Matters of the Mind

Victims on the Front Lines

2010-04-04T10:55:00.000-07:00

The insurance industry and English legal system use the phrase "proximate cause" which has specific meanings relating to legal definitions but can more broadly be thought of as "An act or omission that naturally and directly produces a consequence. It is the superficial or obvious cause for an occurrence. Treating only the "symptoms," or the proximate special cause, may lead to some short-term improvements, but will not prevent the variation from recurring."

Recent events in Portland Oregon surrounding the fatal shooting of Jack Collins by Portland police officer Jason Walters have angered local residents to the point of sparking protests over violent encounters with police officers and even resulted in national media attention and visits from nationally known activists. Much of the discussion has centered upon the actual shooting and the use of deadly force.

While it is easy to view the events as simply a "threat to an officer resulting in the need for deadly force to protect the officer" or "senseless brutality of a person in crisis" depending on your point of view, the issues at work go well beyond the tragedies that both Mr. Collins and officer Walters found themselves entangled.

Mr. Collins, a long-suffering person afflicted with issues of mental illness and substance abuse found himself suffering not only from his disorders, but also from a lack of access to services and effective treatment for his conditions. Indeed, he sought treatment just days before his demise and sought not only help for himself but redemption from the demons that led him to commit a sexual crime decades ago. Mr. Collins was referred to a community mental health treatment provider strapped for resources and with little available access to treatment like so many others who find themselves upon their doorstep. Indeed when attempting to turn himself into the police and confess to past crimes, he was told that the statute of limitations had lapsed and there was nothing that could be done. With only the referral to the clinic as action, Mr. Collins simply disappeared from view only to turn up exiting a public bathroom, bloodied and facing officer Walters.

Officer Walters, a respected and long tenured officer, then found himself in a terrifying and dangerous situation, faced with a person armed with a knife in a difficult physical situation.

However you view the choices officer Walters made, and there are many circumstances to consider, there is no question that neither man deserved to be in the situation that led to the tragic result. It is hard to believe that any person who enters into police work visualizes themselves in a situation where they feel the need to take a life when they swore an oath to serve and protect. Shooting another human being, regardless of their station in life, is a terrible predicament. More often than not, officers have families and loved ones and the stress and resultant difficulties of grand jury investigations, suspensions and fallout from the scrutiny of his actions can exact a terrible toll on anyone in his position.

On the other hand, Mr. Collins neither deserved the loss of his life, or more importantly deserved to suffer the fate of his condition.

So often, there is a desire and need for people to take sides and determine the rightness or wrongness of the participants and far too often we see the unwitting participants as the ones with choices to be made. The point that is missed the the underlying cause, the proximate cause if you will, that set into motion the events that unfolded between the two men who were swept into a chain of events that altered the courses of their existence. There was no winner. Sadly, there were only two people who paid terrible prices for their being thrown into a situation that neither would have chosen had it been their choice to take another path.

We are left with extensive rhetoric about policies and procedures of police engagement, protests of police brutality and lack of understanding of what drove Mr. Collins to acquire a knife and do what he did.

Perhaps we would do better to examine our failures as a community and society. Unless we do, there will undoubtedly be more who suffer the same fate and circumstances as both Mr. Collins and Officer Walters. We can only hope that there is public scrutiny about the problems with access to mental health treatment as well as find better knowledge as to the causes and better treatments for those conditions. Put simply, if there were effective treatments for the challenges faced by Jack Collins, perhaps Jason Walters would not have been called upon to react to a crisis situation and by default be forever linked with the circumstances first suffered by Jack Collins. If not, the names will change and more people will suffer the same tragic fate.

Collins and Walters were truly victimes on the front lines of a struggle that neither wanted to or would have willfully joined. We could prevent others from being future victims. The question before us all is not who is right or wrong, but why we would choose to let others bear the burdens that they have already been asked to bear.

All Suffering is Not Equal

2009-04-06T07:25:00.000-07:00

Friday evening April 3, 2009 Elyn Saks of the University of Southern California presented the Rondeau Lecture at the Oregon Health and Science University in Portland, Oregon. As one of the attendees at that lecture, I can offer my personal observation as to its excellence and to Ms. Saks remarkable story. Elyn Saks is a remarkable individual and should be given credit for her efforts to deal with her disease.

As the auditorium emptied, I was greeted by a long-time acquaintance, a parent who lost their daughter to the effects of schizophrenia. The parent remarked to me that they hoped that not all who attended would view Ms. Saks’ story as being typical. I wholeheartedly agree.

What is particularly frustrating about schizophrenia is the manner in which the disease is diagnosed and treated. Because there is no categorization of mental illness by physical criteria, we are left to use a definition of disease by way of collection of observable and self-reported symptoms. The number of times that I have encountered people, parents and loved ones remark to me that a patient has been misdiagnosed is nauseating. It happened again at the reception prior to Ms. Saks’ presentation. I was introduced to a parent of a person who is hospitalized because of “behavioral/mental” health difficulties. The parent was convinced that the hospital was mistreating the offspring because they were treating them for the wrong disorder. What the parent could not grasp is that there is no “right” treatment for any mental illness. Sadly, treatment can only be evaluated in terms of its effectiveness, at it is far easier to fail at treatment than it is to succeed. There is also, from what I have experienced, no such thing as a “right” diagnosis. Sometimes the diagnosis is consistent over time, but often fluctuates because it is an expression of symptoms.

One of the most frustrating parts of joining the great experiment that we call psychiatry is the gradual realization of the tenuous nature of the diagnosis and treatment of the diseases. While some argue that there is no such thing as mental illness and the study of mental illness is all a scam, nothing could be further from the truth. There is remarkable compelling evidence of pathology in individuals and remarkable stories of treatment and recovery. What is damning about the field is that the history of treatment is littered with failure of treatments and little concrete certainty about anything.

Theories abound as to the causes and treatments for mental disorders but since the definition of the diseases themselves are subject to a degree of interpretation of observations, the diagnosis serves primarily as a way to communicate between those involved with the medical professions, not a mandate for a particular treatment. The invalidity of a given diagnosis is seemingly the most difficult problem facing the field of mental health today. Calling a diagnosis invalid may seem harsh but from the meaning of the term it is perhaps most correct. There is a difference between being reliable (repeatable) and valid (correct).

Ms. Saks has the same diagnosis as my daughter, schizophrenia. In her presentation, she described her treatment and medication regimen which has also been used to a degree of effectiveness with my daughter. To be precise, the exact same medications have been used in both cases, although that is no longer the case. In spite of this, my daughter is not an Oxford Scholar nor does she possess advanced degrees. She does not exhibit the same symptoms and did not react in the same manner as Ms. Saks to her psychosis. She does, however exhibit some of the same symptoms and as a result of displaying those symptoms shares Ms. Saks diagnosis. In spite of the fact that there is no certainty of the causation of either of their conditions, medical science and governments have been clamoring to install “evidence based practices” in the treatment of mental illness. If the precise nature of the illness is not yet defined, how can there be implementation of evidenced based practices to provide treatment? When the search for experimentally validated treatment includes subjects that could have different causes for the same outward symptoms how can the results of such studies have validity when treating an individual case of the disease?

Given the functional nature of disease definitions, the diagnosis of the disease of schizophrenia applies in both cases. However, I can tell from hearing Ms. Saks’ story twice and living through my daughter’s illness, I am reasonably certain that there are substantial differences as to the root causes and reactions to their disorders. Furthermore, Ms. Saks is blessed with a keen intellect and remarkable skills that few people on this planet possess. My daughter is also blessed with some skills, but not of the same type and on the same level as Ms. Saks. The brilliance exhibited by Ms. Saks has rescued her from the terrible fate that is the reality of most who suffer from schizophrenia, disability and the public mental health care system if not incarceration or lack of treatment.

While it is appropriate to celebrate Ms. Saks and hold her story as a remarkable example of what might be achieved, it is more properly respected and looked upon as an anomaly when assessing the state of psychiatric care and treatment. While we salute her efforts and courage, we hope that others do not use her example of what should be expected of others who suffer from the same diagnosis. It is also unreasonable to suggest that others who do not possess her skills would be deserving of our best efforts to provide treatment. After all, while we may be created with equal rights, we are certainly not created with equal capabilities. For some the suffering of similar symptoms will lead to far different personal circumstances. The suffering from the disease will be anything but equal.

The Game Changes

2009-03-30T06:54:00.000-07:00

March 29, 2009 may go down as a watershed day in the history of psychological disorders. The Detroit Tigers Baseball Club placed one of their players, Dontrelle Willis on the disabled list. Making the disabled list of a professional baseball team is of no particular concern to those who follow mental health issues, but the circumstances in this particular case may be profound in their implications.

Mr. Willis made the disabled list not because of an injury in the manner which is most common to baseball players and professional athletes, Mr. Willis was told that "blood tests" had confirmed to doctors who were treating Mr. Willis that there was cause for concern. What makes this such a watershed day are several circumstances surrounding the case have created a kind of perfect storm that threatens to cause seismic tremors in both the sports and psychiatric communities.

Not the least of these concerns is the pairing of the words "blood test" and "anxiety disorder" in reports surrounding the placement of Mr. Willis on the disabled list. As those who follow the mental health medical world know, mental diseases are classified by the Diagnostic and Statistical Manual that governs such things known specifically as DSM-IV-TR. Like all mental disorders, anxiety is labelled and diagnosed not by blood tests, but by laundry lists of diagnostic criteria. DSM-IV-TR lists thirteen categories of disorders, none of which contains the description "unable to throw a curve ball for strikes" within its criteria.

There are two mentions of blood tests for anxiety that I have located in research material, neither of which I can determine has commercial availability. Clearly, neither of the tests has been generally accepted as a diagnostic tool. Reporter Lynn Henning of the Detroit News who covers the Tigers has written about the delicate and mysterious nature of the placement on the disabled list, confirming that the baseball commissioner's office was consulted in the process. All of this is especially tricky when dealing with laws relating to confidentiality of personal medical records.

What provides additional intrigue to the situation is the amount of money paid to people like Mr. Willis to perform their jobs. Reportedly, the Detroit Tigers are contractually obligated to pay Mr. Willis more than 20 million dollars over the two remaining years on his contract. This makes the baseball club extremely interested in Mr. Willis's ability to perform his job. It also creates a very sensitive situation as respects insurance that clubs purchase to guarantee the ability of their athletes to perform the skills that they have been contracted to perform.

All of these issues have come together to create a kind of perfect situation to shine a light on the issues involved. Sadly, that light is also shone on Mr. Willis, who now, because of the loss of his ability to perform his job is subjected to the most cruel scrutiny by fans and interested parties.

The ramifications have already started to appear in other blogs. In particular, one blog has questioned the validity of the diagnosis and expressed anger in the following way: "I don't appreciate having my disease exploited to bail you out of your own stupid mistakes." The argument is that there were no reports of outward symptoms of anxiety, therefore how dare someone give a diagnosis of anxiety. This may be most unkind toward Mr. Willis in that views about such issues without first hand knowledge only perpetuates stigma and hostility toward what is by most accounts a rather tragic situation.

Most of us who have dealt with a mental illness in our close family do know the degree to which symptoms can be hidden from view and realize the tremendous loss of performance that can result from seemingly mysterious circumstances. In defense of Mr. Willis, he is at an age where his physical abilities should be at his peak. Like most people who seek to perform athletically at a very high level, it runs completely contrary to his history to suggest that he would want to do anything but perform at a high level. If one were to compare the type of scrutiny that he will undergo now as opposed to the attention he would get were he able to perform, there would be no question what any rational person would choose. One might conclude then, that the situation that Mr. Willis finds himself was not done by matter of choice. If it was by matter of choice, then one would conclude that some pathology was guiding that choice.

On a more basic level, the mystery surrounding sports performance and mental issues is littered with the wreckage of multiple careers, but it pales with the suffering of millions of people who suffer the same fate in their everyday lives. The situation that has now grabbed attention shows how poorly we deal with issues like the definition of illnesses like anxiety and how little we actually know about the loss of function in people of all professions.

If there is a silver lining to the story, perhaps it will come in the form of promoting understanding about the underlying physical causes of mental diseases and how to more accurately diagnose and treat them. The great weakness of elaborate classification schemes like DSM-IV-TR is that they simply describe collections of symptoms. They are not explanations of why there is a problem, they are simply a way to agree upon what a collection of symptoms should be called. As such, their weakness is apparent. Should Mr. Willis suddenly begin to throw pitches that are in the strike zone and start getting batters out instead of watching the pitches be hit out of the stadium for home runs would he no longer suffer from anxiety? Clearly, something has caused him to not perform at an expected level. Is it a disease that is rooted at a chemical level? DSM-IV-TR cannot tell you nor can medical science at this point in time. What is more important is if we can discover the real cause of his inability to do what he was able to do before and help him regain his skill, think of what might be done for the millions of others among us who have lost their ability to perform at more modest levels.

The discussion needs to engaged about how outward symptoms and behaviors are related to brain and physical function. Were there tests that could identify particular pathologies of function and lead to treatments for those like Mr. Willis that suddenly lose the ability to perform a function that they once did with relative ease, many would benefit. Until that knowledge is developed, we will all suffer while watching promising careers and lives languish in frustration. Those who find themselves in a similar situation deserve better. If the stakes are high enough, perhaps this event will spark interest in what can be done to help those who suffer the same fate. It could be a defining moment in looking for causes, not stigmatizing those who suffer from similar circumstances.

Let's hope that the search for causes prevails. The fact that physical tests are being discussed give a glimmer of hope that understanding might follow. Goodness know that simply placing blame and stigma is not the answer.

Supporting the Caregiver

2009-02-26T07:09:00.001-08:00

On a news show last evening there was a video review of the tone of the message used by President Obama to present his budget to the American people. It compared the manner of presentation with that of former presidents Jimmy Carter and Ronald Reagan. As one old enough to remember both Carter, Regan and that era, it was punctuated with energy shortages, high interest rates, inflation, recession and gloom. President Carter faithfully expressed to America that times were tough and we just had to struggle with the problems.

Regan, on the other hand, expressed optimism and the hope and promise of recovery and better days ahead. Sure enough, the better days followed. Not, one could argue, so much from the implementation of his politics but the readjustment of the American Psyche. Today President Obama is also facing the same dilemma as President Carter, having been presented with enormous challenges. He is finding ways of expressing the need to take action, but not to cloak it in the harsh realism that defined Jimmy Carter. Carter was right about the problems, just not the right person to cheer up and inspire America. America opted for the positive message of Regan in spite of its deficits.

So what, you might ask, does this have to do with supporting the caregiver? Yesterday at the end of a meeting discussing the progress of my ill daughter, my wife and I were asked about what support systems we were using to support ourselves. The person went on to describe how terrible and stressful and demanding and horrible it must be to face what we have faced in getting treatment for our daughter. While I realize and acknowledge that the person was attempting to help, they could have no been more misguided on how I personally view the concept of giving care and how I viewed the message. There are good reasons for this perception because I had called the person to express outrage at the difficulty of dealing with the care system. She mistakenly took this to mean that I was frustrated at having to support my loved one. Nothing could be further from the truth. The anger and frustration that I have comes mostly from engaging the care system, not from needing to provide care for my Daughter.

As a parent who willing and knowingly brought a child into the world, you must learn to separate and convey to others how you view the care giving process. In my case, it is simply an obligation to provide for my daughter what she needs. It is an obligation that I take seriously and completely. As a caregiver, what you realize from life experience is that the progress of any given disease is not under your control. Diseases such as diabetes that you have personally you may influence the outcome. As a caregiver you do not have that luxury. What you do have control over is what services can be provided for your loved one in order that they may access the system of care. In my case, the frustration comes more from my experience with the care system than from the person who I care for. The person who is ill did not cause their disease nor do they deliberately sabotage their treatment. They struggle with the limitations and restrictions imposed by their disease.

From the beginning of my daughter's care, there has been, on behalf of the care system, very restrictive limitations on the access to and amount of treatment available to assist her in recovery from her disease. This is one of the great tragedies of mental illness. Whether it is restriction by lack of services, number of treatments or any other measure, the system is not structured from the viewpoint of providing care as much as it is limiting the care to keep down costs. At an even deeper level, science about "behavioral" health cannot even pinpoint the cause of such illness because not enough is known about the diseases themselves. In some circles, the very concept of psychiatry is thought to be phony even though it exists without a doubt to those who have dealt with its presence in their loved ones.

The horror of the disease of schizophrenia is not that it exists, it comes from the idea that we know so little about it and the system we use to treat it is often demeaning and frustrating to engage. As a caregiver, you begin to experience the rigidity of the care system and its rules and regulations and your attempts to maneuver your loved one through that system. It becomes entangled with gatekeepers and care access requirements and is predicated upon the concept of failure at treatment levels which trigger access to greater care upon failure at a less involved level of care.

That you have the responsibility of providing care for your loved one is not what causes the grief and agony. It is far more stressful to be told that your loved one is not sick enough to enter the hospital and that there is nothing the provider of care can do for her. The suggestion to bring her back next month to another appointment and see if her condition has worsened, i.e. she is now homeless so we might be able to take action is what enrages you as a caregiver.

While all of this goes on, your experience as a caregiver is called horrible, terrifying, frustrating and burdensome. I have yet to hear it described without some measure of negative expression or how bad it is to experience. While it is true that you can become frustrated, irritated and annoyed, it is the outward manifestation of the disease and your interaction with the rigidity of the care system that most wears on your psyche. Anyone who perseveres in providing for their loved one knows that deep inside them is still the essence of someone who shares the same desire to enjoy life and find happiness in the world. The fact that your loved one is still alive and functioning keeps hope alive that you will have some positive interaction at some future time unlike other people who have lost their loved ones forever.

Perhaps we should look to how President Obama and Ronald Regan viewed the collective psyche and express appreciation of the efforts of the caregivers and the success they have achieved in helping their family members. When a person tells you that they want to help you find support because you have experienced a terrible and difficult process that has brought you down and drained your spirit, perhaps it is true. However, describing it as a negative experience fails to acknowledge what the caregiver has accomplished. To keep your loved one relatively safe and secure, to engage them with a treatment process, however flawed, and to give them a chance at recovery where others are lost and whereabouts unknown is an accomplishment that we take considerable pride in, not view with horror and tragedy. The disease is a tragedy, not our experience. The care giver's strength comes from a sense of accomplishment of fighting the good fight however bleak the outcome at the moment. Properly viewed, it is soured by the resistance of the care system to provide well organized and responsive care, not by the progress of their loved one.

The need for support systems for caregivers is not to relieve their burden, it is to make the caregiver even more effective and assist in their efforts. Expressions of support are best viewed as how can we provide greater assistance in helping you help your loved one. Like Jimmy Carter, we are well versed in the reality of what we face. Use a little bit of Ronald Regan and Barack Obama inspiration that focuses more on future potential than on present difficulties. That will lighten the load of caregiving considerably.

The Bigger Picture

2009-02-05T05:26:00.000-08:00

Last evening I attended a meeting that focused on the Crisis Intervention Training program that is intended as a supplemental training for police officers of Portland, Oregon. The roots of this program go back to the mid 1990's but it was the tragic death of Jim Chasse who was in custody of police officers that was the reason that the city of Portland moved to make the training mandatory for police officers.

Crisis Intervention, as a program of training, started in Memphis Tennessee as the response to another tragic situation and was conceived as a voluntary, not mandatory set of skills. The idea was that not all people are of a psychological makeup to integrate and use the skills taught in the program. While the voluntary idea may have some merit, the larger view of society, behavioral problems and the role of police forces could use some examination to help put the training in a proper context.

It is useful to study what societal decisions we have made that get us to the point where we now struggle with mental health problems and understand why those decisions brought us to our present state of affairs. In this case we are at the confluence of mental illness, care for those mental diseases and the maintenance of order in our society.

In the mid-1950's common societal practice was to place those suffering from severe mental disease away from everyday society in mental institutions commonly called asylums. More than half a million people in our country were removed from everyday life and subject to often terrifying conditions of asylums. While originally conceived as separate and compassionate respite homes designed to reduce stressful demands, they had more often deteriorated into overcrowded, decrepit warehouses stuffed with a variety of residents that were a jumble of persons with mismatched and differing behavioral problems.

Because these institutions were very expensive to operate and staff it was a great financial drain on governments to provide proper funding for the residents of the facilities. Because the conditions were poor and because some advances in medications showed promise in treating the diseases and because governments were very interested in saving money, public policy shifted and started a massive closure of the facilities and removal of people with mental disease from institutions and back into the communities. All of this was done in a very rapid manner with only the general promise of the creation of the Community Mental Health system.

Like most promises of Government, the promise was only good until requested to be funded. In true American style, we demand services and refuse to pay for them. In this case, there was a need for about fifteen hundred community mental health facilities and only about seven hundred and fifty were funded. On the expense savings side, however, government was extraordinarily effective and reduced the number of residents in the asylums by 90 percent in a few short years.

What, you might ask, is the result of this massive policy shift? We created a massive homeless class that wanders our streets, ill but untreated, begging for resources that are too few in number. Meanwhile the Federal Government, in order to keep states from just recreating large residential treatment centers, passed a restriction of funding any treatment facility with more that 16 residents. This effectively keeps anyone from gathering large numbers of mentally ill persons in large scale treatment institutions. It did not, however, keep them from being collected elsewhere.

Like all well-intended programs and laws, these actions did not, as hoped, have anything like the desired effect. While a small number of persons were returned to their communities and were successfully reintegrated, those with severe symptoms and very difficult behavioral problems "fell through the cracks" as the expression goes and everyone ends up somewhere. Some simply died. Recent statics on the lifespan of those with severe mental illness suggests that their lifespan is nearly 25 years shorter than their fellow citizens. Some also were helped by newer medications and supportive families. After all, having a social safety net is really great for everyone if those who gave birth to those with illness are put into the position of providing as much of the burden of care as possible.

Many of the rest simply over time were transferred to the care and custody of a different governmental organization. Where might you ask did they go? Look no further that our jails and prisons. The massive increase in prison populations in America coincides with the emptying of asylums.

Few things are more popular with voters that "getting tough on crime." Americans love to put people behind bars and keep the "bad" people away from them. We spend massive amounts on alarms and security, locks and deadbolts, guns to protect ourselves and any other manner of self-protection. We love making mandatory sentences, television shows about "bad guys" and thinking up new laws about how to punish people. We look for our police forces to protect us and control the streets and any incident that brings us harm has us begging for more protection and locking up more people.

The problem with all of this is we simply transferred the populations that once inhabited asylums in terrible conditions into jail cells and asked our police forces to be the front lines in the management of mental health disorders.

Our police forces are now stuck with a responsibility that was never intended, treating medical conditions with guns and weapons. We are asking officers to do the impossible, control mental disorders with techniques that were designed to control people who's intent was to rob or steal for personal gain. This is the heart of the problem. Those who are in mental crisis are not acting out of the same reasons of behavior as those intending to simply steal from or harm another. As a society, we have mixed into the mess on the streets behaviors that are caused by physical and chemical abnormalities of the brain and asked the police to adapt to the situation without proper training. Asking the police to separate mental illness and criminality and make split second judgements regarding their own safety is like looking for a gasoline can in a dark garage with a lighted match. We are creating an explosive situation. We are also, if you look at the situations that pepper our news stories, doing very poorly.

The answer lies not in more police training, although that is also part of the solution, but in creation of a workable mental health treatment system. Perhaps we will as a society someday find a better more humane and intelligent care system. Until then, far too many will find the police departments as their first line of treatment and far too many will have given their lives while we clumsily search for better answers.

Crisis intervention Training is commendable. It is life-changing. It life-saving. It is not, however, a solution. The real solution is the study and treatment of mental disease and finding a way to treat and care for those who suffer its ravages. Until we find cures and effective treatments, we are asking police to do what we have not done as a society. We are asking for the impossible.

Better Life Through Chemistry?

2008-12-06T12:41:00.000-08:00

A current article on MSN written by Rich Maloof poses the question if chocolate or good deeds, either of which lead to a good feeling, are processed differently by the mind or does it make a difference chemically? If there is no difference chemically, then is morality somehow influenced by the resultant chemical reaction in the brain?

It is a very good question, but it points out more about what we do not know about the chemical nature of the brain than what we can pretend to know about the nature of existence and morality or theology. The act of human thought or consciousness confounds us with its seeming simplicity yet profound nature.

Those of us who are involved with mental health issues with family members or loved ones cry out for understanding of the processes that effect mental wellness. We study neurotransmitters and genetics trying to find answers that will bring relief to those who suffer from abnormalities of thought or mood processes. Biology and Chemistry have given us such wonderful scientific models of things like the glucose energy process and the effects of dietary and exercise regimens that can be used to control the effects of unregulated blood glucose levels brought on by the various forms of diabetes. Unlike the blood transport system, the neurotransmitter and mental functions are far less easy to define in their exact chemical nature. Much is known about the areas of the brain that control various functions such as vision and speech, but mental functions and how they affect behavior still pose difficult research problems due to the physical nature of the operations themselves.

If we were to look at the brain as a chemical processor, which it most certainly is, we could simply ask science to continue to further refine and understand the chemical processes and theoretically end up with a model that would explain everything that we want to understand. That however, ends up with a rather "simplistic" reduction of life as a series of chemical processes. Unlike the blood sugar model, there are many times more neurotransmitters and receptors to categorize and explain and that does not begin to account for variations in message transmissions that are encoded in languages that are learned.

For now it might be easier to hope for some explanation of the gross malfunctions of mental disease and hope for better therapies. If chocolate and good deeds lead to a better feeling of wellness, perhaps we can simply be comforted with that thought. The reason why that is does not need immediate attention. Some things my be better left as accepted and wait for an explanation later.

It Will Not Happen Here Next Year

2008-11-07T07:51:00.000-08:00

Earlier this week our nation made an historic choice for president. As Mr. Obama addressed the nation for the first time as president-elect, I was struck by the tone of humility and lack of excitement in his voice as he recounted the momentous occasion. Many of his supporters wept openly and cheered wildly at his words, inspired by his accomplishment. Mr. Obama chose, however, to reflect not upon his personal achievement of being elected, but on the hard work that now faces the new administration. His personal reflections were spoken of in terms of America taking a new direction. In effect, the message was not about himself and personal triumph, but of the need to move forward in a new direction.

There was also a dramatic shift in the rhetoric about his opponent. Both candidates immediately shifted away from the political rancor of the campaign toward a message of the common interests of American citizens. Completely gone were the personal charges of cavorting with terrorists, being unstable and being unprepared to be president.

In a somewhat similar fashion on a microscopic level, I have some of the same feelings as Mr. Obama about the issues surrounding my advocacy efforts on the haunted house issue. Yesterday a letter arrived from the City of Portland detailing the action taken about the protest that I filed about the haunted house being held on a city-owned property. The parties involved had met and the issue had been discussed about the design of the house being based upon the depiction of those in an asylum going on an uncontrolled rampage. The city and facility management both expressed support for the position that events with depictions such as this should not be held on public property. The event planner, while angered over my approach and expressing the position that the event was due to be redesigned, got the message that such depictions were not appropriate.

There was no joy in vindication of my advocacy position. As in the election for President, it was never as much about the vanquishing of an opponent as it was about having people adopt a more enlightened position about such depictions. Further, the design of the house should never have been viewed as displaying an intent to discriminate against those with mental illness, rather, it should be viewed for what it usually is, an insensitive portrayal.

Reflecting upon the issue gives you greater perspective about the path that people of color who are currently in the minority in our country can see in portrayals of stereotypes and stigma surrounding their situation. Much of the portrayal of minorities was perhaps not intended to be hurtful, but a horrifyingly degrading message was nevertheless sent to those in the minority. Those sending the message may be woefully unaware of the harm done to others, and may not understand what they have done.

This should be no excuse for those who promote stigma and prejudice regardless of the intent. Unintentional harm is every bit a bad as that created with intent to the person being harmed. A far worse form of injustice is done when the person who has unintentionally harmed another refuses to admit the error of their ways. That is when advocacy is truly necessary. America has learned some painful lessons in its history and has many more lessons yet to be learned.

The prejudice and stigma associated with mental illness is one such lesson. In this case, pressure can be applied to the situation and keep that venue from hosting such events in the future. More important, however, is the awareness created about the fundamental issue of depictions with those who suffer from mental illness and the unwitting advertisers and promoters of such events. All of the sponsors, publicists and locations involved in this situation responded with empathy to the issue and real progress was made in assuring that sponsors of future events will keep a more critical eye on the design considerations of those events.

If there is a reason to celebrate any part of the process it comes from a personal friend who has spent time in a State Hospital. She wrote "As one of the people who was offended by the Halloween Attraction, I do understand that there was no malice involved . . . Thanks to your sharing this information, I have a much better understanding and wish for a better outcome next year." That Ashleigh is able to put into perspective those thoughts and ease her hurt, is reason to celebrate for her well being.

Like Mr. Obama, the reflection here should not be about the process or "winning" or "losing." The real point is the awareness of people about the issues involved and moving forward to a place of acceptance and understanding. No one should use the plight of others to perpetuate prejudice and profit from that portrayal regardless of the lack of intent to harm others. We must stand vigilant to protect those who are marginalized until they are no longer marginalized. Mr. Obama's election shows that we are ever closer to that goal regarding the issue of race. Perhaps someday, we will recognize that those with mental illness simply suffer from diseases and deserve better than marginalization and prejudicial portrayals.

When that day comes we will be able to say "It will not happen here next year."

It Happens Every Year

2008-10-17T08:19:00.000-07:00

It happens Every Year. Somehow the following statement is supposed to make up for the use of extremely prejudicial choices made by designers of halloween attractions.

Disclaimer: "FrightFx's production of Elshoff Manor is based on a fictional storyline and is meant for entertainment purposes only."

The call this year came from the mother of a person who spends his days at the state mental hospital, institutionalized for a brutal crime that he committed while suffering from psychosis. A local early morning newscast was visiting a halloween attraction touting the wonderful special effects designed to scare the pants off of the persons who would pay their $20 to go to the attraction. I could hear the distress of the mother as she asked me to swing into action and see how bad it was this time.

The truth is, it was the worst I have ever seen.

It has been less than a month since the "Race for the Cure" a benefit in Portland, Oregon attended by over 50,000 participants to benefit breast cancer research. That disease enjoys massive support by the community with an outpouring of emotional and financial support second to none. We are happy to support that cause because the disease does not cause a person to act out in a way that can harm others.

Unfortunately, when individuals suffer from psychotic brain diseases, bad things can happen. Potentially very bad things. What society fails to realize is that just like breast cancer we do not have full control over the outcome of the disease. With cancer some recover, some do not. We celebrate the survivors. With mental illness, some recover, some do not. Instead of celebrating recovery, we mock the possibility of recovery. What really differs however, is our perception of the disease and how we portray those diseases in the public conscoiusness.

Breast Cancer, Kidney Disease and Heart Disease are all given our sympathy. Massive fundraising campaigns support diseases like Muscular Distrophy. Even AIDS, with its taint of association with sexual promiscuity enjoys widespread support.

Mental illness gets hundreds of haunted house displays with descriptions like this:

"Patients who even in their worst mental states normally led calm quiet lives, now often took part in violent outbursts. No one seemed to know why. Per facility records, patient medications weren't changed, the staff seemed to be treating them the same, and everything else seemed status quo. Many of the orderly staff worried about the downward state of the patients, and a few left employment at the Asylum, claiming that their personal safety was at risk. The remaining attending medical staff complained to all that the private sessions that Stone ran with each inmate were unmonitored, and that many of the cases of diminished mental state and violence occurred after these sessions."

Imagine, for a moment, if you were a family member of a person stricken with such a disease, how you would feel. Worse yet, be a person who faces the daily challenge of such a disease and saw how your condition was represented to the public at large. Then try and imagine thousands of people lined up paying $20 each to go to such a display and revel in the concept of your misery.

Then you can experience the reality of the stigma suffered by those whos lives have been shattered by psychotic mental illness.

There is no worse prejudice that lives in our world today than the stigma and prejudice against those who suffer from psychotic mental illness. Not only is the condition terribly misunderstood, the effects of the disease are used to mock the condition of those affected and create unjustified fear and scorn of those who suffer its effects.

If a person suffers from a seizure while driving an automobile and causes an accident, it is believed to be a tragic incident and support for them is not questioned. If a person under the influence of a psychotic delusion does the same, they are guilty of a crime and institutionalized. The cause of the incident is the same, a disease that affects the person's ability to make their body respond in a manner that will enable them to operate the car safely. The results and the effect on their life is anything but the same.

Given the plight of those who have family members who suffer from mental illness, the use of the asylum and its story of untreatable and uncontrollable mental illness is one that not only portrays inaccurate stereotypes and irrational fear, but works counter to the ideals of our society. The Portland Oregonian won a Pulitzer Prize for accurate portrayal of the terrifying conditions of our own state mental hospital and detailed the horrific conditions from which they suffered.

Currently the State of Oregon is facing a lawsuit from the United States Department of Justice for its violations of civil rights under the Civil Rights of Institutionalized Persons Act. In addition the State of Oregon broke ground on a new State Hospital in September of this year which is designed to bring our State’s treatment of persons with mental illness to an enlightened place free from the awful types of stigma that haunted houses portray.

The Portland LumberJax, a Rose Garden tenant, allowed NAMI, the National Alliance on Mental Illness, to publicize the NAMI Walks for the Mind of America event in their lobby. That the same facility would stoop to such blatantly prejudicial portrayal of the plight of the mentally ill that tortures all who have family members who suffer from the diseases.

United States Senators Gordon Smith and Ron Wyden have both lost lives of their immediate family members to mental illness and Senator Smith has worked tirelessly to help those who suffer from these diseases. Former U.S. Senators Fred Thompson and Paul Wellstone have also lost immediate family members to these diseases. Congress just passed a Parity Mental Health Bill to allow citizens of our country to have the same access to mental health treatment as they do for medical illnesses. These events coupled with the rash of suicides and diseases suffered from soldiers returning to our country that have given their all to protect our citizens from those who would harm us show just how out of touch haunted house designers are with the challenges that their fellow citizens face in their daily lives.

It is deeply troubling to the families of those who suffer that companies would use the tragedy of real families and citizens of our country to perpetuate the link between mental illness and fear. The realities are far different from what haunted attractions portray, but the synopsis on the FrightFX website fuels the misinformation and prejudice and fear that results for families like those mentioned above who live with incredible grief over the condition of their family members.

There is no excuse for portrayals such as this. Mental Illness is the issue that remains as the last major issue of extreme prejudice in our society, yet one in 5 families is affected by one of the diseases. It is time to stop the prejudice and create awareness of how we can treat these diseases and save the lives of those who suffer not trivialize their suffering and perpetuate prejudice.

May we all look forward to a time when we can no longer say "It happens Every Year."

How did I get here?

2008-09-28T19:11:00.000-07:00

Have you even stopped what you were doing for a minute and considered from a larger point of view why you are where you are at a moment in time?

What circumstances and events have brought you to that particular moment in time to do what it is you are doing? Sometimes particular choices are made that lead you to events and places, sometimes it seems quite random. My first experience with such a thought was in 1976 in Twining, Michigan when I found myself in front of a class of 10th grade English students. For some reason I was struck by the odd set of circumstances that had brought me to that room and I wondered to myself what I would have thought had someone tried to tell me eight years prior to that day if you had told me while I sat in Jim Englehard's 10th grade English class that I would be the teacher of a class of exactly that subject.

To tell you the truth, I would have laughed aloud at the thought of such a suggestion. Given my distaste for 10th grade English as a subject, I could not have envisioned myself as a teacher of that class under any circumstances. Yet, there I was calling roll and passing out textbooks to the students preparing to instruct them about literature and grammar, hoping to inspire them to improve their skills and master the subject matter.

The same feeling came over me last week as I prepared testimony to the Board of Commissioners of Clackamas County. This time the feeling was the same feeling about why was I about to do something and how it was that I got to that position. It differed to the extent that I had not been to this particular place before, but the feeling about what was I doing there and what circumstances had gotten me to that place was the same.

My mission was to present testimony that would advocate for the placement of a community based treatment center for people institutionalized under the care of the State of Oregon Psychiatric Security Review Board. Writing that testimony made me think about why I was about to express support for people who had committed serious crimes and were considered by the State to be guilty except for reason of insanity.

Many people would immediately think that people who have attempted to harm or have harmed others should never be put into a situation where they could possibly harm others in the future. As a society we have embraced the idea that mentally ill persons are dangerous and should be segregated from those without disease to protect those who might be harmed.

The problem with that logic is that the frequency with which people who have committed crimes of mental distress are far less likely to be repeat offenders of the crime. In fact, the statistics in Oregon over the last 10 years suggest that people released from jail are nearly 15 times more likely to re-offend than those under the psychiatric security review board jurisdiction. Indeed, it appears as though the likelihood of being harmed by a person who would violate your safety is many times greater from the normal population.

How I became involved and informed about this topic is from my experiences with my daughter who suffers from schizophrenia. Her illness is one of those events that changes forever the path of your life and sets in motion the events that lead you to the hearing in Clackamas County.

While I was creating a video presentation to show at the NAMI (National Alliance on Mental Illness) NW Walks fundraiser kickoff luncheon, I was filming interviews with NAMI members. One of those I filmed was Ashleigh B. Her story was so compelling and so amazing to me that it also qualifies as a life changing event. Here was a person who explained calmly and in great detail her experiences with a tragic psychosis that could have resulted in the death of several people, including herself. To look at her and listen to her story today seems very surreal to transpose her into the situation that she created when she thought a gas station attendant was trying to abduct her and she sped away from the gas station with the attendant hanging from the side of her car.

What is most amazing is the remarkable recovery that she has worked toward in her life. She is very repentant about her actions and has shown over time that her condition is carefully controlled. No one wants to minimize the dangerous situation that she created, but as a society we must look beyond the initial event to the end result. Would we be better served if we were simply to lock her away at thousands of dollars a month to insure the safety of the community or can we look at what can be treated and controlled to make the best of an awful situation?

Ashleigh never intended to harm another person. In her temporarily distorted sense of reality, she simply fled from a place that she felt threatened her personal security. Those were the events that brought her to that moment in time. Hearing her story brought me to a deeper understanding of mental illness and why a person could act in a criminal fashion. Thinking that others like her need the opportunity to work through the recovery system and earn the right to rejoin the community is a goal that I can support.

There are other considerations to be sure, but the overall goal can be achieved while protecting the safety of the community while at the same time working to create a better solution than permanently locking people away that can recover and be a help to society instead of a burden.

Dangerous? It's Not That Simple.

2008-08-17T11:03:00.000-07:00

The issues that surround mental health cross the boundaries of many disciplines and make up one of the most varied groups of stakeholders of any issue. It is impossible to examine mental health issues without crossing purposes with a number of different interest groups. It a way, the groups of stakeholders are representative of the complexity of the disorders themselves, defying simple labels and diagnoses. While other diseases are similarly complex and varied, none of them cover a range of social issues as broad as mental health.

Cancer, while seeming to be a unifying concept, touches diet and exercise, various organs, surgery, drugs and a host of causes, both environmental and lifestyle in nature. But unlike mental illness, it does not seem to cross into the realm of public safety and law enforcement.

Mental illness seems to be unique in that it touches not only the person affected by the disease, but often times people around the affected person. When the behavior of the person affected is involved, a whole new level of complexity of the issue is at stake. That seems to be why stigma has developed around disorders of the mind, the twin issues of complexity and potential for danger. Most often this is expressed legally as "danger to self or others."

The problem used in that legal expression is the threshold of the danger posed. Clearly this is a confounding problem and generates the most disagreement among those who take positions regarding how we as a society view the treatment and diagnosis of mental illness.

Philosophical worlds collide both before and after events which are judged both by what happened and what is thought to be the state of the mental condition of the person who is being judged. It is because of the potential for explosive and damning results that most positions are fixated based upon existing beliefs and viewpoints.

The collisions are very apparent in the dilemmas that state legislators are faced with in defining treatment plans for those who have been placed in the custody of the state who are "guilty except by reason of insanity." The dilemma is what to do with those who fall into this category.

Simplistic rules of morality might suggest that the best way to handle such a situation is "You do the crime, you serve the time." The problem with this manner in viewing the problem comes from two perspectives and creates some no-win scenarios. First of all, it is extremely difficult, if not impossible, to be certain of the state of a person's mind at the time of the crime. Secondly, some mental diseases result from not what might be classified as psychotic thought, but delusional thoughts.

A prime example of this situation is the case of Andrea Yates who drowned all five of her children in a bathtub. Mrs. Yates was arguably a person of substantial intelligence. She was valedictorian of her high school class. She was "aware" of her actions to the extent that she phoned police and was able to describe what she had done to the children. Given that information, some conclude that she was a cold-blooded killer. However; she was operating under assumptions of fear that her children were condemned to eternal suffering and she was "saving" them from her being an unfit mother.

Does the definition of insanity include distortions of logic and reality? Because the disorders are defined by DSM-IV behaviorally, the simple answer is yes. When does that depart from what society calls insane? Several times I have listened to people diagnosed as mentally ill tell their stories of "distorted" reality and "voices" driving their behavior. Are there really people who might suggest that Andrea Yates felt that she had something to gain by killing her children? For most people the thought of killing your own children is beyond their ability to conceive of such a vision of reality. In the case of Andrea Yates, not only was such action plausible, it was in her version of reality the only reasonable course of action to save her children.

Does that make Andrea Yates ill or a horrible murderer? The answer is a conflicting "both." She did in fact, kill her children. She did not, however, kill them for personal gain nor intentionally with malice, she killed them from application of a bizarre sense of beliefs and logic that almost anyone else would not accept. I would argue that distinction is where much of the controversy about mental illness lies within society today.

Society argues about propositions of "reality" every single day. There are those who argue that global warming is a reality. There are those who argue that it is a concept put forth by false science. The question becomes which reality is essentially "real?" To Ms. Yates, her reality as expressed by her behaviors was that her children were better off dead than subjected to her "perceived reality" of eternal suffering. Try and imagine the mental state of a person who would make such a choice and you may begin to understand how convinced she must have been to take the actions that she took.

In a similar fashion, people who take their own lives follow the same path of logic. Their decision is based upon a vision of their reality at that point in time that makes no sense to most people, yet research tells us that many people who take their lives experience a sense of relief after having made the decision to end their lives. At that point, the angst over the decision to take the suicidal action is replaced by a relief and the actions become a kind of surreal expression of of the fulfillment of a logical progression, flawed as it is. The result in the Yates case is the expression of a calmness and detachment over having fulfilled an action that resolved the situation. It is only later when a realization of the "other" reality sets in that the actions seem to impact the person. In the case of suicide, however, the "solution" is permanent and irreversible.

From a broader perspective, what is the function of the state in protecting people from potential harm, and where are the boundaries? In the Yates case, Andrea had received care for depressive episodes but her mental health benefits had been exhausted. Her mental health professional had suggested that she not have any more children as that would nearly certainly trigger another episode of severe depression. Her husband had vigorously suggested at the urging of a spiritual advisor that she procreate and bear all children that she could possibly bear. The mental health provider suggested that she was not to be left alone with the children as she could be dangerous, but her husband had thought it was advisable to give her short trial periods alone with the children to keep her from becoming too dependent upon him.

Like most stories, there are circumstances that go well beyond the initial headline that complicate the issues of the case. Some mental health and personal freedom advocates suggest that court systems strip away individual rights and force inhuman treatment. Some suggest people should be free to do as they will. Others, in defense of their perceived safety, want any person with mental health difficulties segregated and locked away.

Answers to these issues are being forced by legal and treatment systems in place. No answer in the extreme is helpful nor particularly effective. Neighborhoods are not necessarily safer because group rehabilitation homes are refused to be located there. There are, without question, predators that are yet to be identified that cannot be relocated away from schools and children. Even recent lawsuits surrounding the behavior of members of the clergy have suggested that dangers lurk in places previously presumed safe. Clearly, society needs to understand the problems better and find more comprehensive measures to treat people in crisis. To believe that there are perfect solutions available is foolish, but to believe that we can do no better than we are doing is equally lacking in wisdom.

One conclusion is certain. Not treating people and not discussing the problems surrounding the issue is not helpful.

Bits and Genes

2008-08-03T14:41:00.000-07:00

Recently, there have been some "breakthrough" articles regarding genetics and schizophrenia. But before I get to the details of that, a bit of background is in order.

My normal occupation is that of computer network technician. Part of my experience is with data storage which is not unlike some aspects of genetic coding. Computer information is made up of one's and zero's, lots of them to be a bit more precise. When they are stored on magnetic types of media. which is what hard disk drives are, or on things like CD-ROM's where they are little bits of reflective material, they are read by some type of reader device and reconstituted back into "reliable" strings of one's and zero's where the computer processes them according to a set of instructions contained in the computer. We see the the results on our screens and we are either happy with the results or infuriated with the lack of them.

If you have used a computer for any length of time, you have become frustrated when the bits of information get fouled up and things go wrong. I am often asked "What caused the problem?"

Far too often, there may not be a specific cause. The timing circuitry in a computer is extremely precise and the one's and zero's in the memory of the computer are represented by voltages which must be nearly constantly refreshed. If that process is subject to fallout of the proper voltages, errors can occur. There are error detection and correction systems that are used to correct for potential errors in the storage media and they have phenomenal measures of reliability. These sometimes are on the order of years of undetected and uncorrected errors. However, we must be careful to remember that if there were 300 million computers all running for one full day and we were looking at an error rate of one undetected and uncorrected error for every ten years of computing time, there would still be 82,192 undetected and uncorrected errors per day on our computers.

If you keep that number of errors in mind, consider the human genome and the billions of people on Earth and its process of replicating the genetic code. Also keep in mind that there are between 20 and 25 thousand genes in the human genome and roughly 3 billion chemical pairs that make up those genes, you can begin to see the potential for error. As a matter of fact, there are some type of errors that are of interest to researchers that have some very interesting characteristics.

As one might suspect, the potential for flaws in the genetic makeup of an individuals DNA is really quite substantial. It seems as though the genetic material is subject to errors, just like any other thing that is subject to a recreation or manufacturing process. In this process some of the genetic material can be missing and some of the material can be reproduced more than once. If some of these errors take place, they might determine either good or bad characteristics in the resulting person.

One of the first genes to be recognized as having multiple copies is the gene CCL3L1. It is of interest because " (CCL3L1), competes with HIV by binding to the protein the virus uses to enter the cell. They found HIV-positive subjects had fewer copies of CCL3L1 than HIV-negative subjects from the same geographical group: each additional copy of the CCL3L1 gene reduced the risk of HIV infection by 5-10%. Duplications of CCL3L1 not only reduced infection rates and also slowed disease progress once infected."

This explains why some people are lacking in their ability to get AIDS which is caused by HIV.

The current research as it applies to schizophrenia suggests that the number of copies of a particular gene (also known as Copy Number Variations or CNV's) had a significant impact on the presence of schizophrenia. In particular, several large scale deletions were associated with schizophrenia. Not only was this found in one study, but simultaneously in two separate independent studies. People who had these particular deletions were nearly 15 times more likely to develop schizophrenia than subjects who did not have the deletions.

This is important not in a particularly practical manner, but more so in finding a small portion of the reason why a small number of the people who suffer from the disease of schizophrenia develop the disease.

One of the problems with the application of basic research is the inability to draw generalization to wide ranges of patients who suffer from the diseases. I was present at a NAMI meeting where Dr. Aaron Janowsky of Oregon Health and Science University was describing research he was involved in that was looking at a sub-group of subjects diagnosed with schizophrenia that were split into groups that either had or did not have a reaction to Niacin. Most people diagnosed with schizophrenia do not have a Niacin reaction, which is characterized by a reddish flushing of the skin when exposed to Niacin. There is no particular conclusion to be made from this fact, other than observing that there is a strong association of a lack of Niacin reaction in those diagnosed with schizophrenia.

One of the devilish problems with research on schizophrenia is that the disease is diagnosed by behaviors and symptoms, not a specific chemical cause. In this case, there may be a disease or form of the disease which could be characterized by the lack of a Niacin reaction and a genetic deletion. But since people who do have Niacin reactions and do not have specific genetic deletions are also classified and diagnosed with schizophrenia, what are we to conclude?

The problem stems from the fact that we diagnose mental diseases in the manner in which we do, by a set of guidelines set up in the DSM-IV manual. While it is inadequate to fully describe the precise nature of mental disease, there is no other alternative to use to attempt to assess and research the aliments of mental disorders. Until then we will look toward each clue that will refine our understanding of what causes the behaviors that we outwardly observe.

Unfortunately, the disorder we call schizophrenia is most likely a series of problems with multiple causes, resulting in behaviors that have a similar outward characteristics. This would really explain why there is a wide range of effectiveness of drug treatments and such variability in the course of the disease(s). In the meantime, research continues and more and more clues are found that help explain the causes. Eventually science will gather more and more clues to this extremely complex set of disorders. Until then we will celebrate the accumulation of clues to the causes that will eventually lead to better treatment .

Justified?

2008-07-28T20:08:00.000-07:00

When Andrew Hanlon was shot to death while undergoing a psychological crisis in Silverton, Oregon it was but another case of deadly interaction between a person in crisis and police officers charged with maintaining public safety. It is too easy to dismiss the incident as a rampaging person out of control that had to be stopped. But that is precisely what happened as a grand jury found that the shooting was "justified."

"Justified" is, unfortunately, a relative term and is applied in this case with a great deal of assistance from a society that wishes to wash it hands of problems and overlook the real problems that lead to the circumstances that "justify" the actions taken. Taken at the precise moment of the incident, where a person out of control is threatening another persons safety and there is the possibility of the loss of a life, the rules of engagement for police officers allow for "justifiable force" to control the situation. Even so, there is a great deal of discrepancy among police departments over what actions can be taken in crises and the training of officers that are trained to handle such situations. I have yet to see where a police officer has been found to be at fault when firing their weapon and killing a person who has behaved irrationally and threatening. In several of these cases, the shots have been fired multiple times into the back of the assailant. In the Fall of 2007 a young man in Washington County, Oregon was shot in the back as he was running into a building. It might have been that he was running for shelter from being shot with rubber bullets, but a decision was made that he was a danger to the person in the building and was fatally wounded.

While it is hard to live with the process of assigning blame to an officer who is acting under crisis and with split-second decisions being made, there is so much more to all of the stories I have encountered.

On Friday July, 25, 2008 the Portland Oregonian published a letter to the editor from a desperate mother of a young man that reflects the depths of the problem and why we keep reading about young people like Andrew Hanlon that are "justifiably" killed in the name of public safety. For the past two years the mother of the young man in question has contacted numerous agencies and desperately tried to gain access to treatment that would prove effective in relieving the symptoms that her son suffers from. The lack of community resources and access to a system of care is appalling. She has been thwarted at every attempt to gain access to care for her son, even though the laws for mental health care supposedly provide for parity for those seeking treatment for mental illness.

I called her and spoke with her about her efforts. In spite of contacting numerous agencies and social service providers, she has been unable to bring the situation regarding her son under a controllable environment. Her pleas to a child welfare hotline resulted in the following advice. He "might be able to get help if he was arrested, adjudicated, and there was a court order for treatment."

This is the plight that citizens are faced with. There is really no entry point into the service system. The problem is even more difficult for a young man like Mr. Hanlon who happened to overstay his VISA and is technically a citizen of another country. We are playing in a system that has no entry point for services until a crisis is encountered and by the time that happens we have 'justified" ending their life. Hospitals supposedly cannot turn those who cannot pay for health care away from their facility. They can, however, turn away from those who have yet to behave in a dangerous enough manner and leave them at risk for early termination of their life based upon a mental crisis. Over and over, we read story after story of those who have put the public in danger and have been killed because of their creation of imminent danger to others. The real danger is to themselves as they struggle for lack of entry to a system of care that could save everyone from the tragedy that inevitably follows.

When will we recognize the real danger from the lack of access to treatment services?

Amen, Doctor

2008-07-24T19:53:00.000-07:00

A long time ago, back in undergraduate school, one of the questions posed in a discussion group was how do we as students see the study of psychology from a theoretical perspective. The great "philosophical divide" was between the behaviorists championed by B.F. Skinner and his operant psychology and conventional psychoanalytic theory championed by Carl Rodgers and his followers.

The purpose of the question was not to judge the correctness of either approach but to clarify how each viewpoint reflected the theoretical framework of the study of behavior. As I see the arguments unfold about treatment theories and public safety I continue to go back to those discussions about the different approaches to studying behavior.

The terminology "studying behavior" is especially appropriate. If you look at the theories of B. F. Skinner there is a brilliant and elaborate set of rules about punishment and reward, behavior shaping and successive approximations. In the rat lab, we as students were able to shape the behavior of our white rats and get them to press levers for food and achieve remarkable success in training behaviors. At the end of the class and lab sessions, you might have been convinced that a rule book for psychology had been written and all behavior could be shaped and modified.

But every theory has its weakness in its application to all situations. When one looked more carefully at the theory, the principles of rewards and reinforcers were not defined in specific terms, they were defined by their effect on the behaviors of the organism under study. That is to say, they were defined functionally. If a stimulus were presented that increased a behavior it was a reinforcer. The theory did not explain why it was a reinforcer, just that it either was or was not a reinforcer. The problems came when you presented the same stimulus to two different people and got opposite results. Let's say, for example, you wanted to get someone to lift some weights and offered them money to lift the weights. One subject might do the lifting for money, the other may not. Money was a reinforcer in one situation but not in the other because the lifting behavior did not increase.

The same sort of problem exists in what might be called the bible of modern psychiatry, the DSM-IV manual. It is, if one examines it's approach, just what B.F. Skinner's definition of psychology is, a wonderful description. DSM-IV lays out in very detailed terms very elaborate criteria for the categorization of observable behaviors that then codifies the behavior and classifies it as a specific disorder. It is, when followed, a rather neat and tidy description of the behaviors associated with the disorder classifications.

Unfortunately, like B.F. Skinner, it does absolutely nothing to explain the whys of behavior. Realistically, there is no way to explain the why because what psychiatry is primarily based upon is a lot of clues and a great deal of accumulated observation mixed in with some great theories that has few if any real answers.

There should be very little doubt in any one's mind, except for the Tom Cruise's of the world, that real pathology does exist. We even have a pretty darn good idea of the areas of origin and some of the genetic and chemical process involved. But we still do not have definitive answers as to the precise nature of why.

This all leads to Dr. Amen. (Yes, that is his name, Dr. Daniel Amen) Dr. Amen is a psychiatrist that has taken the application of SPECT imaging and is relating the images of the brain to the observable behavior symptoms and interviewing data from psychiatric treatment to more precisely determine the areas affected in the brain from a variety of causes. He uses the SPECT imaging process to suggest medications and to evaluate the effects of those medications. It is a step beyond the typical clinical process and is a bold attempt to bring a higher order of observation to the process of diagnosing and treating problems with the brain. He is to be commended for his efforts to move beyond the boundaries of conventional psychiatry and bring some observable imaging technology to assist the process of understanding pathology and monitoring treatment.

The reliance on a manual and observation to create a diagnosis have lead to a great deal of criticism about the field of psychiatry. Some of it is justified. Those who suggest that the entire field is simply imaginary choose to ignore what has been carefully observed and codified. While it might be easy to suggest that brain function should be completely controllable by any person, clearly it is not and that assumption does not allow for any form of dysfunction. Suggesting that something as complex as the brain could not have disease or dysfunction seems preposterous when viewed in the light of all the other documented physical dysfunctions of the human body. Dr. Amen has chosen to take steps beyond observation and chosen to work toward greater quantification of brain function through observation methods that seek to expand our knowledge of the functions of the brain. I wish Dr. Amen and others like him success in furthering our understanding of the Whys of brain function.

Visit his web site at www.amenclinics.com to see his views on brain function and treatment for a wide variety of diseases. It is well worth your investigation.

Falling Through the Cracks

2008-07-21T12:53:00.000-07:00

For those of you prone to suggest that the government really does not understand problems that affect the country, you might want to look at the US Government Accountability Office or GAO for short. In effect, it is a government office that does research into problems that affect us as citizens and reports the findings to government leaders who use this information to craft legislation to help mitigate the findings of GAO reports.

Representative Pete Stark and Senator Gordon Smith asked the GAO to study what happens to citizens who are in the transitional age from childhood to early adulthood that suffer from mental illness. The request was to determine the scope of the problem and what states are doing to deal with the problems presented to those who suffer from diseases such as schizophrenia and bipolar disorder. What the GAO found may shock those of you who are not familiar with the scope and nature of the problem. http://www.gao.gov/new.items/d08678.pdf

The GAO estimated that at least 2.4 million young adults aged 18 through 26, roughly 6.5 percent of the non-institutionalized population in that age range suffered from a serious mental illness in 2006. The actual numbers are even higher because the study did not include homeless, institutionalized and incarcerated persons in the study group. In addition 186,000 young adults received SSA (social security) benefits in 2006 because a mental disability prevented them from engaging in substantial, gainful activity. As a group, they tended to have significantly lower levels of educational achievement.

One of the especially difficult aspects of an early diagnosis and treatment is that the qualification for inclusion into government assistance programs is often lower for children than adults. The transitional process many times results in loss of benefits for children as they transition into adult care programs. This can result in discontinuation of treatment which can exacerbate the symptoms of mental diseases.

The report paints a chilling picture of a complex network of programs that does not coordinate nor serve the needs of the population effectively. To quote the report "families wanted information . . . generally reported feeling overwhelmed by the complexity of the system of agencies and organizations."

The result of this report is legislation proposed by Senator Gordon Smith, Senator Thomas Dodd and Representative Pete Stark, the Healthy Transition Act of 2008. They should be commended for their efforts to illuminate the plight of 2.4 million citizens and their families. Those who are ill enough to be disabled would nearly fill the Rose Bowl stadium and the famed "Big House" in Ann Arbor, Michigan. If you count those who suffer from serious illness you are talking about a number that approximates the attendance for an entire year for any major league baseball team. Every game!

The most shameful part about those who suffer is how they are portrayed. Unlike those who suffer from cancer and diabetes who are seen as sympathetic, those with mental illness are portrayed as flawed or responsible for their condition. Those who know them personally, see the pain and struggle first hand. When we stop and consider the size and complexity of the problem, perhaps we can think about how many suffer and what needs to be done to help treat those who suffer and allow for a path to recover like any other illness. It is not an easy task, but one worth doing to help alleviate the problem of mental diseases.

Senator Smith knows first hand the potential of lack of treatment. His son, Garrett, took his own life as a result of suffering from bipolar disorder. Senator Smith's efforts and his public acknowledgement of Garrett's story helps others who bear the pain of their own personal tragedy. His recognition that Garrett chose a permanent solution to a temporary problem properly reflects what can be accomplished with good access to services. He has taken that tragedy and used it to inspire his service to others. As the parent of one of the 186,000 young adults who make up the members of the study, I can share his pain over the effects of illness and appreciate his efforts to create help for those citizens in need of services. We need fewer cracks in the system and more comprehensive treatment. In the long run, reducing the number on disability and helping those in temporary crisis will benefit all citizens.

For those who are unaware of the problem, it is worthwhile reading the report. For those with family members and loved ones, it is a source for inspiration and hope for a better future. When the numbers and scope of the problem is known, somehow you feel anything but alone.

Welcome

2008-07-21T10:57:00.000-07:00

Welcome to Matters of the Mind, my postings about matters relating to mental health. While I actually majored in Psychology as an undergraduate student, the subject matter was not as much personal as academic. Mental health issues have come to me as a result of family circumstances as my eldest daughter has a diagnosis of schizophrenia.

As I began to process the realities of her illness, the nature of mental disorders and the stigma attached to them began to become more relevant to my daily activities. Almost everywhere I went and almost everyone I spoke to had their own story of their family member, spouse, parent, child or friend that was affected by some type of mental disorder. This exposed a tremendously peculiar feature of our society in that individually and within a family there is often great concern and caring for our loved ones, but within the media and public consciousness there is great scorn and stigma associated with those who suffer from a host of mental diseases.

It is precisely this stigma and misinformation that has led me to the desire to reasonably and rationally discuss many of the aspects of how mental function and dysfunction affects our daily lives.

It matters very little who you are or your position in life if you are to become stricken with a disease of the brain. It happens every day to people everywhere. Famous, privileged, poor, beautiful, ordinary, talented or educated no matter the label, we are all susceptible. The diseases are a non-discriminatory offender.

This blog is designed to examine viewpoints about the diseases, treatments, stigma, research, social implications and any other related topic that is worthy of discussion. There are no limits on the range of issues that can qualify as there are seemingly no limits on the effects on peoples lives. I hope you enjoy the ideas and topics presented and ask for your input into the process of examining the subjects presented.

Again, welcome to matters of the mind.