Kids and Those with Such a Mind

Since this blog focuses on reform, I would like to take a moment and discuss populations that never have a chance to be helped.  I’m referring to children, geriatric patients, and those that are intellectually disabled (ID).

Before I get into specifics, allow me to clear up some misconceptions.  First, a hospital will not raise your child, nor will it make up for poor parenting.  Your child will not conform to whatever version of perfect you have concocted in your head in a matter of days as a result of being in a hospital.  Second, those that are ID, actually have a higher rate of mental illness, so not every behavior can be attributed to them being ID.  This does not mean a hospital will take them, it is just validating.  Finally, an individual with Alzheimer’s will meet criteria to go to a hospital almost 99% of the time, but after a certain point it will do absolutely no good whatsoever.  Best thing you can do is find a memory unit for your loved one so they can be cared for properly.  If you’re concerned about losing the disability check from this happening, you’re a horrible human being.

Children have always been a challenge to the mental health system, and my theory about this is because there is a belief that everything is transient.  That whatever Bubba, Jr is doing now, he’ll “grow out of”.  Mental illness is rarely ever one of those things, with maybe the exception of a few cases of ADHD (which is because it is way over diagnosed).  The sad truth of the matter is that genetically, a child may have a predisposition to mental illness, but it is environment that brings it out in them.  Which means that whatever is wrong with Bubba, Jr, can a lot of times be attributed to Bubba, Sr and Mrs. Bubba.  But we live in a generation where no one can be held accountable for anything anymore, so the decision has been made to hospitalize children at a enormous rate.  One study that is slightly dated suggests that 1 out of 6 discharges are of individuals under the age of seventeen.  In Virginia, there is a shortage of children’s beds, so the existing beds are always full.  There is ONE state hospital that specializes in children, and it is always full.  So what do we do with the kids?  What do we do with Bubba, Jr when he doesn’t want to give up his cell phone and slaps Mrs. Bubba?  Well, detention isn’t an option mainly because that system is not prioritized properly either.  Besides, its easier to create a label for Bubba, Jr. than hold him accountable.  With all the money that the state has placed in outpatient children’s services over the past several years, there have been many programs spring up, but no real progress has been made.  We still have children born to families that never should have children, who abuse and neglect them.  This is a societal issue that needs to be addressed before it is too late.

In 2012, the Department of Justice decided that Virginia was keeping individuals with ID institutionalized, and not offering them any services outside of that.  Yes, I’m aware that institutionalization is something that we as a society supposedly decided was a bad idea.  More on that in a moment.  So, a result of this lawsuit is that the state would have to put more money in community programs, and close some of the training centers that have been operating for years.  We also created a whole statewide program specifically to respond and answer any crisis intervention issues that arose with this population.  Let me be clear so that there is no misunderstanding…it did not accomplish anything.

The problem with institutionalization is two fold.  First there were no limits placed on it.  Yes, someone who is severely mentally ill/intellectually disabled and who cannot function in society should be placed in an institution and cared for as long as possible.  There, I said it.  But, what we were doing was putting people in these “insane asylums” for really horrible reasons, where they were being mistreated and exploited.  Treatment did improve slowly over time but the problem has always been that those in the field of psychology have all the power over someone who may or may not need that power lorded over them.  What I mean is that if I label someone with a descriptor such as “psychotic”, a typical person will have no idea what that means but believe that I must know what I’m talking about because I do what I do.  Since people believed this to be the case, it allowed for some really horrible experimentation on those that were mentally ill, most notably lobotomies, but at one point and time we thought dunking people in ice cold water or spraying them with fire hoses were a good idea as well.  But society allowed us to do this because they did not know any better.

In the present day I think we’re better informed, but the stigma is still there.  Enter the intellectually disabled, a population that is also misunderstood by the general public.  Human beings tend to run away from or do their best to ostracize things we don’t understand as a protective factor.  So given history it makes sense that we would be nervous at individuals living their lives in an institution.  However, the difference is that we can actually quantify intellectual disability so that there is not a lot of ambiguity.  We in the field of psychology though took that a step further and figured we could correlate quality of life with that IQ score.  We got it wrong a few times, so once again we’re back to where we started.  So now we’re placing these individuals in the community, and while we do a good job with wrap around services, we are still lacking in crisis intervention.  There is a total of one hospital in the state that has perhaps two beds dedicated to the ID population.  Otherwise, when hospitalization is necessary, they end up at a state hospital.  Go figure.

Same is true for individuals that suffer from Alzheimer’s.  These individuals become violent or do something unexpected, and we get called to put grandma in handcuffs, placed in the back of a police car, and ship her off to a hospital.*  Then what?  A psychiatric hospital cannot fix a chronic degenerative MEDICAL condition.  But families where it gets to much to handle or assisted living facilities keep sending them.  Then they refuse to take them back; which I think should be a felony (not that anyone asked).  Of course, when that threat is leveled, I should probably just walk away, but I regard myself as better than the individuals that abandon them, and so I try to find a bed for them.  Now, they also go to a state hospital more often than not, because even geriatric facilities do not take individuals with dementia.

So what can be done.  Well, I think we have to stop using hospitals as a default location for people that we don’t want; or not.  We have to decide.  If institutionalization is a good thing, then we need to regulate it heavily and have oversight so we do not end up back where we started.  If it is not a good thing, then we have to stop using hospitals as orphanages and nursing homes, and create alternatives that do more than just pay lip service.  Finally, either  facilities need to be established for these special populations that are accessible to people that do what I do for a living, or private hospitals need to be held accountable for not taking them.  But, I don’t see the latter happening anytime soon since that makes too much sense.


*Note:  Virginia does have a provision for alternative transportation which would eliminate the need for handcuffs.  However, we still have not allowed billing for this and a lot of medical transport companies won’t do it for that reason.

My ideas for reform

My biggest pet peeve with government is that those that make laws or changes typically do not ask for the input of the very people it affects.  In Virginia, multiple committees were formed following the incident with State Senator Creigh Deeds’ son, in order to discuss mental heath reform.  More specifically how to make my job easier.  But, since good ol’ VA did not request the input of those that enforce these rules, they have now gridlocked the system completely.  There was already a shortage of psychiatric beds in the state, but usually if I was persistent enough, I could find one somewhere.  Now, that is not even the case between Friday and Tuesday.

The bigger problem however is two fold.  First eighteen out of twenty recommendations that finally came out of these committees was that more money needed to be put into the system.  We have been trying to rub two pennies together to make a dollar in the mental health system since the VA Tech shooting almost ten years ago.  At that time the state came up with a piece of legislation that allowed for Mandatory Outpatient Treatment.  The problem (at least in our area) is that (1) the person has to meet the same criteria for being in a hospital as they do to be on MOT, and (2) there is no state funding for MOT.  Recent studies indicate that as many as 15% of people in Virginia are uninsured, and I think that CSBs continue to see the majority of these 15%, and rightfully so.  So once again the legislature have come up with ideas of how to reform a system without having having to pay for anything new.

First reform was a psychiatric bed registry.  This is a website that is maintained by the individual facilities on the honor system, and is completely useless.  Why you ask?  You cannot force a private company in the US to do the right thing by just saying please.  What the legislators fail to understand (since they didn’t ask) is that just because there is a bed available, does not mean that that hospital will take my client.  Following this, they mandated that no one that meets criteria for involuntary commitment be released to the community, so now a state hospital has to take them.  Funding for state hospitals have been rapidly declining since the 1980s.  What these two ideals have created is a bigger problem of having nothing available and no back up plan.

The next idea was to regulate those that do what I do for a living.  A bill was created to mandate training and to dictate the credentials that each hierarchal level needed to have.  The bill failed, so Sen. Deeds went through the back door to the Department of Behavioral Health and Developmental Services.  Beginning next fiscal year, ES Supervisors have to have a license and the underlings have to be certified by the state and the CSB in order to perform their job.  This is moving toward having all ES clinicians be licensed, which of course is proof that they are far superior clinically that all of those plebeians who don’t have such a thing.  In fairness, I have been saying for years that this would eventually be the case, but with funding continuing to be cut, the CSBs cannot afford to retain an all licensed staff even if it is for a mandated service.

Police CIT programs received some money.  Though I’m good with this, it really doesn’t do anything for me.  There was also a lawsuit brought against the state by DOJ that mandated funding for the intellectually disabled population.  This created a whole new program that has gone through several names.  But just like most reformative legislation, it was more talk than anything, and this also hasn’t really done anything for me.

So, what is the solution.  Well, lucky for you I have some answers, and since I’m one of the soldiers in the trench of this thing, I think that in and of itself qualifies me to make suggestions.  But just so you don’t think that I’m just complaining about stuff on the internet, I have volunteered several times to be on committees and to consult with different departments within the state to work on these reforms, and my requests have been ignored.

First, we have to make things uniform.  We have to eliminate ambiguity and increase efficiency in the process for our own sanity, but also to make sure clients have access to services that they need.  Has anyone ever tried to make an appointment with a psychiatrist for the first time?  I have for myself and for clients, and its no wonder they give up so easily.  The state should have ONE electronic health record system used by CSBs, instead of each operating independently.  In order to get money from the state, each CSB has to convert to this ONE system and there needs to be funding available to help them do that.  This single thing, if nothing else is done, would eliminate a huge majority of the ass pain that we as trench soldiers experience.  There also needs to be ONE protocol for obtaining an ECO, and one protocol for obtaining a TDO.  Currently, each locality has their own unique way of achieving this, and its headache inducing.

Second, every war fought in trenches needs air support.  If there are no services to help these clients before or after they are hospitalized, then they are going to fall into the revolving door demographic.  So I ask, why cant we have walk in urgent care clinics for mental health patients?  We have them for other things but not for mental health.  We also used to have funding available to be able to give medications to those that could not afford it.  That needs to come back.  Additionally, going back to uniformity for a moment, the more unified a movement, the greater the bargaining power.  A CSB with an annual budget of less than $500,000 trying to negotiate with a pharmacy or pharmaceutical company would get laughed at.  42 combined CSBs with an annual budget of close to a billion (maybe more I’m not sure), would get taken seriously.  I get calls from clients all the time that run out of medications or who need them adjusted, and I have nothing for them.  They don’t need to be in a hospital, they need to see a doctor.  The logical counter to this is to ask why they allow themselves to run out of medications.  These are individuals that have a mental illness; they don’t always take care of themselves or make the best decisions. Those that work in mental health SHOULD know this.

Third is training.  I don’t mean the bullshit training that the state makes us take every year so that if my employer gets sued they can say I did it.  I mean real training.  Job specific training.  Management training.  Make it to where the word “qualified” actually means something when applied to the letters that follow our name.  It should also be decided where those of us that work in emergency services fit in within this system.  If we’re first responders, then we need to have the equipment and training to be such.  If we’re law enforcement, then we need to have the equipment and training to be such.  If we’re medical professionals, then we need to have the training and paycheck to be such.  Training for us in ES should be all inclusive for both basic and advanced functions.  Clinicians should have to be exposed to all levels of the system and have to ride with police so that they can empathize with the struggles of both internal and external consumers.  They should also have to spend a day in the ER working for them.  They should have to work a shift at a PSR program so they know what a “baseline” is and what it means to be seriously mentally ill.  Ever wonder why there is such an extensive process to be a police officer or (sometimes) a fire fighter?  Because those individuals are given great power and we as a society need to make sure they will use that power for good.  It should be no different for people that want to do my job.

Finally, even though I realize that this is a controversial and unpopular opinion, but I don’t think that we should rule out long term treatment for the SMI population.  Within reason of course, and their care should have to be scrutinized and justified on a regular basis.  But I have encountered some people that just cannot function in the community.  Currently, jail is serving this purpose which is not how it should be. The alternative to jail being an assisted living facility, most of which I wouldn’t wish upon my worst enemy.  I realize though that I think differently.  I’ve never understood why we as a society valued life and liberty above all else, despite someone’s quality of life and prognosis being abysmal at best.  Can these individuals achieve some sort of recovery?  Sure, but not when they are stuck in the whirring doors that rest outside of every psychiatric facility in the state.

Reform is difficult because it involves change at a government level, to regulate an individualistic attitude that the government created.  The bottom line is that a lot of what I’m proposing would not be a dramatic increase in spending, but rather the structure of they system, which I think is worse.  Mental Health is divided into kingdoms, and to be open to changing could disrupt that kingdom, which is why change is so very slow.  Until we begin to look at what is right, rather than what is popular, we will continue to incur the same problems that we have had since the beginning.

Introduction (of sorts)

Them: “What do you do for a living?”

Me: “I’m a therapist”

Them: “Physical?”

Me:  “No, the other one”

Frequently I have this conversation with people that I meet for the first time.  It reminds me that I’m a male in a female dominated profession.  Then, when I explain specifically what I do for a living, I’m then reminded how specialized it is.

My job is to work with the 1.5% of people in the United States that have untreated mental illness  and as a result do something to attract attention to themselves.  Individuals that attempt to harm themselves or others; that one is fairly obvious.  The unexpected manifestations are the ones that are most scary for the community.

Most research opines that only somewhere between 2% and 8% of individuals with mental illness commit crimes that can be correlated with that illness.  The gap depends on how crime is operationally defined.  Homicide is obviously a crime, but so is indecent exposure and destruction of property.  Trespassing seems to be a popular one as well.  Then there are crimes involving substance abuse such as possession or being in public under the influence.  One conference I attended, the individual that spoke on just this very topic postulated that if a magic wand were waved and mental illness were eradicated, it would only account for a total of 2% of all crime.

My point is that I am the line in the sand between the community and the mentally ill.  Often the police are called first to report that someone is suicidal or that they are naked in their house claiming to be Jesus while throwing furniture out the second story window.  Then I come in, confirm that Jesus needs to be in a hospital, and work to make that happen.

Sounds simple, right?

There is nothing that I learned in any undergraduate psychology class, or my master’s program that prepared me for a nude Jesus encounter. Particularly when said individual then starts, for reasons not quite known, fighting everyone in the house from one end to the other.  Comedians often joke that no one wants to fight a naked man; I’m one of the few that has been fortunate enough to be put in that position.  Lucky me.

I spent time in law enforcement and I also was an EMT for several years.  Those skills have proven to be invaluable to me, which is unfortunate since there were reasons that I no longer do either of those professions.  My background gives me a bullshit meter that is accurate to the absolute nano-detail of a person.  I can walk into a situation and bring order to the most chaotic scene. Be present in any ER and comfortable enough to just hang out if I need to.  I’m arrogant.  I’m efficient because I realize that everyone has better things to do that to deal with Jesus all night, and that I’m not doing him any good sitting in the ER or the back of a police car.  I’m good at what I do, and I’m proud of that.

That same background also reminds me to be suspicious of everyone and to be hyper-vigilant; two traits that I wish I did not possess despite their usefulness.  Sometimes I wish I could be one of those naive people that go through life not waiting or expecting something to happen. Doing what I do also means that I see people at their absolute worst, often at an odd time of the night, in not such good conditions.  Something that those that aspire to be the next Dr. Phil probably do not understand.

Where ever I go several ghosts of clients past follow me, because I do actually care and want to see people get better.  Most of us that get into helping professions do, but what happens is that we get compassion fatigue.  So then we start hating being around people because we don’t want to run the risk of them making us feel something since we have to save what amount we have left for being able to function at work.  This leads to over-compartmentalizing EVERYTHING.  This compartmentalization also means that our super psychology powers do not work in real life, so we get into situations that we advise our clients against doing.  Substance Abuse being one (been there).  The divorce rate among therapists/social workers/counselors is between 23% and 24%; higher than any profession that I consider closest to what I do (paramedic, police, firefighter) each of which is far less than 20%. Some studies are less optimistic and put the number as high as 51%.   As many as 60% of us experience depression, and there have been few studies done on suicide rates in the past forty years, but at that time it was estimated to be 1 in 15. We also are more likely to be “wounded healers”, and have our own baggage that we carry with us.  I personally have a sleep disorder, periodic panic attacks, a caffeine and nicotine addiction, take three antidepressants a day, and I have woken up more than one day of my life and had to weigh the pros and cons of eating a bullet.  So far the pros have won out in case you were wondering.  But, those are just the things that I haven’t overcome yet; the conquered is a greater and more sinister list.

Most mental health professionals don’t have to deal with Jesus in all his holiness.  They may talk to him in a sanitized setting, or prescribe him medication, or monitor his progress.  But there are not very many among us that have witnessed the flopping penis of the insane.  We also do this for an average of $36,653 a year.  I have had people in my profession stabbed, assaulted, sexually assaulted, and I’ve heard of a couple that have committed suicide (though none that I knew personally).  There is also high legal liability since we are agents of social control and do effect people being able to maintain their rights and sometimes their livelihoods.  Yet training continues to be not even close to adequate, pay continues to be laughable (especially when compared to the amount of student loans), and any attempt to suggest or do something to keep yourself safe in this chaotic vocation is met with resistance.  Management support ranges from doing the best they can to completely unsupportive (I’ve worked for both ends of the spectrum and then some).  A lot of times all they do is keep the ball of shit from rolling down the hill and hitting me in the face, which I appreciate.  Its not always the fault of immediate management though since funding for mental health continues to decline.

So why do I do this?  I love what I do.  I think it makes a difference.  I think that it gives me an opportunity to perform in something that I’m good at.  I really do enjoy helping others and seeing them be better people because they had the luck of running into me.  Do I think it can be done better?  Yes, absolutely so, and since as I mentioned previously I’m arrogant, I think I have good ideas as to how to do it.  Which leads me to why I would write a blog such as this.  I want things to be better.  I want people to know that people like me exist and are not just around to lock them up.  I want others to know that the system needs changing, and our ideas about mental illness need to be looked at differently.

Do I think I can make a difference?  I don’t know.  Time will tell.