Letter from our Executive Director

2017 has been a dynamic year in mental health. For some, it feels like both a lifetime and a single second has passed since the year started back in January.

Thanks to you, some big steps have been made in bringing mental health care in the United States into the 21st Century.

We couldn’t have made progress happen within Higher Education without your generous support.

We maintained coverage for mental health and substance use benefits thanks to the thousands of you who called, emailed, and sent letters to your legislators telling them to make mental health a priority.

Our high student affairs policy standards let peers show their expertise and experience, which opens new career paths and more opportunities to transform lives and services.

This is all thanks to you – with you, we can change the trajectory of thousands of young lives.

We cannot thank you enough for your support. Griffin Ambitions Ltd and Vital Time will not settle for the answers of the past in mental health care and treatment.

With your help, we can take charge of a brighter future—where there is always hope.

To all those preparing for the celebrations, happy holidays from all of us here at Griffin Ambitions!

Be well,

 

Jacob M. Griffin

 

Misintent : Hazing Students | Mental Health

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


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

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

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

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

This Atlantic story is sad, but thought provoking.

Checkout: UNAFFILIATED ARTICLE ON THE NEWS STORY

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

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

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

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

 

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

 

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.

Poetry Addressing Racism and Black American Identity

Here’s some poetry that could also be healing for students addressing racism and Black American Identity:

 

1. A Litany for Survival” by Audre Lorde

So it is better to speakrememberingwe were never meant to survive

Amazon

 

 

So it is better to speak

remembering

we were never meant to survive

2. The Last Quatrain of the Ballad of Emmett Till” by Gwendolyn Brooks

after the murder,

after the burial

Emmett’s mother is a pretty-faced thing;

the tint of pulled taffy.

3. Cordon Negro” by Essex Hemphill

I’m dying twice as fast

as any other American

between eighteen and thirty-five

This disturbs me,

but I try not to show it in public.

4. Where Do You Enter” by Nikki Giovanni

We begin a poemwith longingand end withresponsibilityAnd laugh all through the stormsthat are boundto come

Pictorial Parade / Getty Images

 

We begin a poem

with longing

and end with

responsibility

And laugh

all through the storms

that are bound

to come

5. Lineage” by Margaret Walker

My grandmothers are full of memories

Smelling of soap and onions and wet clay

With veins rolling roughly over quick hands

They have many clean words to say.

My grandmothers were strong.

Why am I not as they?

6. The Night Rains Hot Tar” by Lance Jeffers

The night rains hot tar into my throat,

the taste is good to my heart’s tongue,

into my heart the night pours down its moon

like a yellow molten residue of dung:

the night pours down the sea into my throat

my heart drains off its blood in love and pain:

the night pours a Negro song into my throat,

bloodred is the color of this rain:

7. Bullet Points” by Jericho Brown

I will not shoot myselfIn the head, and I will not shoot myselfIn the back, and I will not hang myselfWith a trashbag, and if I do,I promise you, I will not do it In a police car while handcuffed

Amazon / Via amazon.com

 

 

I will not shoot myself

In the head, and I will not shoot myself

In the back, and I will not hang myself

With a trashbag, and if I do,

I promise you, I will not do it

In a police car while handcuffed

8. ” A Small Needful Fact” by Ross Gay

Is that Eric Garner worked

for some time for the Parks and Rec.

Horticultural Department, which means,

perhaps, that with his very large hands,

perhaps, in all likelihood,

he put gently into the earth

some plants which, most likely,

some of them, in all likelihood,

continue to grow,

9. Black Lady Lazarus” by Diamond Sharp

Dying is an art and we Black girls do it so well.

Sandra &

Aiyana &

Rekia &

10. If It Is The Summer Of 2009” by Hanif Abdurraqib

…we revel in long enough to forget

that we are black in our 20’s which is to say that we are too old

for this shit

and by this shit I of course mean living

I of course mean that we have carried the lifeless bodies of enough younger brothers to never forget that we should be dead by now

we should have the decency to unburden America

by our dying on the side of a cracked road

11. praise song” by Nate Marshall

praise the Hennessy, the brown shine, the dull burn. praise the dare, the take it, the no face you’re supposed to make.praise the house, its many rooms,hardwood and butter leather couches;its richness. praise the rich, their friendship.praise the friends: the child of the well off,the child of the well off, the child of  well,the child of welfare, the child of welfare.

Amazon / Via amazon.com

 

praise the Hennessy, the brown

shine, the dull burn. praise

the dare, the take it, the no face

you’re supposed to make.

praise the house, its many rooms,

hardwood and butter leather couches;

its richness. praise the rich, their friendship.

praise the friends: the child of the well off,

the child of the well off, the child of  well,

the child of welfare, the child of welfare.

12. What They Did Yesterday Afternoon” by Warsan Shire

later that night

i held an atlas in my lap

ran my fingers across the whole world

and whispered

where does it hurt?

it answered

everywhere

everywhere

everywhere.

13. Self-Portrait In Case of Disappearance” by Safia Elhillo

girls with fathers gone or gone missing

sistered to dark boys marked to die & our own

bodies scarved & arranged in rows on prayer mats

we go missing too & who mourns us who

falls into the gap we leave in the world

14. Elegy” by Aracelis Girmay

What to do with this knowledge
that our living is not guaranteed?

Perhaps one day you touch the young branch

of something beautiful. & it grows & grows

despite your birthdays & the death certificate,

& it one day shades the heads of something beautiful

or makes itself useful to the nest. Walk out

of your house, then, believing in this.

Nothing else matters.

15. Gravity” by Angel Nafis

After Carrie Mae Weems’s ‘The Kitchen Table Series’

I. THE STRAW

Can you throw this away Maybe you should hire more Black staff
Where are you really from You’re not busy are you You look ethnic today
Where’s the African American section Can you turn the music down
Fasterfasterfaster Let me see those eyes Beautiful If you were mine
I’d never let you leave the house It’s like you went straight to Africa
to get this one Is that your hair I mean your real hair Blackass
Your gums are black You Black You stink You need a perm
I don’t mean to be
racist

16. Let Me Handle My Business, Damn” by Morgan Parker

Took me awhile to learn the good words

make the rain on my window grown

and sexy now I’m in the tub holding down

that on-sale Bordeaux pretending

to be well adjusted I am on that real

jazz shit sometimes I run the streets

sometimes they run me I’m the body

of the queen of my hood filled up

with bad wine bad drugs mu shu pork

sick beats what more can I say to you

17. Summer, Somewhere” by Danez Smith

no need for geographynow that we’re safe everywhere.point to whatever you please& call it church, home, or sweet love.paradise is a world where everythingis a sanctuary & nothing is a gun.

Courtesy of danezsmithpoet.com / Via danezsmithpoet.com

 

no need for geography

now that we’re safe everywhere.

point to whatever you please

& call it church, home, or sweet love.

paradise is a world where everything

is a sanctuary & nothing is a gun.

Record Gifts for NonProfits last year

I don’t usually wait with bated breath for annual giving trends and studies. But this year was different. Many fundraisers (including me) were eager to understand how the emergence of the Trump Presidency last year may be affecting the giving landscape, particularly at the individual giving level.

Like many people, I was intrigued and delighted at the news of big giving surges that occurred in the wake of Trump’s victory. Planned Parenthood reported receiving over 80,000 donations within days of the election. The American Civil Liberties Union received $24 million in online donations in the weekend that followed the news of Trump’s proposed Muslim travel ban.

The nonprofit Meals on Wheels, which delivers food to families in need across the country, took in more than $100,000 in donations after Trump proposed federal budget cuts. Were these giving surges one-time events or a presage of an enduring phenomenon with lasting impact?

The Giving USA Report: Documenting Increases in Gifts to Nonprofits

The annual Giving USA report is the longest-running report of charitable giving in the United States. The latest report, covering the year 2016, sheds some interesting light on philanthropy trends that may continue to affect nonprofits during the Trump era.

The Giving USA study reports that for 2016, all giving rose to $390.1 billion, which is a 1.4 percent growth over 2015 (adjusted for inflation). Individual donors really helped drive giving in 2016, and continue to represent the biggest piece of the charitable giving pie (72 percent). Individual giving alone had a 3.9 percent increase over the previous year!

Meanwhile, charitable giving from foundations and corporations also increased in 2016. However, gifts by estates decreased sharply (-10 percent).

In the individual donor category, it appears that all categories of recipient organizations saw an increase in giving in 2016, meaning that giving wasn’t isolated to so-called “resistance-oriented” groups. The greatest year-over-year increases were seen in environment and animals (7.2 percent); arts, culture, and humanities (6.4 percent); and international affairs (5.8 percent). Even religious groups saw a 3 percent increase.

Towards the Democratization of Philanthropy

Numerous commentators in the nonprofit philanthropy community seized upon this growth in the individual donor category as an important bellwether of changing giving trends in the Trump era.

Ruth McCambridge writes in The Nonprofit Quarterly: “Amid great political uncertainty, and probably even because of it, people without enormous wealth gave in larger numbers than they have in the recent past. The highest increases among recipient groups were […] front and center in public and political discourse toward the end of 2016 as areas that might be targeted for policy changes and defunding by the new administration.”

McCambridge continues: “All of this should come as little surprise to nonprofits, since we already knew that volunteering and giving are relatively closely linked behaviors. Thus, the massive number of people who volunteered to show up for protests on climate policy, immigration, science, and women’s rights over the past six or seven months should have been something of a predictor of what we could expect in giving trends. That makes this an exciting moment for fundraisers and organizers […] and you get a sense of the potential of this moment.”

Quoted in that same article is Patrick M. Rooney, Ph.D., associate dean for academic affairs and research at the Lilly Family School of Philanthropy, which researched the Giving USA report.

He suggests that “we saw something of a democratization of philanthropy. The strong growth in individual giving may be less attributable to the largest of the large gifts, which were not as robust as we have seen in some prior years, suggesting that more of that growth in 2016 may have come from giving by donors among the general population compared to recent years.”

Making the Most of This New Era of Civic Engagement

Let’s return for a moment to our initial mention of Planned Parenthood, ACLU, and Meals on Wheels, who saw a literal deluge of donations from existing and new donors. Can these — and many other organizations who aren’t mentioned here — take full advantage of this opportunity to cultivate and deepen relationships with donors, volunteers, and subscribers, eager for action?

If current trends and news reports are to be believed, we are well on our way to a new era of civic engagement. Says McCambridge: “It may be time to concentrate on making the most of this period of multi-faceted activism and our very rich landscape of mobilizable human and cash capital.”

Jay Love, writing in the Bloomerang blog, concurs. He believes that “if a strong base of individual supporters can be built via top-notch relationship building, which takes time, they can be retained at well above average retention levels.” He calls for a resurgence in individual donor cultivation.

As Steve MacLaughlin notes in Huffington Post: “Nonprofits are taking more risks, engaging supporters in new ways, and using more science to aid the art of fundraising. The future of fundraising will require risk, innovation, and a drive to move beyond the status quo.”

I, for one, will be watching nonprofit innovation blossom in the Trump era as a sign that we are embracing new strategies and tactics to engage and cultivate supporters. Will you join us in support of changing the support services for college students needing mental and psychological symptoms.

Exemplar: Mental Health Day at the Office

We’ve all heard that we should take a mental health day from time to time, but how many of us are brave enough to actually take one—and let our coworkers and boss know that mental health issues may be the reason for being out of office?

empty desksEFLON/FLICKR – FLIC.KR

Well, Madalyn Parker, a web developer, did exactly that in an email.

She sent an email to her team letting them know she was taking two days off “to focus on my mental health”—and was shocked by the CEO’s response.

She tweeted the email exchange, where it has over 30,000 likes and 8,400 retweets.

MADALYN PARKER/TWITTER – TWITTER.COM

Ben Congleton, the CEO who replied, was so stunned by the outpouring of support that he wrote about it on Medium.

“I wasn’t expecting the exposure, but I am so glad I was able to have such a positive impact on so many people,” he wrote on July 6.

“There were so many stories of people wishing they worked at a place where their CEO cared about their health, and so many people congratulating me on doing such a good thing,” he continues, adding:

It’s 2017. I cannot believe that it is still controversial to speak about mental health in the workplace when 1 in 6 americans are medicated for mental health.

Congleton is sourcing a Scientific American article from December 2016, which goes on to report that “just over one in 10 adults reported taking prescription drugs for ‘problems with emotions, nerves or mental health,'” sourcing statistics from a piece published in JAMA Internal Medicine earlier that month.

A top highlighted quote from Congleton’s Medium piece is “It’s 2017. We are in a knowledge economy. Our jobs require us to execute at peak mental performance. When an athlete is injured they sit on the bench and recover. Let’s get rid of the idea that somehow the brain is different.”

It’s even more difficult for people of color to not only receive mental health care, but to even discuss it.

HuffPost reported in October 2016, “according to the U.S. Department of Health and Human Services of Minority Health, black people are 10 percent more likely to report having serious psychological distress than white people. There’s a stigma when it comes to black men talking about their mental health.”

And it isn’t just about stigma. They continue: “Despite being disproportionately affected by mental health conditions, black men in America have to deal with a lack of health care resources, a higher exposure to factors that can lead to developing a mental health condition, a lack of education about mental health and other factors that serve as barriers to getting proper help.”

It’s also more difficult for people of color to feel as though others—even medical professionals—can relate to their mental health care; “African-Americans make up less than 2 percent of American Psychological Association members, according to a 2014 survey,” Mic reports. Even more, “Latinos are less likely to report mental illness,” with very few Latinos actually seeking help, according to Latina.

Which is why it’s so helpful and important for people like Congleton and Parker to speak openly about the need to take care of mental health.

“What if we talked about physical health the absurd way we talk about mental health?” ATTN: asked in a video posted on May 26.

Parker wrote about her previous hurdles in navigating a job while handling anxiety and depression, noting, “I struggle with illness. Just as the flu would prevent me from completing my work, so do my depression and anxiety.”

Her point is valid, mental and physical health are treated differently. As the video shows, you wouldn’t tell someone with a broken leg, “it’s like you’re not even trying to walk.” Why do we do the same thing to people suffering from mental conditions?

10 Things your OCD will lead you to believe

Staff report—

While working on my obsessive compulsive disorder (OCD) in therapy for a little over a year now, one of the biggest lessons I’ve learned is that OCD loves to lie. Through these sneaky lies, OCD pretends to be a helpful friend who wants to keep us safe. But really, it only manipulates us into doing more and more rituals. When stressed and struggling with an obsession, I’ve found it’s helpful to identify when OCD is trying to tell a lie. Then, I’m more likely to resist doing a ritual or to fight through the discomfort of an exposure.

—> Here are 10 common lies OCD tries to tell…and why you shouldn’t believe them!

1. I have to do rituals to feel safe or keep others safe.

While most people with OCD know their fears are irrational, sometimes in a stressful moment those fears can feel true. At times like this, I try to remember the relief and feelings of safety you feel after doing a compulsion will only be temporary. Doing rituals never makes me feel safe in the long run. Delaying a ritual and sitting with the anxiety is actually what gives me feelings of safety and control.

2. I have to do rituals if I want to feel less anxious.

Because of its cyclical nature, one of the main pitfalls of OCD is that it can grow quickly. Doing a ritual decreases anxiety, which feels really good in the moment, but the relief is only temporary. When the obsession pops up again, we have to do the ritual more and more for our anxiety to go away. With every ritual we do, we continue to learn that ritual equals less anxiety, even though it doesn’t work very well. Exposure and response prevention therapy (ERP) reteaches our brain that if we don’t do a ritual, eventually our anxiety will come down on its own. With every exposure we do, our anxiety comes down faster.

3. This anxiety will last forever.

This lie can feel especially true during an exposure or panic attack, but it’s not only false — it’s impossible. All anxiety will come down eventually. It might soon go back up again, then down, then up, etc., but it will come down. I pinky promise.

4. Just do the ritual one more time. It’s better than trying to resist.

This is one of the lies OCD tells me most often: “One more time!” It’s the same lie music directors and dance teachers always told us in practice, and it’s never true. Giving into the ritual only makes the obsession grow more, which means you’ll have to do the ritual even more times.

5. My thoughts make me dangerous.
Something my therapist told me this week is, “We can’t choose what thoughts we have, but we can choose what we do.” What many people don’t realize is everyone has weird, intrusive thoughts. While most people shrug them off and go about their day, the difference is people with OCD tend to overreact to these thoughts. We feel responsible for our weird thoughts and feel like dangerous people. Because of this, we obsess about the thoughts and engage in rituals to reduce our anxiety, which accidentally makes the thoughts come more often. This lie is simply not true; thoughts are just thoughts.

6. I shouldn’t tell people about my thoughts.

When my OCD tells me my thoughts are dangerous, it also tells me to keep them a secret. We don’t want people to know all the weird thoughts we have. This only makes the thoughts stronger; we fall deeper into the obsession. It also makes it harder to get help. It’s like saying “Voldemort” — you can take some of the power away just by saying it out loud.

7. I should be able to control my thoughts.

Wouldn’t it be nice if we could try really hard and just stop having intrusive thoughts? Yes, that would be nice, but I’m sorry to say that’s not the reality. Go ahead and try, I’ll wait. Tired yet? As nice as it would be to have control over our thoughts, I repeat, “We cannot choose what thoughts we have, but we can choose how we react to them.” The more we react to the thought and try to stop thinking about it, the more we think about it. The less we react to a thought and treat it as just a thought, the sooner it passes.

A common way to demonstrate this phenomenon is the pink elephant experiment. Try it yourself here!

8. There is a high probability that something bad will happen.

This is a common lie all anxiety disorders try to tell, but one I’ve tried especially hard to fight back against and test out many times. What I’ve found is usually, it’s not as bad as I expect it to be, or the bad thing doesn’t even happen at all. Quite often when I do an exposure, the anticipatory anxiety is worse than the anxiety I feel when I’m actually doing the exposure. Our brains really like to keep us safe, which means our brains really like to tell us something bad will happen, even when most of the time it doesn’t happen.

9. If something bad does happen, then I won’t be able to cope.

What about when you take the risk or do an exposure, and the bad thing does happen? I also underestimate my ability to cope with something bad. We are far more capable of coping than we usually believe.

10. I need certainty.

OCD related fears come in all shapes and sizes, but one aspect that ties them all together is an intolerance of uncertainty. Whether you check a lock multiple times or reread a page over and over, the goal is to feel certain that the feared outcome won’t happen. The only way to feel free then is to embrace uncertainty. Instead of responding to a “What if?” by ritualizing and desperately trying to achieve certainty, it’s better to respond with “Maybe…” and work on accepting the uncertainty.

~Morgan

“Smiley” Depression

Staff Reports—

 

When many people think of depression, they often think of sadness — and not much else. This generalization can be harmful to people who experience depression, but may not “look” depressed. For some, depression may look like sadness or exhaustion. For others, depression might look like a smiling face, or a person who “has it all together” — something we think of as “smiling depression.”

It’s important to remember every person’s experience of depression needs to be taken seriously, no matter what it looks like on the outside.2 We wanted to know things only people with “smiling depression” understand, so we asked members of our mental health community to weigh in.

Here’s what they shared with us:

  1. “It’s easier to cheer people up but not myself. I can make them feel great when they’re going through the worst [times], but I cannot get myself happy, really happy. That happiness you see is just a way of not letting people [see] my problems.” — Sofia V.
  2. “I am so tired. So, so tired, all of the time. It doesn’t matter if I’m sitting and pouting or smiling and engaging. [It doesn’t matter if I’m] dancing, running, swimming, eating, brushing my teeth, by myself or in a room full of people or sleeping. I. Am. Exhausted.” — Rinna M.
“Other people don’t get it. What it’s like to feel so trapped and in darkness, because I appear ‘happy’ and strong — even though [it feels like] I’m slowly dying.”
— Nicole G.
  1. “[I] fake it because [I believe] no one wants to hear about [my] depression. [I] fake it because [I am] tired of hearing all the ‘expert’ advice insinuating that [I’m] just [not] trying hard enough.” — Lisa C.
  2. “[I] don’t always wear the mask for other people. Sometimes [I] wear it because [I] don’t want to believe [I] feel as miserable as [I do]. [For me], it isn’t always about making other people with [me feel] OK. Sometimes it’s wearing the mask so [I] don’t lose [my] job or so [I] can just get takeout without being asked what’s wrong.” — Melinda A.
  3. “I can still laugh and give a big belly laugh about things, but on the inside, I feel empty. It’s a weird feeling being happy as much as you can, but your mind won’t follow suit. [I] just feel empty and the happiness isn’t genuine. It’s fake but [I] can’t change that no matter how hard [I] try for it to be a real feeling. Depression drains everything out of me. It takes an enormous amount of strength to appear ‘normal,’ it exhausts me… [My] smile doesn’t reach [my] eyes.” — Rebecca R.
  4. “The problem lies in the fact that no one truly and honestly knows me. I feel like I’m alone every day — even when I’m surrounded by people.” — Jen W.
  5. “[I] constantly doubt whether [my] struggles are real. When [I] finally get the courage and strength to open up about [my] depression, [I] always hear, ‘But you don’t act like you have depression.’ It took me years to come to terms and believe my own struggles.” — Adrianna R.
  6. “Most days, I feel like I’m just barely surviving. Once I’m alone at the end of the day, all I have the energy for is crying. Crying because I’m just so exhausted with life and I’ll convince myself I can’t handle tomorrow and I need to call in sick. But when the next day actually comes, I’m too afraid to not show up. Eventually, after debating with myself for far longer than I should, I drag myself out of bed. The cycle [feels] never-ending. It’s like, if I choose one day to just stay in bed instead of getting up, it would be the most horrible thing in the world, so I eventually always get up, no matter how exhausted I am. It’s inevitable.” — Keira H.
  7. “I try to keep up appearances to protect my family because my depression upsets them. I’m not very outwardly emotional, so everything gets to me more than I show it. I can’t open up to them, because I just get told, ‘Change your thoughts,’ ‘You seem fine, why do you want to go to a therapist?’ It makes those times when I can’t control my emotions even worse. I feel alone, tired and lost.” — Jessica C.
  8. “Sometimes I really, like really want to show people how I’m really feeling, but I just physically cannot take the mask off. It’s like the walls just grow stronger the more I try to tear them down.” — Kira H.
  9. “[I thought] if I faked being happy enough, then maybe I could get a glimpse of what it’s like to be ‘normal.’ I always feel like such a burden on the people [who] love me. [I feel] I have no choice but to pretend.” — Bree N
  10. “The time I’m most encouraging to myself is when I’m telling myself, I can make them laugh so they never suspect anything! I’m funny, right?” — Shelby S
  11. “The physical pain as well as the emotional pain. It hurts to walk, get up, move, force [myself] to smile, try to look ‘normal,’ happy.” — Keara M.
  12. “[ I believe] we are the best actors in the world. Because if I have to explain depression one more time… it’s just easier to fake it until I get home.” — Lisa K.

 

If you or someone you know needs help, visit our suicide prevention resources page.

If you need support right now, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text “START” to 741-741.

 

Suicide Attempts and Immune Response

Suicide kills more than 40,000 people in the United States every year, an estimated 90% of them with a diagnosable severe psychiatric disease. Yet little is known about what causes some individuals to take their own lives, limiting the ability to reduce the number of such deaths.
Findings from a new study published in the Journal of Psychiatric Research suggest that identifying blood-based antibodies may offer a route to more personalized assessment and treatment of suicide risk and, ultimately, to more effective suicide-attempt prevention. The study compared antibody levels to viruses known to attack and inflame the nervous system in psychiatric patients with a history of suicide attempt and patients who had not attempted suicide.
Findings
In the study by Faith Dickerson and colleagues, 162 patients with schizophrenia, bipolar disorder or major depression were assessed for suicide-attempt history and antibodies to neurotropic infectious agents including Toxoplasma gondii (T. gondii). All the patients were in psychiatric treatment and receiving medication during the study.
Among the participants, statistically significant correlations were found for:

  • Lifetime history of suicide attempt and the level of antibodies to T. gondii
  • Lifetime history of suicide attempt and the level of antibodies to a common herpes virus (cytomegalovirus or “CMV”)
  • Lifetime history of suicide attempt and current cigarette smoking.

Individuals with antibodies to both T. gondii and CMV were found to be at heightened risk of attempting suicide, suggesting that exposure to both viruses might be additive, according to the authors. Individuals with antibodies to both viruses were also more likely to have made multiple suicide attempts.
No statistical correlations were found for:

  • The deadliness of suicide attempt and the level of antibodies to either virus
  • Patient age at time of assessment, gender, race, diagnostic group, clinical care setting, cognitive score, psychiatric symptom score, or any of the medication variables

Implications
Suicide rates in the United States have been rising since the mid-2000s, with more individuals per 100,000 population killing themselves than previously. The 21stCentury Cures Act and other federal, state and local initiatives, as well as many national nonprofits, have focused on reducing suicide risk, but the task remains challenging without clarity about the underlying causes.
While “the mechanisms by which inflammation may be associated with increased suicide risk are not known with certainty,” the authors of this study wrote, “the successful identification of blood-based antibody markets would represent an advance in the prediction and prevention of suicide attempts” among psychiatric patients.
“Suicide, for which a previous suicide attempt is the greatest risk factor, is a major cause of death worldwide and is highly prevalent in patients with serious mental illness,” they conclude. “Unfortunately, the ability to predict suicide remains limited and no reliable biological markers are available. The identification of blood-based antibody markers should provide for more personalized methods for the assessment and treatment, and ultimately prevention, of suicide attempts in individuals with serious mental illnesses.”

Mental Health 101

How common are mental health issues?

Studies have shown that 1 in 4 individuals globally struggle with a mental health issue at any given time. If you expand that to the course of a lifetime, the number increases to 1 in 2. That means if it’s not you who is struggling, it’s someone you know or love.

Why is it important to talk about stigma?

When discussing mental health, two main types of stigma exist. One type is external stigma, which refers to the attitudes held by society that people with mental health issues are somehow lacking, incapable, incompetent, or not worthy of dignified and equitable treatment. The other type is internal stigma, which is the attitude held by the person with mental health challenges that they are unworthy, unlovable, and unvalued.

Stigma does a lot of harm to our society. For the people struggling with a mental health challenge, they often lack hope in recovery and don’t pursue treatment because they either don’t believe they can get better or fear discrimination from others. For those who don’t struggle but hold positions of power (such as law enforcement, educators, landlords, community leaders, etc.), stigma can lead to discrimination, which is the unfair treatment of those with mental health challenges.

Having honest conversations about stigma and sharing our personal stories of recovery are small steps we each can take to making our society more equitable and inclusive.

Is recovery actually possible?

Absolutely! One of the biggest misperceptions in society is that mental health issues are a life sentence.

Recovery means many things to many people and is personal in nature. For some, recovery is the complete absence of symptoms. For others, recovery means successfully managing symptoms as a normal part of life with no disruption to daily activities. Research has shown that even for those with the most serious mental illnesses, the right treatment can have someone living an independent, fulfilling, and successful life.

Does everyone with a mental health diagnosis need medication? What alternatives to medication exist?

It’s a common thought that the only cure to a mental health diagnosis is medication and if one stops taking his or her pills, it’s all downhill from there. While medication works for some people, it is hardly a cure-all. In fact, some medications can have side effects that are more harmful than the symptoms of the mental health challenge!

Deciding to try medication is a personal decision. The good news is that it is not the only option. Research has shown that other types of therapies can be extremely effective in maintaing a person’s level of wellness, including mindfulness, talk therapy, peer support, physical activity, and visual and performing arts, to name a few.

So, do I have to share my mental health issue with the world?

Not unless you want to! Some people are very open about their mental health issues because they value transparency and/or want to be an example of recovery. Others may not feel comfortable because they fear stigma, or simply don’t want the world knowing their personal business. Some may choose to tell family and close friends, but not coworkers or acquaintances. There is no right or wrong answer. You should do what makes you comfortable. If you want to start dialogue around mental health but aren’t quite sure if you’re ready to share your experiences, you can always frame the conversation around wellness, which applies to everyone, diagnosis or not.

What should I do if someone discloses their challenge to me?

Just listen. Providing a supportive ear is the best thing you can do for someone who chooses to open up. It’s not always easy to share something so personal with another human being, so taking a genuine interest and being free of judgment can go a long way and do a lot of good.