Tuesday, December 18, 2012

Mental Health (or Lack Thereof)

We’re a country in crisis. There are more people with mental health issues getting poorer care and they have fewer places to turn and it just makes me SO SAD. Last Friday’s crisis had a fair bit to do with guns, as I mentioned yesterday, but more than that, it had to do with a person who desperately needed help.

First: Mental Illness

Mental illness is an extremely varied thing. By far the most common diagnosis is depression, which in women is more a sad, bluesy thing and in men is more an irritable, crabby thing. SOME depressed people are a danger to THEMSLEVES. Most though, are not that extreme, and they are NOT a danger to others. This is the very most common mental illness.

In addition, the OTHER things that can be wrong vary hugely. Depression and bi-polar disorder are MOOD. Schizophrenia is a PSYCHOSIS, which means hallucinations (either aural or visual—more often the former). There are disorders that disturb picking up on social cues. There are disorders related to conscience (or lack thereof). Some disorders can only occur when there is something wrong with the brain, others are more a response to external stressors, the most extreme of which is dissociative identity disorder which results from long-term abuse (usually sexual).

With so many faces, caring for people is complicated and expensive. Even just getting a diagnosis is a big job. Then you add to that teens and young adults, for whom choosing medication is a moving target. Their bodies are changing, so even finding the right thing NOW, may not be the thing that will continue to work.

Talking About It

Part of the problem is most people are pretty poorly informed. Oh, sure, we’ve heard of ‘disorder of the day’—which will go drastically overdiagnosed because it’s ‘popular’. But the real experience? It’s not talked about much. It’s stigmatized so people don’t feel comfortable sharing. And because it’s varied, when somebody shares a story that doesn’t fit somebody elses view on the matter, it can get really sensitive.

There were two great articles, one of which I will just describe, as the author is getting a lot of backlash for ‘outing her son’ as having a dangerous disorder—she was amazing to read—really experiencing a son with a snap temper that causes violent outbursts. The trouble is she didn’t think about his privacy in sharing—she used a false name for him, but not herself, so anyone who KNOWS THEM now knows.

But we CRAVE hearing that voice. It shows just how hard it is to navigate caring for somebody with that extreme an illness.

The other article I am happy to share (there is some swearing—you’ve been warned) about the REACTIONS and how difficult it is to have public discourse because everybody is so freaking sensitive.

Wonkette: Not Allowed to Talk About It

I ALSO strongly recommend Carrie Fisher's books. She has bi-polar disorder and a GIFT for humor when talking about her mental illness. Wishful Drinking is the one that comes to mind, but she has several.

Why So Much of It?

It seems like there is a lot more mental illness than there used to be, doesn’t it? I think there IS more, but in addition, I think we HEAR ABOUT MORE for three reasons: 1) more people actually seeing doctors that have SOME CLUE and get somebody to a system for diagnosis—plus people no longer just shut their ill family in an attic and hide them from the world, 2) over diagnosis (a false positive of those flavor of the week diagnoses) and 3) loss of ‘community’. People used to live near family—a collection of people who could help keep an eye, assist, and otherwise channel that ‘special’ family member. But families don’t tend to be proximal anymore, so there are a lot more incidents of someone getting ‘out there’ and causing all sorts of problems.

But in addition, life has more stressors (poverty, crime) and people experience more trauma. Both of these prime our brains to maladapt. Lack of near social resources. In addition, new medications, food alterations and environmental pollutants of things that NOBODY REALLY KNOWS the long term effects of probably are altering our brain chemistry. Look at the increase in allergies from when we were kids. Doesn’t it seem like if something can make kids allergic to stuff, it might be messing with their processing a little?

And then there is the bigger tools thing… Guns, like I mentioned yesterday. Bomb-making information as handy as the internet.

Filmed at Damasch--Oregon's old mental hospital
A History of Care

I mentioned shutting the nutty relative up in the attic. I’m glad we don’t do this anymore. There also used to be mental health institutions, lovingly referred to as Insane Asylums… These places were fraught with mistreatment, but they DID keep society safe, yeah? In addition, some people had nowhere else to go. The vast majority of publicly owned mental health facilities closed in the 70s. “Isn’t it better to have people at home?” Well, sure. If that’s an option. But some people don’t have help. And some help isn’t equipped for the HUGE undertaking.

Down the street a woman died last year who was seriously mentally ill. Her mother had taken care of her for decades (while the mentally ill daughter beat on her, no less) but the mother died maybe 8 years ago… The daughter had bouts of institutionalization, getting out and doing okay on medication for a while, but then falling back into a pattern that caused me to make my kids walk on the other side of the street. When she died, nobody knew for MONTHS. Alone. Shut in. I can’t help but think if we had facilities now that we might make a better attempt at keeping them safe, pleasant places. Though I know nursing homes often have abuses, too, so maybe I’m delusional.

The Solution?

You think I have a solution?


I do have some ideas though. I think the new health plan will help because more people will be eligible for coverage. I think wherever we can, increasing our sense of community helps. I know with HWMNBMOTI’s health trouble, neighbors and friends have been invaluable. I can’t imagine that wouldn’t be the case with mental health stuff.

But there needs to be an investment, too. And I think it starts in schools. Teachers are amazing and fabulous, but they need the backup. When I was a kid, ALL the schools had counselors. My kids’ elementary shared a counselor with 2 other schools. We’ve cut resources when we need to be ‘adding them’—well child type ‘visit and get to know’ meetings with ALL the kids once or twice a year, so there was no longer the ‘Oh, so and so had to go to the counselor’ ring to it.

PARENT RESOURCES—ohmygawd are parents already overstressed. Any system that would increase how easily they could find WHO they need and HELP they need would be good. Even respite help—taking care of somebody day in and day out is exhausting.

Extreme Measures?  Should there be institutions again? Yeah, probably. And I also would advocate, for a few rare diagnoses and with multiple doctors agreeing, that there are cases forced medication is wise--the two diagnoses I'm familiar with where people are fine medicated and can be dangerous (at least to themselves, but sometimes to others) off of meds are schizophrenia and bi-polar disorder (more so with the former)

I ALSO, and this may be controversial, believe there needs to be SOME SYSTEM whereby people can be flagged as potentially dangerous—spot the neighbor kid blowing up squirrels or something? That HAS to be reported. Animal cruelty is a high risk marker for sociopaths and psychopaths.

Would any of this have helped Friday? Maybe—I suspect that mom who made such poor choices wouldn’t have, had she had better resources to understand the risk her son posed. But maybe not. A school counselor might have flagged him. I have no idea. But I know there are a lot of people who could potentially be dangerous and we are very poorly equipped to cope with that right now.

[hey guys, be sure to read my friend Patti's comments, too. I have psychology education, but she is actually a clinical practitioner, so more informed than I am]


mshatch said...

Excellent post, Hart, I totally agree with everything you've said.

Patti said...

So the mental health piece is hugely important. I don't know the perpetrator's history in the system, but there are a few things I know about mental health care in general.

There is a huge lack of resources for civilians. I work within the VA, and the resources available to veterans vastly surpass what is available in the private sector. This is true both in terms of cost-reduced outpatient services and residential care. The program I work in would cost a civilian thousands and thousands of dollars. None of our vets pay more than $5/day for it. And food/housing is provided. That's dirt cheap.

Patti said...

(part 2)

There are still state psychiatric facilities with some longer-term care. They do still struggle with the problem of funding and ability to provide long term. Community treatment is best. Being with families is best. BUT without the resources to fully manage treatment and symptoms and employers that are understanding of taking an hour or two a week off for appointments, it's much harder.

But beyond that, wee need to increase the knowledge about mental illness and available treatments. Despite adds for happy-bouncy-pill drugs all over the news, our society doesn't know much about mental illness. The vast majority, as you said, are non-violent. Most are not "crazy". Beyond that, most people don't know that treatment is an option. Most people don't know that, for most disorders, we can manage symptoms to a point where you can be considered nearly "cured". For some, this might mean long term medication (e.g., bipolar disorder, schizophrenia). For many (e.g., depression, anxiety, PTSD), there's no reason to be on long term meds, if at all. People should know there are options and that they don't need to be on medication forever.

Patti said...

(part 3)

Even if people do know about treatment options, that there are services, and that in a pinch you can stay in a facility for a period of days (or longer in very rare cases), there are still huge barriers to care. Homelessness, unemployment, underemployment… many employers won’t allow an hour or two a week for individuals to receive good quality care. Forget give a few days off for inpatient or residential stays. It’s more likely that people will be “offered” time off with no pay, or even more likely, just fired.
The rate of mental illness among the homeless is HUGE. Homelessness among the severely mentally ill is HUGE. These are the folks who cannot maintain a job because of mental/medical health needs. IF the diagnosis were well managed, they could. BUT many are under educated, under employed, and uninsured. This is a HUGE problem. No insurance, lack of adequate employment, and huge cost of mental health treatment and medications leads to no treatment.

My biggest recommendation right now is that our society needs more resources for the mentally ill. Both in terms of funding for mental health services, but also transitional living facilities (e.g., group homes). Many don't have families/support for a huge number of reasons. In many cases, this is a result of symptoms of the disorder. Not necessarily violence, but social awkwardness. Lack of empathy. Inability to relate to other people. Impulsivity. Or just plain grumpy or mean. These folks still need a place to go where they can survive. I think some of the group living facilities could be an answer. Lets give people hands on job training as needed. A place to live with a community of people with mental illness and staff that can help address their needs with COMPASSION. Let's help people transition to the least restrictive environment possible, with a hope of independent living one day. This is NOT an unreachable goal for many with mental illness. EVEN the severe disorders.

There are also issues here related to education and the need for skilled labor jobs, rather than a strong focus on college education being the "only" option for people. That's another issue for another day.

But treating those with mental illness with kindness and dignity rather than ostracism and bullying and meanness is needed. Both by adults and kids.

S.A. Larsenッ said...

Fantastic post, Hart! I HUGE problem is the lack of talking about MH, sort of taboo for some reason. As a Nation, we need to change our way of thinking and address this issue with compassion.

Oregon Gifts of Comfort and Joy said...

Wow, Hart, excellent article! I am sharing it. I appreciate all of time that you put into it, and feel that you explained things very well.

Kathy M.

Hart Johnson said...

Thanks so much, guys. And Patti-especially all your fabulous knowledge and information!

Patti said...

There is so much about this that's an incredibly huge and important issue. I believe in rehabilitation of the psychiatrically ill. I know that it is possible. I also know that our society does not necessarily value putting the time, money, and resources into this task, so many are stuck being underserved. Yet we expect people to be able to function without help and without support.

Provision of care to the families of the psychiatrically ill is also critical. These supporters need education and their own support - it's emotionally exhausting to provide for those with mental health diagnoses. Yet these are the people often provided the least support. Historically, little support is provided for the "carers". It's a rough situation.

Alex J. Cavanaugh said...

Catching it early could make a huge difference. Be even better to find the causes and stop it from happening in the first place. I do think there are a lot more cases now. What are we putting into the body and brain that messes us up so bad?

Ella said...

We need a few more safety nets, in place. Not everyone is going to talk to their pastor/minster. It feels like an ocean filled with seaweed and how to we treat it all! I think most people, at some point in time, will have depression. Women I do think because of the hormonal swings are more likely, but men get it too!

I think of your gun post and this one, about mental illness and wonder about Newtown, CT. Why did a teacher who knew her son had a mental illness, put a gun in his hands? She taught him how to shoot. Why?

Education is key! We need more tests at school. We as a society need to be educated and we need to tattle. I hated in school, when the teacher, said not to tattle. WE need to talk and tattle and be proactive as a society. If we witness someone doing or saying something that is odd. We may SAVE a room full of students or a movie theater crowd,or a mall full of people! Tattle people!

Patti said...

As an added challenge, we in mental health industry have very little that predicts violence. Best predictor of future violence is past violence. So the aggressive kids who are fighting or harming animals.... They should receive targeted intervention. Clearly. But screens for depression or anxiety or PTSD or even schizophrenia or aspergers won't predict violence very well. Asperger's isn't characterized by that type of behavior.

Even more so, there is some research suggesting that personality disorders are more predictive of violent or aggressive action. Antisocial personality disorder (ASPD, characterized by severe tendencies to go against societal norms, use people as means to an ends, not care if they harm others, etc) is most notable, tho borderline or narcissistic folks may also fit the bill. Personality disorders do not respond to meds, and have limited success with behavioral treatments. We have seen high success with dialectical behavior therapy for borderline PD (with some research suggesting efficacy for antisocial traits), but that's it. We don't know how to treat personality deficits. Antisocial tendencies are seen in kids - oppositional-defiant and conduct disorders are prerequisite for diagnosis with ASPD. However, many kids grow out of those behaviors as they mature. We know there is a disproportionate number of people with ASPD in prison, which fits the disorder well. But we can't treat it, and people often aren't diagnosed until after serious acts of violence. Current diagnostic procedure discludes diagnosis of ANY personality disorder before age of 18. So, some of the younger violent offenders are never caught.

I think that within the mental health care field, we need more information. I wish we had something with any predictive validity to attempt to prevent such events. To date, sadly, we do not.

Hart Johnson said...

You've been so helpful, Patti! Thank you dahlink!

Helena said...

Thank you, Hart, for once again addressing a serious issue and doing so with passion and intelligence. Between your words and Patti's, there isn't much I can add but this: a society is judged by how it treats its weakest, most vulnerable members. This includes the mentally ill, and how we treat them -- and fail to treat them -- is a national shame.

Unknown said...

Great point, Hart. Many suffer from mental illnesses. WHat gets me is that Lanza's mom underestimated that and continued to house firearms and encourage him to learn how to use them. Not saying it was her fault entirely--no mom expects their kid to be capable of such things.But it was extremely unwise and careless.

Ketutar said...

I don't have any answers. And I have my share of mental illnesses, my own and in the family.
What I can say about myself is that we need to start acknowledging the mental violence and abuse. The emotional, the social, the verbal... all the torture that leaves no visible marks - at first.
In my mind bullying - even the "light" sort - is torture and should be stopped immediately.

Having mental illnesses doesn't make people dangerous, irresponsible, such that you need to keep them away from weapons etc.

Michael Offutt, Phantom Reader said...

As someone that is employed in the mental health business, I can assure you that where I'm at in the country, men and boys are pretty much ignored and women/girls get all the attention. I don't know why that is...but I think there's a connection that no one is looking at with all of these mass shootings. They're all boys doing it. Boys need as much attention (and a different kind) because they are reluctant due to testosterone to come forward and admit that they need help. I also think, Hart, that religion and it's made up rules (I'm atheist) are to blame for adding pressure to families to conform to certain expectations. This probably contributes to mental illness. I know that prozac is prescribed heavily in Provo (south of where I live) which is a very religious community.

I'm heading out now before I get egged by religious fundies.

Trisha said...

Michael, at least you know I will never egg you for that, as I am an atheist too ;)

This is so true that all the mass shooters are men! For some reason it had never occurred to me before I saw you Tweet about it. Can't believe I am saying that as I am such a Twitter newb.