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26 Jan 2022

Category: CASE MANAGEMENTCategory Archives:

Recovery and self-Determination: being authentic with our mental health practices

The Fear 

When people carry a mental health diagnosis there is an almost constant fear of relapsing. Whether from a long-standing chronic condition or new diagnosis, the fear of symptoms re-activating or worsening, is a real problem for people who suffer from mental illness. 

Some common questions are: 

Will I always feel like this?.

What if my symptoms return?

When will I be recovered?

The Myth

First, let’s dispel a myth. People are in control of their health and healing. People are not a the disposal of their illnesses. Keep in mind you have complete control over your mental health and do not need to live in the fear of a lifetime of arbitrary and unexplainable turns in your daily health.

Despite what some people believe, mental health can be managed and maintained with some rhythm and predictability over the long term. There are contributing factors impacting our feelings and what we think, but these are just markers. 

Self-Determination

I believe in self-determination. For people to maintain their mental health, recognizing new symptoms when they activate and working on eliminating the impact of extraneous factors contributing to limited or poor mental health is truly a great place to start self-managing. Additionally, self-determination is the mobility needed to work on ourselves. With enough self-awareness, people will soon realize their strengths, as well as limitations, come from within. 

Sure, some people are put in impossible situations. Some are born into poverty, victimized, abused, and maltreated. Still, even in these circumstances, some rediscover resilience and make it, despite the seemingly disparate nature of their problems.

A Lifespan of illness: Chronicity

People fear relapsing. People, regardless of the success often lose sight of the bigger picture. For people in recovery, the road ahead can seem long. Seem long, and belong if your illness is chronic and likely long-term. For young and even middle-aged people a lifetime ahead can seem like a lot of work or too much effort to sustain long-term across the life span.

Maintaining good health will only make a living more manageable and tolerable in the long term. Creating and allowing for more solutions during difficult situations and making everything more manageable, aside from remembering this reasonable explanation for why people lose sight of their recovery plan.

Recovery plans, self-care, and being authentic with our health

Remember, rationalizing or discontinuing behaviors promoting healthier decision-making is a step back from acceptable self-management practices. Instead, consistently engage in everyday routines and self-care measures during the tenure of their illness. Due to several reasons. Sometimes people deem themselves as cured. People often encounter a seemingly impossible situation created by their negative behaviors as a result of playing out symptoms of a disorder.

Whatever the reason, there are many, almost infinite self-rationalizations people can manifest to discontinue critical self-care practices. Negative self-messages people create usually become cognitive distortions, seemingly real and authentic, but at the root of it, are untruths and outright lies your minds manifest. 

Self-CBT

Distortions are maladaptive, unhelpful, and sometimes frightening, and if we follow these negative thoughts to their horrific conclusion, they are disturbing to most of us from experiencing them. Self CBT, disputing and challenging these rationalizations every day, and when they first occur, will go a long way in sustaining your positive behaviors and persisting towards your goals for yourselves and good mental health.

Ultimately, when people are left to their devices, they set limits and create better solutions.  Life can sometimes seem like we are on a ride or just passengers in our lives. Driving your health forward at a rate and speed and course of your choice is the safest bet. I recommend allying with your therapist, treatment team, and close peers with a vested interest in your mental health, establishing a deep trust with those who have close personal contact with you every day.

In doing so, collaterals may detect an extreme and toxic abnormality in your health. Feel safe to take stock in their advice and concern very seriously. Sure, no clinician or friend can get a perfect read on our health. But for those of you without a great deal of self-awareness or drive to look after yourself, there are still options and strategies to stay healthy without relying entirely on your own devices. Indeed, not everyone cares enough about their health to self-monitor all the time. 

In other cases, the priority of the day will capture our attention, e.g., paying the rent, housing, and employment. Disruptions to our mental health and even put our lives in jeopardy regardless of diagnosis. Regardless, taking your health and the quality of your mental status into your own hands is the best way to maintain good mental health and reduce the likelihood of relapse.

Plan ‘B”

Staying connected with collateral contacts to delegate health needs is a great plan “B”. When your self-care takes a back seat to the priorities of life, working towards good mental health might mean leaning on a friend or family member for help. A second more short-term plan can always be handing out responsibilities or delegating. 

Upon feeling too overwhelmed to get chores and other ADLs done, ask family, friends, and those you trust to help. For some of us, our disorder disrupts our capacity to stay connected to reality. Disruptions can take the form of elaborate delusions, which complicate our interpretive eye to know what is truly happening with our health.

Impression

In the end, manage your own mental health and be independent. Have a plan, and have another goal when the original road map to better health becomes unworkable. Ultimately, whether you have a chronic condition or an acute diagnosis, relapse is only to be feared when you aren’t doing what you need to do to work towards better health and healing. 

Relapse is real. Relapse is awful. But it isn’t the end of the world. Relapsing and experiencing the renewal of old symptoms can still remind you to get back on track with your recovery. Keep going! Don’t stop! When you stop taking care of yourself, be prepared for your worst fears not just to haunt you but become the grim reality you feared so vehemently instead of investing the same mental energy in health and healing.

The Communication and Support That Allows Progress in Treatment

To make progress in life, maintaining a presence in mental health treatment is needed for many people. Personally, I know there are barriers to maintaining a presence in treatment. The goals of a practitioner and someone receiving treatment do not always coincide. It is interesting to determine at what point the purposes of the consumer and practitioner intersect. I know that treatment is beneficial in my life, but communication has become very difficult with service providers. For this reason, support needs to be established with common goals in a therapeutic alliance. 

Goal setting in treatment may be one way to establish a common ground and language. However, varying temperaments in a therapeutic relationship will slow the road to meaningful therapeutic gains. There are inevitable conflicts, with baggage on both sides hindering real productive communication and goal setting. Ironically, sometimes it is the practitioner that carries more weight and credence to drive treatment forward. Objectivity is difficult whenever people and perception are involved, as everyone has the best idea.

All too often, treatment gets disrupted, many times, without warning and naturally throughout care. When progress and accurate work in treatment unravel, establishing or resetting a goal and kickstarting the momentum of the work is almost impossible without a social worker communicating the clinical play by play when cases have robust moving parts. When personal ambitions interfere with goals, it also may be challenging to maintain the ethical reins to keep treatment smoothly and without incident.

In fact, specific measures such as more extended unnecessary hospital stays could be avoided in some cases with better communication from the treatment team. Certain attitudes by social workers may exacerbate symptoms rather than give relief when a clinician takes cues from the wrong parties or isn’t truly engaged in their work enough to be a real changemaker and cheerleader in their client care.

All too often, patients are triggered by treatment providers without empathy. These feelings can lead to an ‘episode’ or the unraveling of a patient’s progress to date. Sometimes, these clinical missteps are so critical and negligent they make further treatment and additional clinical services necessary. With proper caution executed, and good listening with precise language, treatment progress can be maintained and preserved during touch-and-go blips that arise during care provision. 

With a well-seasoned treatment team, enrollment and selection of programs and tandem services after discharge can be successful for many years. In the end, treatment at one level of care cannot go on or be maintained indefinitely. With time, everything changes, and someone may show the most signs of relapse when significant progress is being made. 

For this reason, identifying valuable resources for patient education is critical for long-term progress after discharge and incredible natural support for patients to draw from when other artificial supports are inaccessible. Some supports need to be titrated down for the well-being of the consumer. When someone craves independence, but their goals are being withheld, severe conflict may worsen psychotic symptoms.

In cases of serious conflict, the proper change may be medication, but there may be more going on in the environment, or socially that can ease the episode. Changes in both may be needed, but good communication and appropriate support can certainly help to calm an attack. 

In the end, the nature of life is dynamic, mental health treatment should be regarded as such. If life becomes stagnant due to failure to understand the needs of someone, symptoms can flare up. In worst-case scenarios, prison may be an outcome. However, communication and support are more attainable with grasping the history of someone. Responses will be more appropriate, and crises can be avoided with a reasonable, empathetic method of questioning. 

How a brain injury through an accident enabled the help, I deserved but wasn’t getting

Most of my life before I gained the recognition of having the serious mental illness of bipolar was bright, activity-filled, and fulfilling. It was really only a period of less than a year that I can recall where I had symptoms that demanded I see a doctor. Unfortunately, the next 9 years of taking medications and intensely pursuing schoolwork did not bring about much of a recovery that was long-lasting. Although I attended groups at day treatment and was compliant with my medications, my life fell in shambles in the spring of 2007. I had been searching for 4 years starting in 2003 for a treatment that could help my whole sense of being.

I had felt that day programs and cognitive behavioral therapy were not going far enough to help me to return to the self that I recalled from the 80s and 90s. I can say now in 2020  that I clearly recall myself then. In fact, there’s a wealth of emotions, good and bad, that have returned to me more clearly in the past 13 years I have been receiving treatment for my condition- for my brain injury, not for bipolar. There are 2 main doctors I can attribute to major recovery in my sense of self for many years.  They are neurologists, not psychiatrists. Neither of these doctors prescribed medications for my bipolar but helped me understand my illness and head injury in the context of my life story. No psychiatrist I have ever had has taken my life story into account and addressed me accordingly.

However, my neurologists have. The past is very important in the context of the brain. With this taken into account, I have been prescribed speech therapy. This helps me restructure my thoughts into patterns that are more clear and easier to describe. My life has become much easier from the addition of this therapeutic since 2016. This is something that could have helped me before I had the head injury. So much of what I was searching for in 2004 has actually been manifested since proper treatment from a neurologist and neuropsychologist. 

So why isn’t speech therapy widely recognized as effective for people with serious mental illnesses such as schizophrenia and bipolar? I know in my case that this was only available because of my diagnosis of a traumatic frontal lobe head injury. I have regained some short-term memory, problem-solving skills, and reading comprehension. Those were things that I had wanted for over 10 years, but I was basically told that this person was forever gone. People with schizophrenia-related illnesses often need attention in these areas. 

I gained the help of a neurologist in 2015 through self-guided advocacy resulting from constant dizziness in my group home apartment. No one had ever thought of this, despite my visible lack of balance. This took an all-night-long emergency room visit and a referral to an institute that specializes in treating neurological conditions. The referral from a neurologist to a physical therapist for my balance and speech therapists for disorganized thoughts has completely changed my life. I have suffered disorganized thoughts for decades. I guess that disorganization truly Is a symptom of my illness, not just my brain injury. The sense of self I have recovered is mostly possible with neurological treatment. Compliance with psychiatric protocols, but with advocating for my best interests, is also necessary. 

I think my story, although tragic at parts, illustrates the need for serious mental illnesses such as mine ( bipolar 1 with psychotic features) to be seen as a whole-brain phenomenon, not simply something that only behaviors can mitigate in therapy. But no one generally goes through things like what I did. I am fortunate to have survived this brush with death. Other people with severe brain illnesses like mine have similar experiences that, like mine, could have been prevented with more cognitive restructuring therapeutics that restore emotional well-being.

The Law does not mean anything to Brazil’s Psychiatric Institutions & Therapists

Francisco’s Case

The Brazilian Law 10, 216 of 2001 clearly states and prohibits all Brazilian psychiatric institutions and asylums in the nation from any forms of bad practice, ill-treatment, and torture against people with behavior, mental health diagnosis, and all kinds of inhumane practice, according to the Law. However, the psychiatric clinics continue to, again and again, follow cruel rules. These include raping, torturing, killing, kidnapping, forcing people into institutions, beating the patients to death, and even starving them to death literally, and there has been very little accountability. 

Francisco’s death is evidence of these abuses, violence the lack of accountability for these kinds of crimes. Francisco Osvaldo, a patient at the Sao Francisco Neuropsychiatry Clinic, died three days after returning home with signs of aggression and abuse. 

Francisco Osvaldo Dias de Sousa was 38 years old an inventor, a strong, healthy man who lived with his mother in São José de Ribamar, in the metropolitan region of São Luis – MA. Francisco suffered from depression and bipolar disorder. He had been using controlled medication continuously for about 13 years. With the pandemic, he lived a healthy and everyday life, the Unified Health Service (SUS), which gave the inventor the medicine. 

The UHS suspended the medication supply.

According to information from family members, the employees claimed that the reason for Francisco Osvaldo not getting the medication that he needed to treated his condition was caused by the COVID-19 pandemic. And that the medicine did not reach the State Pharmacy of Specialized Medicines (FEME), to pass it on to patients. 

Mr. Francisco Osvaldo was working and an inventor that he even created a ( patent) brand for the automotive market. The family started to buy the drug that Francisco needed. However, due to the period, he was without treatment, which always guaranteed him the quality of life. Francisco started to have outbreaks of crisis. He had to be taken by medic emergency (SAMU) to Nina Rodrigues Hospital on 11/24/ 2020. 

The following day, 11/25, 2020, he was referred to the São Francisco Neuropsychiatry clinic, located in the Operária City neighborhood in São Luís. According to Francisco’s sister, Sidney de Dias, visits were initially allowed on Thursdays. However, when Francisco’s mother realized that he had signs of maltreatment, in his body like bruises, over his body the visits were suspended. From 12/31/2 the suspension continued on the grounds social isolation was needed due to the COVID-19 pandemic. 

On 03/05/2021, the mother tried at least one phone call in an attempt to speak with her son, but the social worker claimed that it was not possible to talk to him because he was troubled and agitated. Strangely, on March 10th, that is, five days later, he was delivered to the family, without prior notice, in the company of the same social worker who informed her that he was already well and with a guide for treatment at the CAPS”, says the sister. 

According to the family members’ reports, the young man’s health status was frightening: Forty kilos (40 kg) thinner, with marks of aggression on his body, bite, black eye, and total confusion. His health was already so fragile that he died three days after being delivered to his family. With evidence pointing out ill-treatment, torture, and total medical negligence, which would have led to the man’s death after a long pilgrimage to the hospital, he could not resist passing away.

To this day, there has been no public condemnation about the institution that has harmed and caused Francisco’s death.  

After Francisco’s passing family started researching and seeking the truth behind Francisco’s sudden death, they learned that he was not the only victim and was not an isolated case. Five years ago, a young man name Vitor Vinicius Sallys died at the age of 21 at the same clinic in very similar condition. Young Vitor Sally’s Mother found him dead inhumanely, with broken teeth, fractured arms, and ribs. 

We also know the other patients are currently suffering and are at risk of life and death because of the abuses.  The Law 10, 2016 of 2001 prohibited psychiatric clinics from applying any inhumane treatment of the old asylums continues disregarding the Law. 

The Value of Good Complex Case Management for Comorbid Psychiatric Issues

In the battle of maintaining mental health, unique tools may be needed when desperate times call for them. Understanding what tools are needed for specific circumstances can make the difference that keeps life from falling apart. 

In terms of adjusting, complex mental health conditions such as schizoaffective are complicated by physical ailments such as a brain injury. In this circumstance, the therapist may utilize specific tools to simplify the person’s life and allow for functioning to run more smoothly. 

One such tool that I have had to utilize is speech therapy due to a cognitive-communication disorder caused by my brain injury. Www. Healthline.com states that cognitive-communication conditions can result in memory issues, problems in problem-solving, difficulty speaking, or difficulty listening.  

Although I have had my brain injury for nearly 14 years, I find that maintaining my presence in speech therapy once yearly can help to keep me from slipping too far into the maze of disorganization. 

Speech therapy is probably better known for children, but speech therapy for adults can help adults with speech, language, and cognitive-communication (www.healthline.com). 

I initially needed speech therapy at the hospital following my physical recovery. Still, I went for close to ten years after my hospital discharge before anyone determined that I needed speech therapy again. Yet, the main push that made neuropsychological evaluation necessary was acquiring more independent living after eight years of group home living—the results of this evaluation, in turn, allowed for a speech therapy script from my neurologist. In turn, a neurologist was assigned to my team because of an overnight emergency room visit resulting from dizziness. 

The neurologist initially prescribed for dizziness and speech therapy due to other conditions evaluated by my neurologist. Once I was in speech therapy, tools were used, such as flashcards, to help me form word associations better. The treatment team heavily emphasized the pragmatic re-organization of objects in my room. The team and I determined that thinking would be made more apparent through a more structured environment. 

Speech therapy alone was not an automatic cure-all to my disorganization and trouble structuring my life. Thankfully, with the combined approaches in therapy, my skills at cooking, shopping, and organizing my living space only continued to improve dramatically. 

The speech therapist provided tips for forming a grocery list and provided quizzes in memory and cognition that I found especially difficult. 

Therapy helped my independence progress to my current situation. I am now living in a residential neighborhood. 

These were some tough times that highlighted the need for speech therapy. At the time of my neuropsychological evaluation in 2016, my concentration, memory, and ability to form complete sentences were in slipshod condition. Some of this may have been affected by my schizoaffective disease, but my traumatic brain injury allowed for a speech therapy script. 

The intensive Speech therapy at a rehabilitative agency assisted with my speaking. With time and careful and comprehensive work, the very structure and semblance of the order became more visible in my apartment and living situation. 

However, my efforts were not always enough, and on two occasions, I was given rental violations due to my disorganized apartment. 

Communication is critical in complex case and care management due to .my brain injury’s complexity. Without question, I had a more challenging time living up to the standards needed to survive in the treatment apartment system. Yet the only way anyone ever understood I needed a neurologist Is because I spent a night in the medical emergency room. Yet I had complained Of dizziness for years. If my TBI condition was this serious, then why did no one ever consider that some of my problems could have resulted from this? 

If my brain injury was considered a critical comorbid issue requiring careful planning, the transition might have been easier. However, my brain injury wasn’t considered in the larger clinical picture at work by the psychiatric establishment. While the oversight may have had to do with poor care coordination and the transfer to a psychiatric ward, I was transferred to the state psychiatric hospital after the brain injury rehab unit dropped the ball. 

The reason for this quick shift out of the brain injury rehab unit was the insurance running out. However, being given more time for recuperating would have helped things move along so much better. At the very least better communication from one level of care to another could have ensured that the transition to independence would have been smoother. 

Yet as taught by my counselor, gratitude for my present situation helps offset additional mistakes. However, I do know that in my position, more than feel-good coping skills. Ultimately, I think this is the case for the mental health system—greater awareness of a whole person, which will allow for smoother transitions and more minor crises.

My journey in mental health housing and recommendations for change and reform

Those of us with mental illness know full well that there are many challenges required of us. Acquiring and maintaining stable housing is one of the biggest challenges of them all. With a complicated condition, the healing journey can be difficult and even more dangerous without stable housing.

My mental health housing system was strenuous and trying throughout and during the tenure of time, healing from a brain injury and schizoaffective illness living wasn’t exactly a cakewalk. My dual diagnoses presented unexpected challenges that created multiple obstacles to living independently without incident.

To live the way I wanted was viewed as impossible by the ‘higher-ups’ and powers in charge at my prior mental health living residences. It was hard to show my strengths and how resilient I was despite my illnesses. Thinking back, I have to ask: why did it take over 12 years to transfer me from continuing inpatient hospital care to private living? Seems like a long time to wait for living in a residential neighborhood of my choice?

I must stress that I am thankful for the skills I picked up along the mental health system. From self-management skills in hospitals and supervised living residences, I relearned how to be more independent. At one point, it seemed like a stretch to my case managers at the group home to move me to apartment care. They opened my eyes to things I never knew that I was doing to interfere with that goal. We all needed a lot of patience exhibited at certain times to learn how to get closer to my destination without further setbacks.

On the other hand, I am not thankful for how the mental health system delegitimized my goals for independence. It’s one thing to be instructive or ‘directive’ about following instructions and recommendations for self-care, but it’s another thing altogether to underestimate a client’s intelligence.

A primary goal of mine at the state hospital in 2008 was to make something of myself after all that I had been through. After a self-harm episode left me in a six-week-long coma with a subsequent frontal lobe traumatic brain injury, I was lucky to have an exceptional neuropsychologist who inspired me to show the world my mettle.

This yearning Paid off: By 2017, I had earned two scholarships and had maintained my position as a group facilitator at the state hospital for four years. This achievement started in 2009 when I went through an educational training program and continued my SUNY studies.

However, recovering from frontal lobe traumatic head injury with lots of stimulation in subsequent group residences was a difficult task indeed. Thankfully, I maintained the same residential housing for seven years after my discharge from the hospital.

It was the transition into apartment living that threw me for a loop. The continuation of care across all levels was indeed a challenge for the case managers and me.

Some symptoms of TBI plus schizoaffective came out more frequently at the apartment level. Two episodes created a significant problem for me. They led to a supportive apartment arrangement through SPOA (single point of access), resulting in a two-week-long stay at a motel between residences.

For most of my time at the group home level, my positive symptoms were generally under control. Yet, due to the increased stress at the supervised apartment level, positive signs made the worst appearance they had since my hospital stays ten years prior.

Because of these sudden episodes, I believe there was a lack of communication across all levels of care in hindsight. The transition could have gone smoother. One thing that would have helped would have been a greater acknowledgment of my favorable traits by case managers. Also, my counselor at my treatment agency could have helped me mentally prepare amidst everything I was involved in. The road ahead would mean Consecutive scholarships, orientation for Roswell Park Cancer Institute, and group facilitation at the state psychiatric hospital, amongst my move.

Yet, I think it’s common practice for treatment providers to delegitimize patients and clients, unfortunately, because of this. I had a tough time In the 2.5 years spanning group home to my current neighborhood apartment. I am thankful; meanwhile, I now in my independent apartment, and I know I had to get here in one way or another. If I had stayed at the group home level, I would have felt cheated out of my destiny. This conflict may have created worse problems down the line than what I have already described.

Since I understand my dual conditions complicate my level of functioning, I feel very fortunate to be where I am now.. Since there is little outside stimulation in this arrangement than there was at the congregate care, there’s been practically no issues that can’t be resolved without my treatment agency or my landlord. There have been very few problems here.

I am Also thankful for a hospital diversion program at my treatment agency that allows for phone communications throughout the pandemic. They were instrumental in my transition from a treatment apartment to a residential apartment.

Some things worked out well for me. Other experiences could have worked out with less incident. The overriding theme is that communication could have been better across different levels of care coordination. Especially since I experienced significant trauma that not even my counselor considered until I made clear it was a real issue.

Indeed, more effective trauma-sensitive approaches in residential treatment should become prevalent since people with mental illness experience trauma at a high level.

I know that with an in-tune trauma-sensitive approach executed with more respect, the transition would have been better, and some incidents would have never happened in the first place. Mental illness is a thing, but better communication will ease its effects across all mental health care systems.

Systems-based disparities for African American Medicaid Recipients in the NY OMH Article 31 Clinic

“WHAT DO YOU MEAN I’VE BEEN DISCHARGED?”

“YOU’VE MISSED TWO SESSIONS. WE TALKED ABOUT ATTENDANCE, AND IN THIS CLINIC, IF YOU MISS TWO CONSECUTIVE SESSIONS, IT WILL RESULT IN YOUR DISCHARGE”

“DISCHARGE? I’M GOING END UP IN THE HOSPITAL!”

“YOU’RE ALWAYS WELCOME TO REAPPLY FOR TREATMENT WHEN YOU’RE READY TO COMMIT TO YOUR MENTAL HEALTH“

Tell me: is your skin crawling? You’ve heard this before. Or maybe you were complicit, or even worse, believe it. Remember, commitment to therapy is a two-way street. Invest in your care as a patient is not just a reflection of attendance or frequency of psychotherapy sessions. In a system where contact and numbers are driving clinic scheduling and reimbursement for therapy, ‘welcome’ and ‘ready’ reflect dollars and cents.

The conversation that just transpired is common practice in many outpatient mental health clinics operating on state Medicaid benefits and insurance to pay for treatment. In New York, the ‘Article 31 clinic’ (free-standing mental health community clinic) continues to be the semiotic locus for mental health treatment for impoverished, low-income, and disabled Americans seeking psychotherapy or medication management for psychiatric illness.

Clinic directors are under the clinical gun, “wire,” and mandate to move nonpayers or unreimbursable sessions and the clients that need them off their census to lower deficit and overhead.

This overhead eats into profits, hiring, staff retention, and other clinic operations needing money to keep the doors open. The management issues around Medicaid are numerous, and the system is broken. The fix, or solution by the NYS Office of Mental Health, has not been the loosening of regulations around line items keeping a patient enrolled in treatment.

Instead, the government launched studies and other programs to fix the deficits and cracks within the NY Medicaid system. Programs like HARP, after the silos, fell, and the rise of Care Management is now out there evaluating and reevaluating the impact of these cracks on the care and provision of treatment inside mental health treatment centers and clinics. The system is looking at itself, albeit slowly. Iinternal affairs is at work in the system. HARP (a program in the new Medicaid redesign will see if the system is able to correct itself. Future investigations by independent researchers to revise Medicaid further will look at HARP outcomes to chart a new course for Medicaid and benefits associated with being under the auspices of the ‘system’s care.

Initial findings suggest more flexibility. Well, ask any provider already treating African Americans and other oppressed populations which historically have connectivity issues with outpatient free-standing and hospital-based clinics with rigid rules for treatment is a gosh darn no brainer!

I mean, who would have predicted folks without cars, and a few dollars to their name, can make the time to take four busses after work and get to therapy when the pressing need at the moment is putting food on the table. I can tell you one thing if a child went without dinner and CPS (Child Protective Services) got involved, which is more likely if you are an African American family, there is no right path forward. Treatment or dinner? Wait for a second, arent both requirements for survival?

African Americans and low-income service recipients are NOT given a VIABLE way ahead in treatment. Certainly not stable enough to reap its benefits.

Instead, all too often, barriers and cracks within the system, which continue to be a problem today, are working at the cross purposes of the people seeking its very care. Ladies and gentlemen, this isn’t inaccessible. It is dangerous to the consumer. We need to loosen regulations in treatment, and we need to do it today. Forget moving the problem patients into the hospital into some psychiatric limbo until a paperwork nightmare and systems snafu is worked out. Passing the problem along is too easy, and asking why this happens is far too often a question we forget to ask as advocates fear ruffling and creating waves in the system.

We need answers to the disparities today. If not now, when? 

Ask yourself and your collegues:

Why do these systematic issues exist? 

Where are they coming from? 

How do we eliminate them? 

 

In the end, it might not even be a program or internal mechanism to correct our failing mental health system and the inherent disparities. It can be as simple as offering more ‘solutions-focused therapy’ as a billable treatment or medical intervention for insurance reimbursement, allowing consumers to come to treatment when they need treatment and not just when prescribed for them. 

Following NYS regulation is a double-edged sword, though. How would this work in terms of therapy and conducting treatment? In most Article 31, the frequency of contact a therapist has with a patient has implications. First, it is considered bad practice to have erratic contact with a client. If contact is sporadic, there must be a clinical explanation for the irregular intervals between therapy sessions. 

I suspect, in the end, this goes back to issues around Evidence-Based Treatment (EBP). 

NYS Office of Mental Health (NY OMH) and other state un regulatory commissions in Mental Health push EBT as the gold standard in care. Wait a minute, why is EBP the gold standard of care if it isn’t the best treatment fit for BiPOC communities? Why should the push be to keep clinics to “best practices” to keep their doors open and -licensed by the state commission to operate if therapy doesn’t work for everyone? I recommend keeping these questions front and center when evaluating the disparities in NY and other states for black and Latino communities in the community mental health clinic. 

MARCH WINDS AND APRIL SHOWERS BRING MAY REVENGE

In 1886, a proverb came into being: “March winds and April showers bring May flowers and June bugs.” Some people have altered the meaning and made it into a joke. March winds bring April showers which bring May flowers, but what do Mayflowers bring? The answer is “Pilgrims.” Not very funny, but very punny, one might say.

The saying is also altered for this particular story, “March winds and April showers bring May revenge.” It begins in Delray Beach, Florida, a warm sunny day with no clouds in the sky but quite windy whipping across the land. A man, 39, born in Houston, Texas, sitting on a red rusty bench in front of his house. He is both contemplating his past and thinking about his future. What was done is now done, he thought to himself. He cannot change this, but this mantra can guide life ahead. This man is feared by many. His name is Eddie Franklin, Jr.

His ex-wife is Laura Haines, 38, with long light brown hair and eyes. She stands about five feet four inches and is extremely thin, and has long, slim legs and well-developed arms. She is outgoing and has several friends nearby. On December 13, 2001, they were married and had no children and were divorced precisely five years later. During the entire marriage, people speculate that Laura had extramarital affairs. Jake Pierson, 39, Eddie’s best friend for many years. They met in first grade, and they spent lots of quality time together.

While drinking beer and watching Cowboys football together, Eddie would fantasize about catching touchdowns and getting all the women he wants. Something was off because he was cheating on his best friend. They eyed the same woman since high school, and she wanted to love them equally, but that is not possible. So she picked Eddie to marry and stay in love with Jake. Within a year after the divorce, Jake Pierson married Laura Haines. For many years, Pastor Joseph Meyer, 61, has led the church a few blocks from where Eddie and Laura lived. During all this time, he helped Eddie through his issues. Their talks began in first grade. Then it was a teenager, falling in and of love. Pastor Joe, which is the way he wanted to be called, officiated at Laura and Eddie’s wedding.

Besides, he intervened where necessary to keep their marriage together. What changed was when Pastor Joe married Laura and Jake. One day after his ex-wife’s wedding to his supposedly best friend, he was thinking about his first-grade teacher, Ms. Nancy Barnes. She was a total knockout, young and stunning. While she instructed us,  she was only twenty-five, with long blonde hair, deep blue eyes, with a huge smile that made her vivacious lips more inviting.

As a teacher, she led by strict rules. When you answered her questions, you needed to be always correct. If not, they were to put both hands on the desk, and then she would take out a ruler or some other instrument and strike us. The more wrong the answer, the more complex and the amount would be, ranging from one to five. 

And there was Cedric Downs, who was Eddie’s Lawyer Accountant. Although he was 78, he helped keep Eddie in the black. Also, he needed legal representation, and he did that as well. For Eddie’s divorce, he did not defend him and thought it was the right decision, and he took Laura’s side. Cedric was a heavy drinker, and he liked to play the horses. However, he was not good at it and often lost lots of money, a couple of times in the thousands. Since Eddie was twelve, he was always in trouble with his first arrest on August 13, 1993, for shoplifting. He was born on February 13, 1981, but he grew up relatively poor. At age 17, on November 13, 1998, he stole a TV and a couple of laptops because his family needed them.

The police arrested him, and Cedric was there, and charges were reduced. Almost two years later, he tied up, strangled, and killed Nancy Barnes with a ruler and other instruments. With masking tape, Eddie closed her mouth and her eyes, so she saw no one and could not say anything. Of course, since she was dead, she did not. 2001 was a unique year for Eddie. April 13, he shot and killed his ex-wife, Laura, and her husband, Jake Pierson. When he finished the killings, he robbed their house. On July 13, Eddie attempted to beat Pastor Joe to death outside of his church three months later. But the police were walking by, and Eddie was arrested for attempted murder. Again, he was defended by Cedric Downs. He was convicted for twenty-five years to life. Eddie had issues to deal with a few years earlier, so Cedric agreed to take him home. Other than the names above, most of what you read never actually happened. 

What did occur was that Eddie had an episode of Paranoia or a form of Schizophrenia where he thought this transpired. On his seventeenth birthday, February 13, 1998, he was diagnosed with Paranoid  Schizophrenia. A month later, he was committed to a Psych Unit. He was hospitalized on and off for the next eleven years. For those years, everything was real for Eddie. His treatment was agreed upon between his entire team, Eddie included.

With therapy every other week and medication from a psychiatrist monthly, his life has improved. His symptoms happen less often. During his recovery, he got married on December 13, 2002, to Laura Haines, and they have two kids, Katy, 14, and Ian, 12. Also, Jake Pierson was his best man, and Pastor Joe performed a wonderful ceremony. Furthermore, he has been an Architect for the same firm for eleven years and in 2019 was promoted to Senior Architect.

As one can see, having a Mental Health Issue can control one’s life. With the proper treatment and a healthier environment, one can exact revenge on their mental health issue. There will be bumps in our road to recovery, but we will survive! Eddie survived. This writer has too, and others can. 

MENTAL HEALTH LIVES MATTER. See you in the NewsBlogs.

Eleven years and no progress

The entire mental health system is not only broken, but it has fractured into tiny shards of ineffective state and local level outpatient programs, underfunded outpatient psychotherapy clinics, and psychiatric in-patient hospitals with limited beds and shortened length of stays.

This is the case for so many people in the public mental health system who cannot afford other treatments.

I still remember starting off my journey in the “system of care” after being discharged from a six-month inpatient stay in a state hospital facility operated by my state’s Office of Mental Health (OMH). I was still dysregulated at the time of my discharge, albeit eager to return home. The state hospital system simply doesn’t have enough open beds for the sheer volume of patients requiring this level of care.

Eleven years ago, my psychiatrist in the state hospital discharged me. I was clinically stable for discharge but still slightly symptomatic. While I could maintain my own safety (and not pose a risk to the safety of others) in the community, I needed 24-hour assistance and support from my parents if I was ever to survive in the world. The plan from the hospital was partial hospitalization until I could benefit from outpatient treatment.

I can still hear my friend Minerva prattle on the phone in our partial program about her career as a big-time writer.

“I’m on Lexington and Fifth, darling” Minerva repeated, loudly. “Darling! I’m with my literary agent! We just got out of a meeting in the boardroom, and it seems I am being published again!”

“Again! Yes, well, when you’ve been published this many times it’s a real bore!” lamented Minerva, taking off her sunglasses to look to check her makeup and fix her eyelash makeup through the tinted glass reflection. “A bore, can’t you hear me?!” she screamed into the phone.

“Minerva, is that you screaming? You know, there is a noise policy in this program!” A distant voice echoed.

“Minerva! I said, please stop screaming!” The voice was moving closer in proximity.

“Yes, Nurse Gottlieb! What is it now?” Minerva was almost smug with her tone, but more so with her eye-rolling.

“Minerva, you missed your afternoon meds! Wipe that smirk off your face! This is serious, you can’t just skip your meds, and make noisy calls outside the hallway when the group is in session. There are rules in this program, Minerva, and you will follow them!” Nurse Gottlieb exclaimed, starring Minerva in the eye, who was almost in shock by the directness and the tone of the nurse at the Ongoing Day Program (Partial Hospital) for the Mentally Ill.

“Get me out of here! I can’t stand this program!” Minerva said as she turned to me and kicked my leg in the treatment room.

“We’re going to the beach house this weekend, and you have an invite, Minerva. Everyone will be there. Just make sure you’re packed and ready,” I told Minerva to calm her down so she wouldn’t kick my leg anymore and we wouldn’t get in trouble with the staff in the program.

~

“How did you two meet?” My therapist inquired.

“In partial hospital…”

I elaborated at length.

I met Minerva in the Partial Hospital program after my discharge in 2008. I’ve known her for over 11 years, just about a third of my age now, 33. When I met Minerva, she had recently been in the hospital for a long time and was still hypomanic. Back then, Minerva was younger, hopeful, and supposedly ready to recover after a decade of ups, downs, manic extremes, and depressive lows. If it was an altered mental health state, Minerva had experienced it. In fact, she was passing through over the better half of the last two decades of experiencing severe bipolar disorder.

We bonded over mental health stories, mostly our own, and would meet for coffee during our stint in partial hospital.

When I attended graduate school for social work a few years into my recovery, we lost touch for a bit. After all, I was three hours away in a rigorous graduate program trying to stay afloat given the extreme nature of my illness and being new to recovery and healing from my own mental health diagnosis.

After returning home with my Master’s in Social Work (MSW), and becoming a licensed master (then clinical) social worker, I entered the system of care in my community on the other side as a clinician with my own psychotherapy practice. Given I was ramping up again, this time with employment and working, I didn’t have as much time for weekly coffee visits with anyone, Minerva included.

Venturing out into my own community where I had been hospitalized several times in the past and even had therapists of my own, I would run into people who treated my illness during the earlier days of my recovery. I also stumbled upon old faces, people like Minerva, and others, who I knew from treatment from when I was discharged from years ago. Now on the other side, it was rather awkward, especially in the case of Minerva.

I say this because when I reengaged with Minerva she was in the same spot as she was 11 years ago. Maybe even worse off. I am judging this by her level of care. Also, by the sheer amount of time that elapsed with little or no gains made in terms of insight into her illness or judgment when it came to repeated relapses without gaining additional perspective on her condition. Minerva was now in a Continuing Day program called PROs, which was on the campus we met at 11 years ago, just in a different building.

I couldn’t fathom going to the same small mental health campus for over a decade, and not benefiting from it whatsoever. During the last 11 years, Minerva had crashed another two cars during additional manic episodes and gone off her meds two more times without doctor supervision. When I found Minerva this last time, she was washing her laundry at the local halfway house, which was connected to the agency that subsidizes her supported housing program.

Eleven years and no progress, I thought to myself. This can’t be the case. I mean, it must take real work to stay in a holding pattern in life for so long without budging. Either that or she must be very sick or symptomatic most of the time. I would later find out that cases like Minerva exist everywhere, and she is no more unique than her biography is to other people with a mental health disorder who share their story.

“We meet for coffee every so often at the diner…” I said to my therapist, finalizing my thought.

faceless woman with pill in teeth and nose piercing

Reflections on Mental Health treatment: Recommendations for reform

There are general themes that circulate in the mental health world. Mainstream mental health seems to reflect the sentiment the patient comes to the mental health system broken. If this is the case, people need to rely on nurses and counselors for a sense of wholeness to heal and recover.

The work of doctors and social workers is invaluable. I question, however, that any healing or restoration of ‘the self’ is done without patient participation. What doctors do to accommodate humanity is essential. However, proper communication must be emphasized by treatment team staff and to patients by providers. Good communication relies on humility, too; often, doctors have a sense of superiority, eliminating the essence of humanity in care.

Psychiatry should consider that having problems is ‘ok’. Understanding people do not need to be fixed by medical staff should be another consideration for psychiatric training. Since human life and recovery are a puzzle, a sense of “complete” or “finished” is ongoing.
Since a doctor or counselor cannot restore a sense of wholeness fully, it is crucial to consider an inventory of factors before making a diagnosis or determination. Notably, the right balance of system intervention and self-determination is possible but takes time.

Faith in doctors and belief in one’s self are necessary. The ultimate balance relies on the individual.

Doctors continually prescribe different levels of restriction within a treatment, depending on the status of a patient and their behaviors/needs. In any case, maintaining humane treatment must be a necessity. Exclusion from a quality and unrestrictive treatment needs to hinge on more than perceived disobedience from a doctor. What is disobedience? Afterall?

Understand that there can be meaningful motives in rebellion. From my own experience as a hospital patient, doctors responding to noncompliance rather than reacting did a world of good.
I have overreacted in the past to psychiatric workers.

My overreactions were to behaviors I considered threatening. The threatening behaviors were from staff and based on patient/doctor relations. Yet, rather than looking into these origins, most teams suppressed or punished me. Instead of simply explaining why treatment was set up and operated the way it was and how the clinical process works. If they had spent just a little bit of time explaining all of this to me on a more humane level, I might not have been labeled as ‘noncompliant.’
Noncompliance carries with it certain connotations, mostly pejorative. When a patient is ‘noncompliant,’ it is essential to distinguish between the symptoms and allow for space and freedom to express their needs.

Making this distinction can make the difference enough to create a good outcome and a thriving individual. Inserting this freedom can also allow for the pathway to more voluntary treatment and reinforce ‘adherence’ over forced ‘compliance’ in care.

Mental Health Affairs 2022

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