, and for the addict, to keep from having to part with their now beloved substance, behavior or “solution.” They are hooked, and they in one way or another hook everyone around them.
The cycle of self-medicating emotional or psychological pain such as depression or anxiety with drugs, alcohol or addictive behaviors gains traction and rolls through the generations. But no one knows quite what is happening or why.
I will talk more about “compulsive combinations” or the brain chemistry or addiction and the intergenerational spread of self-medication in future blogs.

Higher Death Rate Among Youth with First Episode Psychosis

New study shows that AFTER people have experienced first episode psychosis they have higher mortality rates than previously believed. Demonstrating that we should treat people who have experienced first episode psychosis. Note that the age range was 16-30, not adolescent children.

NIH-funded study highlights need for increased early intervention programs such as Griffin Ambitions programming

A new study shows that young people experiencing first episode psychosis have a much higher death rate than previously thought. Researchers analyzed data on approximately 5,000 individuals aged 16-30 with commercial health insurance who had received a new psychosis diagnosis, and followed them for the next 12 months. They found that the group had a mortality rate at least 24 times greater than the same age group in the general population, in the 12 months after the initial psychosis diagnosis. This study, funded by the National Institute of Mental Health (NIMH), part of the National Institutes of Health, underscores that young people experiencing psychosis warrant intensive and proactive treatments, services and supports.

The research, led by Michael Schoenbaum, Ph.D., Senior Advisor for Mental Health Services, Epidemiology, and Economics at NIMH, was published online April 6, 2017 in the journal Schizophrenia Bulletin.

The research team used insurance claims data to identify young people aged 16-30 who had been diagnosed with a first episode of psychosis in 2008-2009. They used data from the Social Security Administration to identify deaths in this population within 12 months of the initial psychosis diagnosis. Data on cause or manner of death were not available for this research. The 12-month mortality rate for these young people—from any cause—was at least 24 times higher than their peers in the general population. In the general United States population, only individuals over age 70 come close to a similar 12-month mortality rate.

“These findings show the importance of tracking mortality in individuals with mental illness,” said Schoenbaum. “Health systems do this in other areas of medicine, such as cancer and cardiology, but not for mental illness. Of course, we also need to learn how these young people are losing their lives.”

In addition to mortality, the study examined the health care individuals received in the 12 months after the initial psychosis diagnosis. Those data showed that young people with a new psychosis diagnosis had surprisingly low rates of medical oversight and only modest involvement with psychosocial treatment providers. Overall, 61 percent of them did not receive any antipsychotic medications, and 41 percent did not receive any psychotherapy. Those who died within 12 months of diagnosis received even less outpatient treatment and relied more heavily on hospital and emergency care.

“Other studies have shown that early coordinated treatment for psychosis produces the best results. However, we know that the typical duration of untreated psychosis in the United States is around 17 months,” said Robert Heinssen, Ph.D., director of the NIMH Division of Intervention Services and co-author on the paper. “This study reinforces federal and state support for funding evidence-based psychosis treatment programs across the country, and the need for communities to invest in more treatment programs.”

“Grants from the Substance Abuse and Mental Health Services Administration promote many of these programs in communities throughout the U.S.,” said Acting Deputy Assistant Secretary Kana Enomoto, head of the Substance Abuse and Mental Health Services Administration (SAMHSA).

“The future of this research will show us what is happening with young people in this population, and help us tailor interventions to address their risks,” added Schoenbaum. “In the meantime, this study is a wake-up call telling us that young people experiencing psychosis need intensive, integrated clinical and psychosocial supports.”

Hospital emergency department entrance

Reference

Schoenbaum, M., Sutherland, J., Chappel, A., Azrin, S., Goldstein, A., Rupp, A., Heinssen, R. Twelve-Month Health Care Use and Mortality in Commercially Insured Young People with Incident Psychosis in the United States. Schizophrenia Bulletin, April 6, 2017.

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