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Val's Waking Nightmare

11/22/2014

First let me say that I have a pretty eccentric make-up, and that uniqueness gives me something in common with millions, probably billions of fellow human beings.
  When I moved to Colorado in 1998 with my husband and infant son, I began having migraine headaches, something I had never had down in Oklahoma where I am from and much closer to sea level than Colorado.
I attributed the migraines and subsequent vomiting at least in part to the altitude but figured it was a God awful painful & trying nuisance and nothing really serious serious.
Well by 2006, I had plenty of stressors in my life AND nothing I would have anticipated losing my mind over.
One morning fully into the first (and thankfully only) manic prodromal phase of my life, I experienced flashes of light. Hey, this is just like Paul on the Road to Damascus, I thought -- I'm really onto something here.
Later, I would come to view this as perhaps a miny stroke or some other unwelcome neurological event -- at the time, I was being inspired by God.
Well, it just so happened that I was scheduled to go on a business trip to Detroit for State Legal Service Developers for the Elderly across the country. Let me just say that the attendees got quite a show, but that was nothing compared to the people in the Detroit Airport where I was saying very loudly to any persons who appeared in conflict, "Praise the Lord, Praise the Lord."
Let me just say here that despite coming from Oklahoma, I had a very broad liberal religious upbringing, AND what I was experiencing was far beyond that of my most conservative Southern Baptist friends.
Well at this point, it's been relatively harmless. Things are just gearing up. On the plane ride back, tears are streaming down my face -- tears of joy -- because God is sending me messages through the airflight movies. My mind is going a mile a minute.
I get home, AND now I'm flipping through the Bible and circling passages at an incredibly rapid rate.
I don't think I can accurately describe how fast my mind is racing at this point and how many connections it is making.
I'm going from one thing to another almost second by second with an impulsiveness that is hard to describe. Well, of course, I think I'm being inspired by God.
One of these lightening quick thoughts involves serious harm to others -- But it's okay because we're all going to heaven. I take some steps to complete this thought AND THANK "GOD" -- there's another lightening fast "inspiration from God" that that is not the thing to do!
My husband gets me to Porter South (the psych ward at Porter Hospital). I come back to reality.
And now I have this terrible horrible secret.

What I want to say is that those who know me best--- my mother (who has since passed away) and my husband (oh, did I mention he has a Ph.D in Biological Psychology), never saw this coming and I certainly never saw it coming.

To paraphrase Shakespeare,

There is more to the human mind and human behavior, Horatio, than dreamt of in all your versions of the DSM.

Factors for "Mental Illness":

genetics
one's gut biome (allegedly more complex than the human genome)
diet
sleep apnea
physical environment
emotional environment
altitude?
etc.

Factors specifically for "Bipolar Disorder":

genetics
anti-histamines (can you believe it?)
crossing time zones
etc.

Articles on Altitude & Mood Disorders:

Positive Association Between Altitude & Suicide in 2584 US Counties
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114154/

Treating Mood Disorders At A High Altitude
http://www.dailyutahchronicle.com/2014/11/13/treating-mood-disorders-at-a-high-altitude/

There's a Suicide Epidemic in Utah — And One Neuroscientist Thinks He Knows Why
http://mic.com/articles/104096/there-s-a-suicide-epidemic-in-utah-and-one-neuroscientist-thinks-he-knows-why?utm_source=vayner&utm_medium=social&utm_campaign=story_utah

William Shakespeare (1564 -1616), playwright, credited with "inventing the human" by Yale Scholar Harold Bloom -- maybe a little over the top AND we haven't outgrown Shakespeare yet.

"There are more things in heaven and
earth, Horatio, than dreamt of in all your philosophy."
--- Hamlet, Act 1, Scene 5

Dr. Tom Insel, Director of the National Institute of Mental Health

Dr. Insel's Blog: Atonement
Oct. 8, 2014

"My own favorite atonement issue for Mental Illness Awareness Week this year is the lack of humility in our field. Mental disorders are among the most complex problems in medicine, with challenges at every level from neurons to neighborhoods.

"Yet, we know so little about mechanisms at each level. Too often, we have been guided more by religion than science. That is, so much of mental health care is based on faith and intuition, not science and evidence.

"On the plus side, we put a premium on listening and compassion. We help people to change through understanding. But not enough of our care has been standardized to a high level of quality, as expected in the rest of medicine."

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We Can't Handle the Truth about Intent, Mental Disorders, the State of the Science, or our Failed Service Delivery System

11/10/2014

Ari Liggett (Chopped Up Mom, long history of mental illness),
James Holmes (Aurora Theater Shooting, history of mental illness)
Karl Pierson (Arapahoe High School Shooting, history of emotional problems)
Ad Nauseum

We have to have safety. We have to. AND nothing I say below is intended to undermine that fundamental fact.
Socrates allegedly made quite a few enemies by asking what appeared to be simple definitional questions such as "What is virtue?"
Well, "What is mental illness?" ; "What is insanity?"
In our society those turn out to be very complicated questions involving two primary disciplines: mental health and law.
Both mental health and law are constrained by the limitations of the other.
The law doesn't turn on a dime -- if a statutory definition is behind current knowledge then it has to be changed either in the legislature or challenged in the Court System.
In my humble opinion, the laws regarding "Competency to Stand Trial" and "Not Guilty By Reason of Insanity" are about as arbitrary and capricious as it gets.
Speaking of being humble (which I'm not), Dr. Tom Insel none other than the Director of the National Institute of Mental Health speaks about the need for "Atonement" in the area of mental health and the need to be "humble."
Our current criminal laws involving competency and insanity are based on mental health AND dare one say they are not very humble.
If one is paying attention to the science, with the identification of bio-markers in mental health one could easily come to the conclusion that at some point in the future this "insanity" regarding the criminal law and our failed service delivery system will be largely fixed.
Now, the question really is how long do we have to wait for the madness to stop?

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Let's Get Serious AND ACT

11/7/2014

Well, the obvious question is if Assertive Community Treatment is so great, why don't we have more of it?
For the State, the answer is cost. And for the mental health activist community, the concern is that "Assertive" can become "Coercive."
With respect to cost, see NAMI's ACT Cost Summary.
With respect to "Coercion," I think such concerns can be addressed as were done below in New York AND regardless of whether a civil liberties provision is incorporated in a certification manual, rule, or statute -- it still has to be actualized and enforced.

ACT 3.12
Recipient Rights

Recipients are informed of their rights and their rights are respected.
The program incorporates recipient input into program practices and provides full, immediate access to their charts. Recipients shall be able to object to their treatment, or complain or discuss issues related to program policies and procedures, program staff or services without fear of retribution (Grievance procedure).
Recipients have a right to culturally sensitive and competent treatment and services.

New York State Office of Mental Health ACT Certification Manual (2007)

One of the things that gets bandied about with ACT is Intensive Case Management (ICM). In some of the literature, ICM is referred to as ACT-lite.
My experience with ICM is that in certain circumstances it just isn't enough. I find that folks in the system may say, "That's all he needs, someone to check in with on a daily basis and help him with a mountain of complex social work needs that resist the best good faith efforts at resolution of multiple people in multiple executive departments." (I'm paraphrasing of course).
Yeah that's really all he needs AND he can't get it, AND we've been working on this for over 6 months AND my guy is still homeless AND still NOT getting the level of assistance he needs.
So my take is the proof is in the pudding -- if ICM can keep someone from being homeless, hospitalized, or incarcerated that's great -- if not more services are needed.
See below an interesting review of literature which found the "weakest outcomes" with ICM alone.

A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless

A review of 16 controlled outcome evaluations of housing and support interventions for people with mental illness who have been homeless revealed significant reductions in homelessness and hospitalization and improvements in other outcomes (e.g., well-being) resulting from programs that provided permanent housing and support, assertive community treatment (ACT), and intensive case management (ICM). The best outcomes for housing stability were found for programs that combined housing and support (effect size = .67), followed by ACT alone (effect size = .47), while the weakest outcomes were found for ICM programs alone (effect size = .28). The results of this review were discussed in terms of their implications for policy, practice, and future research.

American Journal of Orthopsychiatry (2007)

We need to cost it out and seek additional funding this legislative session for Medicaid Assertive Community Treatment for people where it is "reasonably medically necessary." Failure to do so, amounts to the continued unwitting discrimination of people with mental illness.
It's time to ACT!

PRINCIPLES OF ACT
Assertive Community Treatment services adhere to certain essential standards and the following basic principles:
PRIMARY PROVIDER OF SERVICES: The multidisciplinary make-up of each team (psychiatrist, nurses, social workers, rehabilitation, etc.) and the small client to staff ratio, helps the team provide most services with minimal referrals to other mental health programs or providers. The ACT team members share offices and their roles are interchangeable when providing services to ensure that services are not disrupted due to staff absence or turnover.
SERVICES ARE PROVIDED OUT OF OFFICE: Services are provided within community settings, such as a person's own home and neighborhood, local restaurants, parks and nearby stores.
HIGHLY INDIVIDUALIZED SERVICES: Treatment plans, developed with the client, are based on individual strengths and needs, hopes and desires. The plans are modified as needed through an ongoing assessment and goal setting process.
ASSERTIVE APPROACH: ACT team members are pro-active with clients, assisting them to participate in and continue treatment, live independently, and recover from disability.
LONG-TERM SERVICES: ACT services are intended to be long-term due to the severe impairments often associated with serious and persistent mental illness. The process of recovery often takes many years.
EMPHASIS ON VOCATIONAL EXPECTATIONS: The team encourages all clients to participate in community employment and provides many vocational rehabilitation services directly.
SUBSTANCE ABUSE SERVICES: The team coordinates and provides substance abuse services.
PSYCHOEDUCATIONAL SERVICES: Staff work with clients and their family members to become collaborative partners in the treatment process. Clients are taught about mental illness and the skills needed to better manage their illnesses and their lives.
FAMILY SUPPORT AND EDUCATION: With the active involvement of the client, ACT staff work to include the client's natural support systems (family, significant others) in treatment, educating them and including them as part of the ACT services. It is often necessary to help improve family relationships in order to reduce conflicts and increase client autonomy.
COMMUNITY INTEGRATION: ACT staff help clients become less socially isolated and more integrated into the community by encouraging participation in community activities and membership in organizations of their choice.
ATTENTION TO HEALTH CARE NEEDS: The ACT team provides health education, access, and coordination of health care services.

Assertive Community Treatment Association (ACTA)

Oregon Center for Excellence for Assertive Community Treatment

Orchid Links:

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Let's Have An "Open Dialogue" About the Need for Standardized Mental Health Risk Assessments & Statewide Support for Professionals Making These Difficult Decisions

11/6/2014

The conventional wisdom used to be that if a person with a serious "mental illness" could just get to the mental health professionals -- all would be fine or at least safe.
Well, that hasn't panned out -- James Holmes (Aurora Theater Shooting), Navy Veteran Aaron Alexis (Washington Shipyard Shooting), Karl Pierson (Arapahoe High School Shooting), etc.
Bio-markers may be the ultimate answer, AND we're NOT there yet.
There are risk assessments out there AND there is nothing that is being used in a standardized form across the state nor are we uniformly collecting statistics on mental health certifications that I'm aware of.
Further, mental health professionals do not have equal experience or access to support in making these difficult decisions.
I could be really wrong on this, AND it seems to me that when mental health professionals go on a tear about needing the law changed, it is sometimes (not always) about feeling uncomfortable about being subjected to cross examination, really regardless of what the standards are.
That's not true for everyone, such as the psychiatrists at the Colorado Mental Health Institutes at Ft. Logan and Pueblo who get plenty of court experience in these matters. That's not to say that I always agree with the Institute Docs, AND I don't think they are intimidated as someone might be who has rarely if ever testified.
With respect to support for mental health professionals, I think it is just as important to have a statewide mental health hotline for professionals as it is for individuals.
Also, hopefully that hotline for professionals could gather important data as well as incorporate research from other sources to continually improve our risk assessments until something more accurate and definitive is developed.
Maybe if we acknowledge the reality that mental health has a long way to go as a science we will start addressing the issue of our imperfect risk assessments rather than seeking to curtail people's civil liberties.

Finnish Model of "Open Dialogue" to reduce mental health hospitalizations and medication use.

The University of Massachusetts' Department of Psychiatry recently completed work to adapt the approach to the U.S.

See Orchid's page on "Open Dialogue"

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How Arapahoe High School & the Rest of the Country Got To Now: Mental Health, Uncertainty, & a CYA Culture

11/3/2014

I love PBS' new show with Steven Johnson -- "How We Got to Now," and not surprisingly I loved James Burke's "Connections" as well.
When we really consider history, history of science, history of ideas, etc. from a safe distance it is quite amazing the connections and relationships that lead from one thing to another .
And considering these questions in the present with highly, highly charged emotions and a tragedy in the backdrop, well . . . it's not easy.
Which brings me to Arapahoe High School. As a matter of full disclosure, my husband and I are Arapahoe High School parents and our son was in the school during the shooting.
This was such a horrible event and what I think we were most struck by was Claire Davis herself and the beautiful message of love, forgiveness and laughter Claire and the Davis Family gave us. To me this really was an historic moment and the Davis family appeared so ahead of their time.
With respect to "mental health" and "uncertainty," the sad truth is that mental health professionals struggle mightily over questions of danger to self or others -- and sometimes they get it wrong -- James Holmes (Aurora Theater Shooting), apparently Karl Pierson (Arapahoe High School), etc.
After decades of seemingly floundering medical research, the National Institute of Health (NIH) and the National Institute of Mental Health (NIMH) have committed to improved funding procedures for research AND it really is starting to bear fruit -- most importantly bio-markers for "mental illness."
We now know that "schizophrenia" is a misnomer AND what we have been calling "schizophrenia" is actually "8 distinct genetic disorders." Research has found bio-markers in the blood of people with depression.
So all of this is great news right? Well it is and it points to much better risk assessments sometime . . . in the future.
Of course, we're living now in a CYA Culture and when that comes to mental health one need look no further than the Aurora Theater Shooting and the Arapahoe High School Shooting to see how this plays out.
Aurora spawned all kinds of activity to amend and wordsmith Colorado's civil commitment laws even though the law wasn't the problem in Aurora -- it was a good faith mistaken clinical judgment.
Arapahoe is well . . . sad. Certainly some students and parents are disappointed in the handling of things and the apparent attempts to muzzle security guards.
I think what the Littleton School District would find is that the community wants to support both the administration AND the security guards.
Maybe the example of Claire Davis and the Davis family could lead to a reconciliation.

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DAMN IT -- WE NEED PEOPLE OUT OF THE CRIMINAL JUSTICE SYSTEM -- WITH ALL APPROPRIATE SERVICES & SAFETY PROTOCOLS --- NOW ---- & AS FAR AS I KNOW THAT MEANS MEDICAID

11/1/2014

We can't wait any longer, people are dying AND saying we're now not going to subject people with mental illness to "administrative segregation" is NOT near enough.
The misguided idea that we can subject people with "mental illness," brain injury, neurological disease or developmental disability to further emotional trauma to obtain some penological goal is in itself delusional and not based on any evidence that I am aware of.
We need to be able to ramp up the CO Medicaid Community Mental Health Services Waiver that has struggled and struggled to be relevant to the actual needs of people with "mental illness."
( For more "insight" see our Instructive Comparison of the HCBS-EBD Waiver & the HCBS-CMHS Waiver)
At the top of the list --- Assertive Community Treatment (ACT) and ULTRA Intensive Case Management -- on a daily basis if necessary. And if we are really smart "housing as healthcare."
WE CAN DO THIS & WE NEED TO DO IT NOW!

Let's Start Costing It Out NOW for this Upcoming Legislative Session.
Some of the Intended Benefits:

Terminating the practice of putting people with bad behaviors in torture chambers (aka modern prisons & jails) to "teach them a lesson."
Terminating the practice of scapegoating people from jailors to judges in impossible positions with inadequate alternatives and training.
Achieving greater community safety than what we currently have.

Research reveals that get-tough tactics may worsen rates of juvenile delinquency
http://www.scientificamerican.com/article/how-to-turn-around-troubled-teens/

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Val's Blog

Val's Waking Nightmare

We Can't Handle the Truth about Intent, Mental Disorders, the State of the Science, or our Failed Service Delivery System

Let's Get Serious AND ACT

Let's Have An "Open Dialogue" About the Need for Standardized Mental Health Risk Assessments & Statewide Support for Professionals Making These Difficult Decisions

How Arapahoe High School & the Rest of the Country Got To Now: Mental Health, Uncertainty, & a CYA Culture

DAMN IT -- WE NEED PEOPLE OUT OF THE CRIMINAL JUSTICE SYSTEM -- WITH ALL APPROPRIATE SERVICES & SAFETY PROTOCOLS --- NOW ---- & AS FAR AS I KNOW THAT MEANS MEDICAID

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