MENTAL HEALTH NEWSTM YOUR TRUSTED SOURCE OF INFORMATION, EDUCATION, ADVOCACY AND RESOURCES SUMMER 2003 FROM THE LOCAL, STATE, AND NATIONAL NEWS SCENE VOL. 5 NO. 3 Employment for People With Mental Illness

Ira H. Minot, Founder & Publisher by their illness require the same under- However, much remains to be done in Mental Health News takes pride in Mental Health News standing and accommodations accorded education and legislation to turn the tide. bringing the efforts of the mental health any other form of disability. Those with a serious mental illness community to enhance opportunities in hile conflicts test our na- When the barriers to employment are face the greatest barriers to employment employment for people with mental ill- tion in distant lands, the lifted for people with mental illness, a and the highest degree of stigmatization ness--and to encourage and support more struggles of people with broad and just vision to accept the good in the workplace. The unemployment and more employers to provide meaning- mental illness continue and the ability of all men and women are rate for this population is reported to be ful job opportunities for consumers. Where at home. The injustices of stigma valued. This, in turn, may have far- as high as 70-90%. The majority of peo- We hope that this issue of Mental against people with mental illness con- reaching effects in lessening peoples’ ple with a mental illness want to work, Health News helps to advance your un- tinue to surface within the social fabric fear of a disabled population, which is at and recent surveys report that approxi- derstanding of this vital topic and further and the workplace in communities the root of all stigma. mately 70% of those with significant encourages leaders in the business com- throughout the nation. Many employers have embraced this psychiatric problems rank work as an munity to become involved. For people with mental illness, the vision and have taken a leadership role important goal for themselves. (Source: Please see our table of contents for struggle and challenges often imposed in employing people with mental illness. Matrix Research Institute, 1995.) the complete story. The Effect of War on Our Mental Health

By Robert Abramovitz, M.D. What is The Fear Response Chief Psychiatrist and Director, JBFCS Fear is an innate, primal emotional reaction that in- Center for Trauma Program Innovation volves a feeling of alarm or dread invoked by some 3 hese are extraordinary times filled with threats specific object or situation that signals danger. Fear that evoke fear, uncertainty and anxiety. How serves a useful function by mobilizing us to respond to a threat. Manageable levels of both fear and anxiety can does one go about daily life while simultane- ously balancing being on alert with the need to facilitate adaptive functioning. However, if the intensity keepT from over-reacting? As mental health profession- is too great, maladaptive responses cause freezing, withdrawal, disorganization, confusion and helpless- als, the message we should convey is that people can learn “how to function effectively in spite of being ness. afraid.” We are not telling people “don’t be afraid.” Acts of terrorism are designed to cause such intense fear in order to interfere with effective action even in In these uncertain times, each of us needs to work to promote resiliency and adaptive coping strategies. Part the absence of an actual attack. They also disrupt nor- of this effort involves integrating the useful knowledge mal trusting bonds, which further erodes one’s sense of security and safety. Anxiety is defined as an unpleasant we now have about how the brain processes threats,1 how going into survival mode affects thinking and be- state of tension associated with a more generalized, long-term anticipation that something unpleasant may havior,2 and how the use of expanded concepts of safety happen.4 Freud defined signal anxiety as the fear that can promote adaptive coping. Coping With Fear and Anxiety is a guide that was arises from the anticipation of a perceived threat of dan- developed at the Jewish Board of Family and Children’s Although the guide was intended for the clinician, ger. Fear can also have an adaptive function in that foreseeing the possibility of danger allows one to pre- Services Center for Traumatic Program Innovation. we feel that consumers’ families and the general public This guide is designed primarily to assist mental health will also gain a great deal from reading it. pare to avoid or prevent the dangerous situation. professionals help clients and the general public by con- Everyone can benefit by a better understanding of Understanding how our fear reactions are triggered and how they change our thinking and behavior can be verting conceptual frameworks into useful psycho- ways to identify and express troubling feelings that they educational and coping skills training. Many other pro- may be experiencing. Should these feelings become too useful for everyone but especially anxious, fearful peo- fessionals may also find it useful. severe, we would urge you to seek the help of a quali- ple. This knowledge can help contain maladaptive reac- tions that perpetuate the fear. We wish to thank Mental Health News for bringing fied mental health professional in your community, Coping With Fear and Anxiety to its readership. many of which are featured in Mental Health News. see The Effect on page 22

- Timothy’s Law Campaign: Spearheads Parity Battle in New York State Also Inside This Issue Of Mental Health News - Shocking Trend: Parents Giving Up Custody to Get Child MH Services

NON PROFIT Mental Health News Education, Inc. ORGANIZATION 65 Waller Avenue U.S. POSTAGE PAID White Plains, NY 10605 WHITE PLAINS, NY PERMIT NO. 153 PAGE 2 MENTAL HEALTH NEWS ~ SUMMER 2003 MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 3

Table of Contents - Summer 2003 Issue

Publisher’s Desk Employment: Cover Story The Currents of Our Times (Page - 5) NYS-OMH on Supported Employment (Page - 9) Your Letters to Mental Health News (Page - 6) DCMH Westchester: What’s Out There (Page - 9) Local Businesses Hire Consumers (Page - 12) Mental Health NewsDesk Columbia University’s Workplace Center (Page - 31) Disturbing New Government Report (Page - 7) Project Renewal’s “Job Links” Program (Page - 32 Pulitzer For Levy of New York Times (Page - 7) Recovery and Employment: A Journey (Page - 32) Medicaid Reform and Public Mental Health (Page - 8) FEGS L.I.F.E. Program: Building Careers (Page - 33) House Legislation Protects SSI and SSDI (Page - 8) ICL’s Phoenix: Winning Consumer Business (Page - 34) JBFCS Addresses Employment Needs (Page - 36) Columns NY Works Success Story (Page - 37) MHA of NYC: Cognitive Remediation (Page - 38) The NAMI Corner (Page - 13) Pathways Provides Consumer Choice (Page - 39) Point Of View (Page - 14) Southwest Connecticut’s Model (Page - 43) The NYAPRS Advocacy Watch (Page - 14) Getting to Work (Page - 45) The MHA Connection (Page - 15) The Coalition Report (Page - 15) The NARSAD Report (Page - 16) Thank You: Advertising Sponsors Working With Medications (Page - 17) SLS Health, MHA of Rockland County, New York-Presbyterian The NYSPA Report (Page - 18) Psychiatry, The Guidance Center, WRO, NARSAD, NYSPA, MHA in Putnam County, Search for Change, MHA of Westchester, Feature Stories Psychiatric Society of Westchester, Westchester Jewish Community Services, Putnam Family Support and Advocacy, NY Presbyterian’s New Inpatient Services (Page - 10) Family Services of Westchester, The Center for Career Freedom, Four Winds Hospital Supplement (Page 23 - 26) Four Winds Hospital, Timothy Law Campaign Donors, Human Timothy’s Law Campaign: Hope for Parity (Page - 28) Development Services, Putnam Family and Community Services, Recovered Therapist Treat Eating Disorders (Page 41) Saint Joseph’s Medical Center, FEGS, Institute for Community Searching for Meaning in Recovery (Page 44) Living, Jewish Board of Family and Children’s Services, Silver Hill Hospital Seminar Review (Page - 46) Fordham-Tremont Community Mental Health Center, JASA, MHA of New York City, Pathways to Housing, Saint Vincent Catholic Effect of War: Cover Story Medical Centers, Center for Eating Disorder Recovery, Coping With Fear and Anxiety (Page - 1) Hall-Brooke Behavioral Health Services, Norwalk Hospital, The Effects of War on Children (Page - 20) NAMI: Westchester & Rockland, Silver Hill Hospital, Treatment in the Context of Ongoing Threat (Page - 27) Westchester Medical Center:Behavioral Health Center

Mental Health News TM is a publication of Mental Health News Education, Inc., a tax-exempt, not-for-profit organization. 65 Waller Avenue, White Plains, New York 10605 Ira H. Minot, C.S.W., President & Publisher Jane E. McCarty, Assistant Editor

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Mental Health News does not endorse the views, products, or services contained herein. No part of this publication may be reproduced in any form without written permission. Mental Health News is not responsible for omissions or errors. Copyright © 2003 Mental Health News Education, Inc., All rights reserved. PAGE 4 MENTAL HEALTH NEWS ~ SUMMER 2003 Mental Health News Advisory Council

Hon. Tom Abinanti Pam Forde, Director Andrew P. Levin, M.D., Medical Director Phillip Saperia, Executive Director Westchester County Legislature - 12th District Putnam Family Support and Advocacy, Inc. Westchester Jewish Community Services Coalition of Voluntary Mental Health Agencies

Nadia Allen, Executive Director Richard J. Frances, M.D., Medical Director Robert M. Lichtman, Ph.D., CASAC, Director Jennifer Schaffer, Ph.D., Commissioner Mental Health Association in Orange County Silver Hill Hospital Mount Vernon Service Center Westchester County Department of Community Mental Health

Richard Altesman, M.D., Representative Maurice J. Friedman, Director Constance Lieber, President, Board of Directors Jack C. Schoenholtz, M.D., L.F.A.P.A., Medical Director American Psychiatric Association National Assembly Westchester Library System NARSAD Rye Hospital Center

Gene Aronowitz, Ph.D. Michael B. Friedman, C.S.W. Robert Litwak, C.S.W., Assistant Executive Director Judy L. Scheel, Ph.D., Director Management Consultant Public Policy Consultant Mental Health Association of Westchester Center for Eating Disorder Recovery

Peter C. Ashenden, Executive Director Steven J. Friedman Hon. Nita M. Lowey Edythe S. Schwartz, A.C.S.W., Executive Director Mental Health Empowerment Project Mental Health & Public Policy Analyst U.S. Congress - 18th District Putnam Family & Community Services

Hon. Chris Ashman, M.S., Commissioner Alfred A. Fusco, Executive Director Frank A. Marquit, CEO - President J. David Seay J. D., Executive Director Orange County Department of Community Mental Health Mental Health Association in Onondaga County National Artists for Mental Health, Inc. NAMI - New York State

Alan D. Barry, Ph.D., Administrative Director, Kenneth M. Glatt, Ph.D., Commissioner Randall Marshall, M.D., Associate Professor of Clinical Janet Z. Segal, C.S.W., Chief Operating Officer Department of Psychiatry, Norwalk Hospital Dutchess County Department of Mental Hygiene Psychiatry, New York State Psychiatric Institute Four Winds Hospital

Jeannine Baart, M.S. Joseph A. Glazer, President & CEO Hon. Naomi C. Matusow Kren K. Shriver, M.P.H., M.D., Clinical Director Mental Health Education Consultant Mental Health Association In New York State New York State Assembly - 89th District Hudson River Psychiatric Center

Alfred Bergman, Chief Executive Officer J.B. Goss, R.Ph., Ph.D. Richard H. McCarthy, Ph.D., M.D., C.M. Michael Silverberg, President Supervised Lifestyles Comprehensive NeuroScience Comprehensive NeuroScience NAMI - New York State

Sheldon Blitstein, C.S.W. Arnold Gould, Co-President Steven Miccio, Executive Director Alan B. Siskind, Ph.D., Executive Vice President & CEO NY United Hospital - Behavioral Health Services NAMI Queens/Nassau PEOPLe Jewish Board of Family and Children’s Services

James Bopp, Executive Director Steven Greenfield, Executive Director David H. Minot, Ithaca College, Chairman Steven H. Smith, Psy.D., Consulting Psychologist Rockland and Middletown Psychiatric Centers Mental Health Association of Nassau County Mental Health News - University Advocacy Division Grace Church Community Center

Joe Bravo, Executive Director Ralph A. Gregory, President & CPO Grant E. Mitchell, M.D., Director, Mental Health Services Jeffery Smith, M.D. Westchester Independent Living Center United Way Of Westchester & Putnam The Mount Vernon Hospital Private Practice - Scarsdale, NY

Linda Breton, C.S.W., Assistant Executive Director Mary Guardino, Founder & Executive Director Margaret E. Moran, CSW, VP, Administrative Services Andrew Solomon, Contributing Writer, Magazine Westchester Jewish Community Services Freedom From Fear Behavioral Health Services - St. Vincent’s Catholic Medical Centers The New York Times

David Brizer, M.D., Chairman, Department of Psychiatry Mark D. Gustin, M.B.A., MPS, Senior Associate Director Meryl Nadel, D.S.W., Chairwoman Hon. Nicholas A. Spano Norwalk Hospital Kings County Hospital Center Iona College - School of Social Work New York State Senate - 35th District

David S. Brownell, Commissioner Mary Hanrahan, Director, Treatment Services Sarah Newitter, Executive Director Hon. Andrew J. Spano Onondaga County Department of Mental Health New York-Presbyterian Hospital NAMI of Westchester, Inc. Westchester County Executive

Jacqueline Brownstein, Executive Director Dean B. Harlam, M.D., Associate Medical Director Evelyn J. Nieves, Ph.D., Executive Director Giselle Stolper, Executive Director Mental Health Association in Dutchess County Saint Vincent’s Behavioral Health Center - Westchester Fordham-Tremont Community Mental Health Center Mental Health Association of New York City

John F. Butler, Manager of Community Affairs Carolyn S. Hedlund, Ph.D., Executive Director Terri M. Nieves, MS.Ed, M.S., Director of Counseling Services Harris B. Stratyner, Ph.D., C.A.S.A.C., Director Verizon - New York Mental Health Association of Westchester Mercy College NYPH & UHC Chemical Dependency Program

Alison Carroll, C.S.W., Director of Day Treatment Rhona Hetsrony, Executive Director Megan Nowell, Director Jeannie Straussman, Director, Central NY Field Office Putnam Family & Community Services North Shore LIJ Health System - Zucker Hillside Hospital Mental Health Association of Putnam County New York State Office of Mental Health

Amy Chalfy, C.S.W., Bronx District Director Richard S. Hobish, Esq., Executive Director Karen A. Oates, President & CEO Timothy B. Sullivan, M.D., Clinical Director JASA Pro Bono Partnership Mental Health Association of Rockland County Saint Vincent’s Behavioral Health Center - Westchester

Steven K. Coe, Executive Director Marsha Hurst, Ph.D., Director, Health Advocacy Program Hon. Suzi Oppenheimer Janet Susin, Co-President Community Access Sarah Lawrence College New York State Senate - 36th District NAMI Queens/Nassau

George M. Colabella, President Doug Hovey, Executive Director Matthew O’Shaughnessy, Senior Vice President Richard P. Swierat, Executive Director Colabella & Associates Independent Living Center of Orange County WVOX & WRTN Radio Westchester ARC

Robert S. and Susan W. Cole Beth Jenkins, Executive Director Ellen L. Pendegar, M.S., R.N., C.S., CEO Maria L. Tiamson, M.D., President Cole Communications Mental Health Association in Tompkins County Mental Health Association In Ulster County Psychiatric Society of Westchester

Marianne Coughlin, Administrator Tom Jewell, Ph.D. Barry B. Perlman, M.D., Chief of Psychiatry Alan Trager, Executive Director & CEO New York-Presbyterian Hospital Westchester Division Family Institute for Education Practice and Research St. Joseph’s Hospital - Yonkers Westchester Jewish Community Services

Anthony A. Cupaiuolo, Director Sabrina L. Johnson, B.A., Recipient Affairs Liaison Susan Perr, M.A., Mental Health Advocacy Coordinator Anthony F. Villamena, M.D., Chief of Psychiatry Michaelian Institute - PACE University Westchester County Department of Community Mental Health WILC - Mental Health Advocacy Project Lawrence Hospital Center

Anna Danoy, Deputy Director Rami P. Kaminski, M.D., Medical Director of Operations Cynthia R. Pfeffer, M.D., Professor of Psychiatry Jonas Waizer, Ph.D., Chief Operating Officer Mental Health Association of Westchester New York State Office of Mental Health Weill Cornell Medical College of Cornell University FEGS - Behavioral & Health Related Services

Joseph Deltito, M.D., Clinical Professor of Psychiatry and John M. Kane, M.D., Chief of Psychiatry Hon. Michael J. Piazza, Jr., Commissioner Joyce Wale, Assistant Vice President - Behavioral Health Behavioral Science, New York Medical College Hillside Hospital Putnam County Department of Mental Health New York City Health & Hospitals Corporation

Anthony B. DeLuca, ACSW, Commissioner James J. Killoran, Executive Director Premkumar Peter, M.D., Medical Director Maralee Walsh, Ph.D., Program Director-Behavioral Health Center Tompkins County Mental Health Services Habitat For Humanity - Westchester Putnam Hospital Center - Mental Health Services Westchester Medical Center

Frank DeSiervo, ACSW, Division Chief, MH Services Samuel C. Klagsbrun, M.D., Executive Medical Director James R. Regan, Ph.D., Chief Executive Officer Hon. Mary Ann Walsh-Tozer, Commissioner Dutchess County Department of Mental Hygiene Four Winds Hospitals Hudson River Psychiatric Center Rockland County Department of Mental Health

Steve Dougherty, Executive Director Marge Klein, Executive Director Starr R. Rexdale, M.D., Medical Director Michael Wein, CSW-R, CASAC, Administrator Laurel House The Guidance Center The Guidance Center NY United Hospital - Behavioral Health Services

Toni Downs, Executive Director Lee-Ann Klein, M.S., R.D., Nutritionist Lisa Rattenni, Vice President, Behavioral Health Services Peter Yee, Assistant Executive Director Westchester Residential Opportunities Albert Einstein College of Medicine Westchester Medical Center Hamilton-Madison House

Douglas Drew, Consumer Link Advocate Easy Klein, Media Coordinator John Rock, Consumer Liaison Neil Zolkind, M.D., Clinical Director Mental Health Association of Nassau County NAMI - New York Metro Division Hudson River Psychiatric Center Westchester Medical Center - Behavioral Health Center

Denneth J. Dudek, Executive Director Andrea Kocsis, C.S.W., Executive Director Evelyn Roberts, Executive Director Fountain House Human Development Services of Westchester NAMI - New York City Metro Mental Health News Mary Grace Ferone, Esq. Joshua Koerner, Executive Director Harvey Rosenthal, Executive Director Westchester - Putnam Legal Services Choice NYAPRS Wishes to Express Its Sincere Gratitude And Appreciation Barbara Finkelstein, Esq., Executive Director Lois Kroplick, M.D., Founder & Chairwoman L. Mark Russakoff, M.D., Director of Psychiatry Westchester - Putnam Legal Services Mental Health Coalition of Rockland County Phelps Memorial Hospital Center To The Members Of Our

Rena Finkelstein, President Rabbi Simon Lauber, Executive Director Joseph F. Ryan, Ph.D., Dean Advisory Council And To The NAMI-FAMILYA of Rockland County Bikur Cholim of Rockland County PACE University School of Public Administration Organizations and Supporters Who

Donald M. Fitch, MS., Executive Director Joseph Lazar, Director, NYC Field Office Thomas E. Sanders, C.S.W., President & CEO Make This Publication Possible The Center For Career Freedom New York State Office of Mental Health Family Service of Westchester MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 5 The Publisher’s Desk

• people are still struggling Coalition of Voluntary Mental in silence because of the Health Agencies, Center for The Currents stigma against mental ill- Urban Community Services, ness and Association for Community Living, New York Presbyterian • the consumer movement is Hospital, New York State Psy- marred by an atmosphere chiatric Association, Ellis of non-inclusiveness and Hospital, Law & Public Policy an unclear agenda. Consulting, Samaritans Sui- cide Prevention Center, Men- In our NewsDesk, a dis- tal Health Association of turbing report by the federal Westchester, Mental Health government indicates that Association of NYC, Mental parents are giving up custody Health Association in New of their children in order to York State, National Alliance get them the care they need for the Mentally Ill in New to battle serious emotional York State, Schuyler Center disturbances. for Analysis and Advocacy, Next, we are elated to NASW - NYS Chapter, Mental learn that Clifford Levy of the Ira Minot Health News, and National Of Our Times NY Times (so admired for his Alliance for the Mentally Ill of hard hitting reporting of criti- mentum to reduce insurance New York City. cal mental health issues) has discrimination against treat- There are many, many By Ira H. Minot, Founder & just won the Pulitzer Prize. ing people with mental ill- more vital mental health or- Publisher Mental Health News But we are saddened, that ness. The pitifully sad part is ganizations that represent the Levy’s exposé has not yet re- that a beautiful child named true spirit of our community sulted in major changes for Timothy took his life while in all parts of the nation. people with mental illnesses battling a mental illness, and They are the fabric of our or almost everyone who live in adult homes or that he was not afforded ade- landscape. They are hard at afflicted by a mental nursing homes. quate insurance coverage work year in and year out to illness or connected We learn that the Presi- that would have probably provide treatment, housing, in other ways to the dent is proposing Medicaid saved his life. employment, research and mentalF health community, reform which would put mil- The stories are many and vital advocacy efforts on be- our present day universe of- lions of Americans with men- the problems deep, as we half of the system as a whole ten defies logic and under- tal illnesses at risk, by allow- read about them in every is- and on behalf of the individ- standing. It’s as if we are rid- ing states to reduce eligibility sue of Mental Health News. ual consumer and their fami- ing in an H. G. Wells time- and benefits to Medicaid re- From inadequate housing, to lies. machine that can’t make up cipients; which is predicted to budgetary cut-backs, to bat- Thanks to you, Mental its mind in which direction increase homelessness, insti- tles over the right of people to Health News has become a we are going—to a much de- tutionalization and criminali- receive proper medications vital forum for ideas and a sired utopian future or back zation, which will result from when they may be the cutting catalyst for change. We are to our shadowed past. This more people being untreated edge they need to recover. proud of our role and will dichotomy is quite troubling for mental illnesses. And Yes, the currents of our continue to devote ourselves and unfortunate. this, at a time when New times run in many directions to represent the best that our The last twenty years have York’s mental health system and when you’re caught in community has to offer. seen great advances in the takes additional steps to tie them, it may seem like we’re This current issue of Men- science, medicine, public pol- mental health services to swimmers caught in a deadly tal Health News is devoted to icy and relative acceptance of Medicaid funding in order to rip-tide. There has always Employment; the one previ- the disease model of mental fill skyrocketing budget gaps. been one constant at work ous to this one was about illness. However, the social We are encouraged by the throughout the history of the housing—two vital issues that and political environment much fought-for Medicaid mental health community: affect the daily lives of people surrounding mental illness buy-in program, due to begin the people. The people I refer with mental illness. continues to flip-flop, taking this summer, but wonder if it to are those who care, sup- In upcoming issues, Men- one step forward and then will be the answer to why port and fight for the rights of tal Health News will again fo- two steps back. 85% of people with mental people with mental illness. cus on more clinical topics, The articles and editorials illness do not hold jobs. This constant, is the life- including: Understanding and in this issue of Mental Health Hopefully, with Medicaid buy- preserver that wraps around Treating Adolescent Depres- News are a good example of in more will want to return to us, giving us buoyancy and sion, The Crisis of Suicide in the ebb and flow of the cur- work without the fear of los- safety in difficult times. America, Eating Disorders: rents of our times. For exam- ing their health coverage. We are not living in a per- The Conflict Within, and Un- ple: in Your Letters, you have The compelling story of fect time or with a perfect derstanding and Treating written to us about: Timothy O’Clair and the par- mental health system or na- Sleep Disorders. ents whose courage to fight tional agenda. But we have Thank you for your con- • people with mental illness for our cause is Timothy’s our people. People who repre- tinued readership, participa- continue to fall through Law Campaign and may well sent our most precious or- tion and support, which reaf- the cracks, be the story of the year. But ganizations such as the ones firms our commitment to this alas, it’s a happy and sad who united to support Timo- vital educational mission. • the business community story again, indeed. The thy’s Law and the ad cam- needs to consider hiring happy part is that our com- paign in this issue of Mental Have A Great Summer ! people with mental illness, munity is rallying with mo- Health News. They include: Ira H. Minot PAGE 6 MENTAL HEALTH NEWS ~ SUMMER 2003 Your Letters to Mental Health News

Fix Our Mental Health System Employing Consumers

wish to thank Mental Health News as many of the homeless died this bitter oth my husband and I have or instability in work habits and work for its efforts to present a balanced winter hired a large number of em- relationships. picture on Housing for persons The President’s Commission Interim ployees over the years—he On the other hand, if someone with a disabled by mental illness. While a Report is a fine document. It tells us in his New York business, mental illness has had the benefit Inumber of viewpoints were presented, I that half of all persons in our great coun- Band I in my Connecticut based real es- of training and preparation for working am not certain the real picture came try with mental illness receive no treat- tate complex. We have both had the ex- in competitive employment, he across. ment. The report states that one result of perience of working successfully with may be more reliable than someone To stay in reasonable physical condi- our fragmented system is that 30,000 employees who have psychiatric condi- who, because he was never diagnosed, tion and also to practice what I preach to persons with mental illness kill them- tions. didn't have that preparation. So, one the folks with mental disability that I selves each year and that these are pre- People from all walks of life, educa- thing I would check on is his work with, I often take a long walk in ventable deaths. tion and social strata may become ill background, just as you would for any the late evening. I walk downtown And if you believe data collected by with some form of mental illness at other employee. NYC on Broadway and return on Co- the US Dept of Justice, we learn that some point in their life. All employers Secondly, I would want to know that lumbus Avenue. Almost every night on 300,000 persons with mental illness are need to recognize that sooner or later, he is taking care of himself medically; these cold winter evenings I pass folks now incarcerated in our jails and pris- they are likely to encounter someone being open to understanding what the who seem homeless. Some search in ons--a number higher than the total who has such a diagnosis and that elimi- illness is and what the employee needs trash, appear poorly dressed for the number of incarcerated persons with nating them from the pool of likely can- to maintain stability is likely to forestall weather, and some seem confused. I try mental illness in all the other countries didates solely on this basis also means any misunderstanding later—which to help when I can with a little cash or in the world! Prior to 1956, we had only they are limiting the range of potential makes me wonder how often employers advice to get someplace warm. 6000 persons with mental illness incar- for finding employees who have the show interest in the physical health of Last week, I saw a man in his 30's cerated. The big jump in numbers in our skills for becoming successful employ- other employees. Being interested in the lying on the street on 72nd Street. It jails came after 1980 when our president ees. As a practicing psychologist, and as general health of your employees would was much below freezing, and his coat kept his pledge to "Get the government someone who has encountered mental go a long way, not only to having pro- was open. Few of those rushing by off the backs of the people" and illness with a family member, I can say ductive employees, but also to enhanc- seemed to notice him. We've gotten closed our 700 Community Mental that I understand much about the fears ing relationships with them if you are used to the homeless. Health Centers. and myths that employers may have in indicating you care about their health. What happened on 72nd street is hap- Incarceration is risky for people with regard to working with people who have Thirdly, I would want to know what pening across our country. Most people mental illness. Many leave incarcera- psychiatric conditions. kind of support system the candidate do not care what happens to people with tion with diseases like HIV, TB and Employers may fear that such people has. Is there a caring family; does he/ mental illness. Psychiatric hospitals are hepatitis. To make matters worse, in will demonstrate emotional fragility she have friendships and social relation- no solution. People should be free to be most states they lose all Federal benefits or instability in work habits and work ships. Is there someone he can talk to homeless. like Medicaid and Medicare and must relationships. I know what I find when he is troubled. It is always a good The Governor has a plan. In five or re-apply. Not only are folks with mental necessary in hiring such an employee, idea that there be someone in the work- ten years everything will be ok. The illness dying prematurely when they are and it is not very different than place he can talk to as well. Once again, government is appropriating a few bucks homeless, even when domiciled in NYC what an employer would look for in any how is this different from what any other to build more residences and shelters. In (C. Levy, 2003) their employee. Of course, you are never employee needs? the meantime, the young chap on 72nd guaranteed that a so-called "normal" street will be dead. Dead of exposure, see Fix on page 10 employee won't show emotional fragility see Employing on page 19

Let’s Not Suffer in Silence “Peer Movement” Conundrum

y car read the outside until this mysterious illness arrived. I hen I first heard that weighed by the frustrations I’ve encoun- temperature as a cold 20 was wrong. My mind had taken a terri- there was a c/s/x tered in dealing with my fellow c/s/x's in degrees. It was a late win- bly wrong turn. I was feeling hopeless (consumer/survivor/ex- the peer movement and now call into ter’s day as I began my and lost. I resigned myself to the fact patient) movement, I was question if our peer movement is hon- Mdrive home from work. The sun was that this was how I was going to live the Weager to get involved and help promote estly what it claims to be. setting. The ducts of the car pumped out rest of my life. what seemed like a good cause. Now I My observation is that our peer a steady stream of warm air over my That day I reached down to use my am having critical second thoughts. movement in NYS, isn’t unified nor skin. From the outside I looked like any cell phone to check to see if I had any In the late 1960’s, when I personally does it have clear and identifiable goals. other commuter. On the inside nothing messages. I remember dreading that experienced some difficulties trying to Behind the scenes, it’s everyone for could be farther from the truth. would only bring me more bad news. navigate the psychiatric system, there themselves. In the last months, my mind had been But I did it anyway, and I was right. was nothing in the way of peer support Some peers insist that the mental held captive to an insidious depression Two more deals were starting to unravel. or self-help groups for psychiatric pa- health system is completely wrong, pe- that refused to go away. Everything My hands began to shake. My mind be- tients. With societal stigma abound, I riod. Others think that any treatment is looked bleak; nothing provided me with gan to race from one thought to another. quickly learned to keep my situation acceptable if a person chooses to partici- any relief. I didn’t understand what had I had to stop the pain. private, which may be one reason I pate. Some feel that medications are taken over. In fact, I had a lot to be Suffice it to say that later that eve- never knew about the peer movement lifesavers, while a large contingent de- happy about. My family loved me and ning, I came close to ending my life but that was growing around me. Once I did nounces psychotropic drugs and the was healthy. I was receiving some of the stopped short through a miraculous in- become aware, I learned as much as I manufacturers that promote them. Some best medical treatment from a kind and tervention by somebody else. My behav- could about self-help, peer support, con- stand up firmly against forced treatment, very skilled doctor. He was desperately ior did land me in the hospital where I sumer-run organizations and other c/s/x while others waver on this issue. These trying to find a medication that worked, spent the next seven days. oriented groups and activities. I at- issues are just the tip of the iceberg. one that would stop the pain and misery. My depression gradually lifted. tended training in advocacy issues and Along with great disparity in the Thoughts of harming myself had started Maybe I just felt relieved being in a safe went back to college to earn a degree in goals of c/s/x activists, there is an ever to fly in and out of my mind again and place. Maybe the burden of my thoughts Community & Human Services to better decreasing quantity of funds to maintain had become more pronounced. had lifted. Maybe it was simply the na- serve this good cause. peer organizations, let alone to start new I knew that I should have been more ture of my depression. It doesn’t really Now, after several years of working ones. The competition for available dol- forthcoming with my doctor. I thought I matter. in the field, the discouragement I used to lars is fierce, unrelenting and often could handle the situation. I had handled feel in dealing with an impersonal men- almost everything else that life presented see In Silence on page 19 tal health system, is more than out- see Conundrum on page 10 MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 7

MENTAL HEALTH NEWSDESK

Disturbing New Government Report: Parents Giving Up

Custody of Children to Provide Them With Mental Health Services Thousands are placed in child welfare, juvenile justice systems to obtain needed services

The Bazelon Center they can’t find the help their children Senator Susan Collins (R-ME) and Thirteen states— Colorado, Connecti- for Mental Health Law with mental and emotional disorders Representatives Patrick Kennedy (D-RI) cut, Idaho, Indiana, Iowa, Maine, Massa- need.” and Pete Stark (D-CA) requested the ashington, DC April 21, Approximately 3,700 children were chusetts, Minnesota, North Dakota, Ore- gon, Rhode Island, Vermont and Wis- GAO report. In response to the GAO’s 2003—Thousands of placed in child welfare systems, accord- findings, the lawmakers plan to intro- families have been forced ing to the report. The GAO estimated consin—have passed laws that prohibit child welfare from requiring custody duce a proposal to improve state systems to choose between obtain- that another 9,000 were “placed” in the of care for children with mental or emo- Wing needed mental health services and juvenile justice system by police who relinquishment in order for parents to obtain mental health care for their chil- tional disorders. relinquishing custody of their children had detained children—sometimes at “Families have faced the terrible with mental or emotional disorders, ac- parents’ request—for delinquent behav- dren. But such laws do nothing to im- choice between retaining custody and cording to a new government study iors that stemmed from or were related prove access. obtaining needed mental health services scheduled to be released today. to their mental or emotional disorders. “Just banning the practice closes one The US General Accounting Office The GAO identified several factors door to services without opening an- for far too long,“ said Stine. “Congress (GAO), Congress’ investigative arm, that influence parents’ decisions to relin- other,” said Stine. “States certainly must can and should act this year to end this documented at least 12,700 cases in fis- quish custody: act, but a more coordinated effort with horrible practice.” cal year 2001 of children placed in child the federal government is needed.” The Bazelon Center for Mental • Gaps in and limits on mental health Many barriers to accessing care can Health Law is the nation’s leading advo- welfare and juvenile justice systems so coverage—Some mental illnesses are not they could access needed mental health be removed at the federal level, accord- cate for the rights of children and adults covered and families often face limits on ing to the Bazelon Center. The group with mental disabilities. The Bazelon services. the intensity or duration of care that pri- also believes that more can be done to Center authored Relinquishing Custody: “Custody relinquishment is abso- vate insurers will pay for. Medicaid, the lutely devastating to families,” said Lau- give states and communities the incen- The Tragic Result of Failure to Meet main public funder of child mental rel Stine, director of federal relations at tive to develop and implement the kinds Children’s Mental Health Needs. health services, covers a limited number of services that can keep children out of the Bazelon Center for Mental Health of children who could benefit from men- Law, a national non-profit organization crisis and with their families. tal health services. Both public systems that has worked for three years to end “In the private sector, families need NYAPRS Note and private insurers often fail to cover parity in insurance coverage for mental the dilemma that faces many parents the intensive community-based services This Bazelon report gives power- who lack access to mental health ser- health services, so children aren’t denied that could reduce the need for more ex- access to needed services because of ful testimony as to why New York vices for their children. “Children with pensive residential treatment. mental health needs face the added stress stigma and discrimination,” continued must approve Timothy's Law this Stine. “In the public sector, states and session. of being displaced and feeling aban- • Limited child mental health re- doned. Meanwhile, parents have to give the federal government need to expand sources—Parents may be encouraged to Medicaid eligibility to cover more chil- Having such legislation on the up their say about key aspects of their take drastic measures to make their chil- children’s lives, like where or whether dren.” books would have saved Timothy dren a priority for scarce mental health The Family Opportunity Act, which O'Clair's parents from having to they go to church and how late they can resources. stay up at night.” has been reintroduced in Congress again surrender his custody to get him this year, would reduce the need for cus- Custody relinquishment may be even • Lack of coordination—Eligibility re- the mental health care he needed more prevalent than the GAO’s study quirements for services often differ from tody relinquishment by expanding access and, ultimately, couldn’t get suggests. Data on the practice are not agency to agency, making it difficult for to Medicaid-financed mental health ser- enough of in time to prevent his generally tracked and officials in 32 vices for more children. Despite broad children to obtain coordinated care. Ac- tragic loss. states—including the five with the high- cording to the GAO, some service pro- bipartisan support for the bill, Congress est child populations—did not respond to viders and officials have also adjourned last year without passing the Without passage of decent men- the agency’s request for data on custody “misunderstood the role of their own and bill. tal health parity legislation, too relinquishment. other agencies” and have given parents “The congressional logjam shouldn’t many more such tragedies will “This may be the tip of a much larger incomplete or inaccurate information, stymie efforts to enact legislation to deal follow, both in New York and iceberg,” said Stine. “Families across with this problem,” said Stine. “Custody creating service gaps for children with nationally. (see pages 28 & 29) America are being ripped apart because mental health needs. relinquishment is not a partisan issue.”

Levy Awarded Pulitzer for Adult Home Exposé

NYAPRS E-News posed the abuse of mentally ill adults Before coming to The Times, in state-regulated homes prompted Levy was a reporter for the New York eartfelt congratulations to the award. bureau of United Press International Cliff Levy for his much Clifford J. Levy became a special for a year. deserved acknowledge- projects reporter on the metropolitan Born in New Rochelle, N.Y., Levy ment by the Pulitzer desk of The New York Times in graduated from Princeton University in BoardH of his outstanding coverage of 2000. He previously served as chief 1989 with a degree in public policy and New York's adult home crisis. of the Albany bureau of The Times Levy was granted the award for a and as a political reporter, City Hall international affairs. distinguished example of investiga- correspondent and Newark corre- Mr. Levy receive the 1998 George tive reporting by an individual or spondent. Polk Award for local reporting for his team, presented as a single article or He joined The Times in 1990 as a articles in The Times on the campaign series. His vivid, brilliantly written news assistant and was promoted to Courtesy NY Times finance practices of prominent state series, "Broken Homes," that ex- reporter in 1992. Clifford J. Levy officials in New York. PAGE 8 MENTAL HEALTH NEWS ~ SUMMER 2003

MENTAL HEALTH NEWSDESK

Medicaid Reform Proposal Threatens Public Mental Health

Bazelon Center for Mental Health Law tection that is all the more important in uninsured or have insurance that has these hard economic times. extremely limited mental health cover- he Bazelon Center for Mental Currently, Medicaid pays for about age. Children with severe mental disor- Health Law today condemned half of all community mental health care ders, a group that represents 7-11 percent President Bush's Medicaid re- furnished through state public mental of all children in the country, according form proposal as a threat to the health systems. By allowing states to the Surgeon General—must have access Tpublic's access to needed mental health reduce eligibility and benefits to Medi- to in-home services, day treatment and services. The statement below was re- caid recipients, the Administration's pro- other intensive community services not leased at a recent national news confer- posal risks the increased homelessness, covered by private insurance, as well as ence on the proposal held in Washing- institutionalization and criminalization to medications and therapy. ton, DC. that can result from untreated mental Across the country, children's mental illnesses. health needs are often left unmet. The Statement of Laurel Stine, Director of Significant reductions in Medicaid- Administration's proposal would exacer- Federal Relations at the Bazelon Center funded services would prove disastrous bate the problem by further reducing for Mental Health Law for people prioritized by public mental coverage of services for children with health systems—low-income Americans mental disabilities. We are troubled by the crisis facing with the most serious mental disorders, Adults who have high medical costs state Medicaid programs across the like schizophrenia, manic depression, can also be covered under Medicaid's country but have grave concerns about depression, attention deficit disorder and optional eligibility criteria. Inclusion in the Administration's proposed policy to autism. Such cuts would exacerbate the this category allows Medicaid to cover drastically change the program. current crisis in public mental health services for people with schizophrenia It not only states they are feeling the systems by reducing systems' capacity to Laurel Stine whose incomes are too high to otherwise pinch but also the nation's poor, many of serve some of America's most vulnerable be Medicaid-eligible but who would be whom rely on Medicaid to access needed populations. covered under Medicaid's optional eligi- unable to afford essential mental health mental health services. The President's Adults and children with mental dis- bility categories. care they need to continue their lives in proposal would put at great risk the abilities would be hit particularly hard if Included in this group are children the community. safety net that millions of Americans states opt for the Administration's pro- from families whose incomes are just with mental illnesses count on—a pro- posed reductions in benefits for people over the poverty line but who are either see Medicaid Reform on page 19 House Legislation Protects SSI and SSDI

NAMI E-News require Social Security to establish a - Require non-governmental fee-for- gain access to representation by: system to issue written receipts for earn- services organizational representative - Extending the voluntary attorneys fee n April 2, the House of Rep- ings reports submitted by SSDI benefici- payees to be bonded and licensed under payment system to SSI claims. resentatives passed the So- aries and a computerized system for state or local law. - Imposing a $75 cap (indexed for infla- cial Security Protection tracking earnings. - Provide that when an organization has tion) on the current 6.3% assessment on Act, H.R. 743, by a vote of Over the years, SSDI beneficiaries O been found to misuse an individual’s approved attorney fees for Social Secu- 396 to 28. This bipartisan bill would have grown enormously frustrated in benefits, the organization would not rity and SSI claimants. make important improvements in the their efforts to accurately assess whether qualify for the fee. representative payee program for benefi- earnings from part-time work in a given The legislation would also further - Allow SSA to re-issue benefits to bene- ciaries of the Supplemental Security month exceed the Substantial Gainful protect Social Security programs and ficiaries whose funds had been misused. Income (SSI) program and the Title II Activity (SGA) limit. individuals by: (SSDI) disability programs. It would Because Social Security is way be- - Allow SSA to treat misused benefits as - Requiring the Social Security Admini- also require the Social Security Admini- hind in tracking earnings, beneficiaries ?overpayments? to the representative stration (SSA) to help people avoid stration to issue written receipts and es- can, through no fault of their own, go payee or thereby triggering SSA’s au- overpayments by issuing receipts to tablish a centralized computer file for above limits in the program and be thority to recover the money through tax beneficiaries who report changes in earn- beneficiaries reports of earnings or forced to pay back overpayments of refund offsets, referral to collection ings or work status and by implementing changes in work status. benefits. Issuance of receipts from So- agencies, notifying credit bureaus, and a centralized computer file to maintain NAMI strongly supports this legisla- cial Security for submitted earnings re- offset of any future federal bene- records of beneficiaries reports. fits/payments. tion as an important step to restore integ- ports will help provide a more accurate - Clarifying civil monetary penalty au- rity of the Representative Payee program written record of earnings and help bene- - Require monitoring of representative thority so that sanctions may be imposed and to protect the interests of SSI and ficiaries track their earnings. Likewise, payees, including monitoring of against people who withhold material SSDI beneficiaries with severe mental a computerized tracking system at Social organizations over a certain size and facts in order to obtain or increase illnesses who receive their cash benefits Security will help SSDI beneficiaries government agencies serving as benefits. through rep payees. This legislation track earnings and use of “trial work representative payees. grew out of several high profile cases in period” months. - Denying Social Security benefits to - Require representative payees who are people fleeing prosecution, custody, or which institutional representative payees Background on HR 743 delinquent in filing annual accounting were found to have illegally diverted confinement for a felony, as well as pro- Approximately 8 million SSI and reports to receive the individual’s bene- bation/parole violators. cash benefits from SSI recipients. In fits in person at a local office. these cases, beneficiaries were prevented SSDI beneficiaries have representative - Requiring the Commissioner to publish from recovering back benefits that were payees, often family members or friends, - Disqualify as representative payees regulations that allow a waiver, where they never received. who receive the benefits on behalf of the people convicted of offenses and impris- good cause exists, of the non-payment of This is the third time the House has beneficiaries and have a responsibility to oned more than a year, and people flee- benefits to fugitive felons and those in passed this legislation since 2000. Each manage the benefits on behalf of these ing prosecution, custody, or confinement violation of parole or probation. for a felony. time, the legislation has stalled in the beneficiaries. HR 743 includes provi- - Requiring individuals who provide Senate, or been derailed by extraneous sions to strengthen SSA’s ability to ad- HR 743 would also make improve- Social Security-related services for a fee provisions. NAMI also strongly supports dress abuses by representative payees. ments to the attorney fee payment sys- the provisions in HR 743 that would The provisions would: tem to help individuals with disabilities see House Legislation on page 19 MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 9 The New York State Office of Mental Health Working to Increase Supported Employment Opportunities

By James L. Stone, Commissioner rapid job placement and ongoing sup- 3,000 individuals, and have achieved comes-based system of payment and so NYS Office of Mental Health ports, we can achieve employment rates wages and hours that are superior to far it is producing some really impres- up to 40 percent. We also expect that those found in national studies. sive results. We hope to incorporate the new Medicaid buy-in initiative will We have developed the Work Ex- some the findings from this project into enable more individuals to enter the change, a technical assistance center for future employment programs. workforce by giving them the opportu- supported employment established under We have also strengthened our col- nity to purchase needed health insurance the auspices of the New York Coalition laborative efforts with Vocational and coverage at affordable rates. of Voluntary Mental Health Agencies, Educational Services for Individuals Supported employment not only gives Inc. Available to more than 100 agen- with Disabilities (VESID), and together people a chance to exercise their choices cies across the State, the Work Exchange we are supporting providers and sharing for different job roles and settings, but it is a program that operates a web-based our outcome data. also gives them the chance to experience employment information and referral a real-world work environment. Sup- database designed to facilitate the inte- One of our joint projects is the New ports can include job coaches, special- gration of clinical and employment ser- York State Interagency Supported Em- ized job training, and help with manag- vices. It provides technical assistance to ployment Reports (NYISER). OMH and ing symptoms in the job setting. An- providers wishing to incorporate the best VESID, as well as the Office of Mental other important feature of supported practices in this area into their existing Retardation and Developmental Disabili- employment is equitable compensation: programs, and also offers formal staff ties and the Commission for the Blind wages and benefits are the same as other development opportunities using the and Visually Handicapped, are gathering workers in similar jobs. nation’s premier authorities on supported detailed feedback and employment infor- A large body of evidence has found work and other work issues. mation through these reports. that supported employment produces a OMH is implementing Assertive Approximately three-quarters of number of positive outcomes. Studies Community Treatment (ACT) across the OMH’s vocational providers are now James L. Stone have shown that providing individual- state, with the teams serving as a plat- completing and submitting the NYISER ized support services in competitive em- form for the delivery of evidence-based forms, which provide us with data on ployment settings can help achieve job practices - including supported employ- or most people, having an in- retention, improvements in quality of life ment. ACT teams include an employ- client outcomes such as the numbers of teresting and challenging job is and self-sufficiency, and lessen depend- ment specialist, and training for ACT individuals who are working, where they central to a meaningful and ence on entitlements. Competitive em- teams which focuses on supported em- are employed, how much money they are fulfilling life. For individuals ployment has also been found to reduce ployment is also currently underway. earning, and their length of time on the Fwith mental illness, however, access to the stigma associated with mental ill- OMH has recently completed and is job. This information is helping plan- employment has historically been very ness. evaluating a demonstration project ners at all involved agencies to identify limited. Employment is ranked number Supported employment is an estab- which used performance-based contract- areas in need of improvement. It is my one among goals expressed by consum- lished evidence-based practice, and is ing for supported employment services. goal for all OMH providers to be on ers, yet only one out of five individuals one part of OMH’s quality campaign to Part of an award-winning national pro- board by the end of calendar 2003. with serious mental illness who want to improve outcomes for and promote the ject to create results-based financing, In summary, it is OMH’s goal to help work are actually employed. recovery of individuals with mental ill- this program uses the principles and individuals get the jobs they want, in a I am pleased to say that times are ness. OMH has undertaken a number of practices of the evidence base in sup- reasonably short period of time, and then changing. Supported employment pro- initiatives designed to increase supported ported employment. Providers are com- vides opportunities for people with se- employment opportunities. pensated for achieving specific, progres- to provide the supports needed to help vere mental illness to work in competi- We are working to raise awareness sive milestones in the employment them succeed in their chosen workplace. tive, real-world settings by offering on- through collaborations with local gov- placement process, and the further the I look forward to working with provider site and as-needed support services ernments on targeted employment initia- client gets toward achieving his or her agencies, other State agencies, recipients which are designed to help individuals tives. Local innovative programs have placement goal, the more money the and other stakeholders to make that goal perform their jobs. We know that with led to positive outcomes for more than provider receives. It’s an entirely out- a reality for all. Work Programs in Westchester DCMH Helps You Get To Know What’s Out There

Staff Writer help individuals to achieve their personal individuals the opportunity to explore If you or anyone you may know is in- Mental Health News goals. new careers while being supported. And terested in returning to work or has inter- Currently, the County receives a little the internship simultaneously helps to fill est in beginning to work on job skills, over two million dollars specifically for in gaps on resumes prior to applying for they should discuss this interest with their he Commissioner of the West- vocational programs from the New York competitive employment positions. Hu- treatment provider, case manager, pri- chester County Department of State Office of Mental Health. These man Development Services and The mary therapist or contact a drop in center. Community Mental Health, funds are distributed to various hospitals Guidance Center also have funds avail- Since there is no one central point of Jennifer Schaffer, Ph.D., re- and agencies to provide the financial sup- able to help individuals with educational intake for work opportunities in the Tcently addressed the Mental Hygiene port for their vocational programs. The goals they may wish to pursue. County, you must explore the various Area Councils in the County. In her in- Guidance Center, New York Presbyte- The office of Vocational and Educa- options out there with your treatment pro- troduction she informed the councils that rian, and St. Vincent’s provide IPRT’s. tional Services for Individuals with Dis- she is committed to providing a system of These programs provide initial training in abilities, VESID, is a completely separate vider. Once you begin to become famil- care in this county that supports the re- managing life issues and also help con- funding source but offers individuals with iar with the different agencies and the covery of all individuals who have mental sumers begin to discover their vocational mental illness many resources for voca- different programs offered you will better illness. One important aspect of the re- interests. Careers, the Guidance Center, tional assessment, training, and job place- be able to decide where you would like to covery process is work. County Execu- Human Development Services, Jawonio, ment as well. Some individuals prefer to start based on your own goals and needs. tive Andy Spano said, “Work has been the Mental Health Association, and stay with the agencies they are more fa- Sue Erway, M.P.A. Program Director, such an integral part of my life that I Search for Change provide assisted com- miliar with in the mental health system Westchester County Department of Com- know how important it’s been in contrib- petitive employment, which allows indi- such as the programs listed above while munity Mental Health, is also available to uting towards my feeling of self- viduals to have job coaches and other others pursue these goals with Vesid. assist if you have questions regarding the fulfillment and personal integrity.” West- supports onsite as they begin employ- Each individual can make a choice as to current system or if you need help access- chester County therefore will continue to ment. The Volunteer Center of the United which program will meet his or her needs ing a program. She can be reached at provide supports to many work efforts to Way provides internships, which allows the best. 914-995-6073. PAGE 10 MENTAL HEALTH NEWS ~ SUMMER 2003 Conundrum from page 6 tioned stars run the show. In many ways the “peer” label will always keep c/s/x’s brings out the worst agendas within the separate and seated at the kids table. NewYork-Presbyterian peer movement. Alliances and factions Thankfully, the NYS Office of Men- work to thwart the plans, sometime the tal Health supports self-help and peer very existence, of groups whose goals support as important components in re- Psychiatry they disagree with. Maneuvering and covery, and many professionals do re- back room discussions are the politics spect the concept, especially those who which can pull funding from one peer- have a person-centered orientation. Opens Premier run program only to show up later as the However, there are many who look upon funding source for a competitive peer the “peer movement” as an amusing program. Radical or anti-system view- exercise in letting the inmates feel like points are snubbed and dismissed as they’re running the asylum. Inpatient Services irrelevant by other peer leaders who After several years working with peer disagree with them, along with unpro- activists all over the state, I can under- Staff Writer private bedrooms and baths for the fessional ethics that further marginalize stand that viewpoint, but I am not at all Mental Health News comfort of patients.

those individuals deemed as problem- amused. With respect to the hundreds of The Columbia uilding on its long tradition atic. well meaning men and women who are Neuropsychiatry Service It has been my observation that a trying to address life-affecting problems of providing the finest psy- number of peer leaders at the top of the for consumers of mental health services chiatric care to the com- The Columbia Neuropsychiatry peer movement have employed various such as forced treatment, therapeutic munity, NewYork- Service can be especially helpful for means to disparage or even shut out rival choices, fair accommodations and so on, PresbyterianB Psychiatry has estab- individuals whose illnesses have been or rising leaders. Their agenda is not I have serious questions about the effec- lished two inpatient services for pa- refractory to standard treatments, or inclusive and is highly sensitive to any tiveness and the very purpose of this so- tients desiring a level of individual who pose diagnostic dilemmas requir- dissent. called peer movement. What I’ve wit- amenities, comfort, and privacy be- ing the expertise of a tertiary care Ironically, in a movement meant to nessed among the peer leadership are far yond that available in the typical hos- medical center. Each patient receives embrace other peers, a veil of stigma too many people trying to hold on to pital setting. individualized attention from world- exists within the peer community itself, positions of power and far too few who The Haven at Westchester, located renowned faculty, who consult in di- exhibited in the movements tendency to know what it means to truly serve and to on the serene wooded grounds of the agnosis and provide pyschopharma- relegate “lower functioning,” mental help empower other people. Westchester Division of NewYork cology and psychotherapeutic ap- health consumers to the sidelines— Presbyterian Hospital, and the Colum- proaches as appropriate. Experts in while the political savvy, better posi- Gene Ira Katz bia Neuropsychiatric Service on the internal medicine, neurology, radiol- luxurious McKeen Pavilion at Colum- ogy and all other clinical specialties bia Presbyterian Medical Center of are available as needed. Jeffrey Pines, NewYork-Presbyterian Hospital, offer MD and Carolyn Douglas, MD co- direct the program and personally care Fix from page 6 tes is a tough disease to cope with and is outstanding evaluation and treatment a major cause of blindness. for adults seeking discreet care for for every patient. Both are Associate average life expectancy is 58 The President's Commission Interim psychiatric disorders, including dual Clinical Professors of Psychiatry at years. Why so few years? Life expec- Report needs to be read. There are bright diagnosis. Each program ensures ac- Columbia University College of Phy- tancy like infant mortality is one of our spots. We have many fine professionals cesssibility to the full spectrum of ex- sicians & Surgeons. best measures of the quality of health and advocates working in our field. We pert psychiatric and medical subspe- All patients at the Neuropsychiatric care. have many fine facilities working hard cialites available at NewYork- Service receive a thorough, structured It is time we required facilities which to provide a decent level of treatment Presbyterian Hospital. diagnostic and cognitive assessment provide housing for persons with mental by a neuropsychologist, and, where care and rehabilitation. The Haven at Westchester illness to make public resident life ex- But despite the bright spots, we appropriate, a substance abuse assess- pectancy data. should not delude ourselves. The report The Haven at Westchester offers a ment by a clinical psychologist with Almost half of persons with mental is a wake-up call. If you want to under- premier secure inpatient facility for expertise in addiction treatment. Treat- illness have co-occurring disor- stand something about the quality of adults 18 years of age and older in ments include intensive psychotherapy ders. Sure, substance abuse but also care provided, simply examine life ex- need of psychiatric treatment for all using individual, group, family and hepatitis, obesity and diabetes. Sernyak major diagnostic categories, including cognitive modalities. Substance abuse and Rosenheck (April, American Journal pectancy for persons with mental illness. America needs to catch up and fix affective, psychotic, dual diagnosis detoxification, treatment and referral of Psychiatry, 2002) studied 38,000 vet- and personality disorders. Program for aftercare rehabilitation are pro- erans with a diagnosis of schizophrenia our health and mental health care sys- tem. goals include the rapid stabilization of vided for patients requiring these ser- and found that many had diabe- acute symptoms, identification of vices. tes. Some 24% of those being treated stressors that interfere with optimal The Columbia Neuropsychiatry with the newer antipsychotic medication Martin Gittelman, Editor, also had a diagnosis of diabetes. Diabe- International Journal of Mental Health functioning at home and in the work- Service offers two treatment settings. place, and creation of an effective af- Selection of the appropriate setting tercare plan for the patient. depends upon the patient’s clinical A multidisciplinary team providing suitability for an open or a locked unit. intensive psychotherapy and pharma- The least restrictive environment is cological treatment is led by Raj Vela- always preferred. Patients may be Mental Health Association moor, MD, BS, Unit Chief of the Ha- admitted to either the open, medical ven and Assistant Professor at the surgical unit on the McKeen Pavilion of Rockland County Weill Medical College of Cornell Uni- or to the newly renovated locked Gar- versity. George Alexopoulos, Profes- den Unit on the same floor of the Mil- sor of Psychiatry and Director of the stein Hospital Building. Some pa- Weill Cornell Institute of Geriatric tients admitted to the Garden Unit for Psychiatry, is the Unit Director. Weill reasons of clinical necessity may Cornell faculty with international transfer to the McKeen Pavilion as “Working For The Community’s Mental Health” reputations for expertise in a wide ar- their conditions stabilize. ray of psychiatric subspecialties pro- vide consultations to patients at The Further information on these two Haven. programs is available on the web at 845-639-7400 Patients are treated in a deluxe set- www.nyppsychiatry.org.. For addi- ting that includes concierge services tional questions or to make a referral, and a variety of amenities tailored to please call The Haven at Westchester 20 Squadron Boulevard . New City . NY individual needs. The Haven at West- at (888) 694-5700, or The Columbia visit us at: www.mharockland.org chester occupies an elegant space, re- Neuropsychiatry Service at (212) 305- designed and newly furnished, with 2599. MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 11 PAGE 12 MENTAL HEALTH NEWS ~ SUMMER 2003 Local Businesses Hire Employees With Disabilities

Staff Writer Plains and Weaver Street in Mental Health News Mamaroneck. Stop and Shop en- courages its store managers to everal area businesses, hire from within the community in Westchester, have as a way of providing jobs for lo- learned the value of hir- cal residents and maintaining a S ing dependable, part- positive public image. Guidance time employees while keeping the Center clients experience the lid on expenses. They hire people same application and interview with disabilities to get the job process as do all other job appli- done. cants and have been hired to fill For the Guidance Center, a a number of positions at the leading mental health provider in stores. Westchester County, Zanaro’s “Hiring employees who have Restaurant, Weber Studios, and disabilities is a new experience Stop and Shop seek out clients of for me because the supermarket The Guidance Center’s Voca- chain I previously worked at did tional Services Program. not have the same policy about When Zanaro’s restaurant hiring people with disabilities as was opening in New Roc City, Stop and Shop,” said Antoine Go- New Rochelle this past April, Ed mes, manager of the Stop and Lachterman, executive general Shop store in new Roc City. “But manager, called the Job Place- I have five employees who came ment and Retention Program at from The Guidance Center pro- The Guidance Center. Job devel- gram and I can’t even tell they oper Waliyyah Salaam-Hussain have a disability. Lori is very car- and job coach Lori Jarhoud- ing and comes in regularly to Saleh helped him find four em- check on the workers and it’s Pictured from left to right: Front Row: Ed Lachterman, Executive Gen- ployees to provide cleaning and working out very well for the eral Manager; Edward Prieto, Kitchen Manager. Back Row: John maintenance services and pack- store.” Amicucci, vocational program participant; Joseph Ruggerio, Restaurant age leftover food for his custom- Chris McGovern, manager of Supervisor; Nana Yao, Assistant General Manager; Isaac Gannie, voca- ers. the Weaver Street Stop and Shop tional program participant; Yoshi Hirata, vocational program partici- “These employees want to in Mamaroneck, is satisfied not work, and they work very hard,” only with the job performance of pant and Lerian T. Maxwell III, vocational program participant. said Mr. Lachterman. “They take his three Guidance Center hires pride in their work and make but also noted the cost benefits sure that they arrive on time. that the store has realized by hir- One of them even leaves his ing these individuals. home at 5:15 in the morning to “The turnover rate of these arrive here by 7:45 and begin his associates is much lower than day. They are good people.” that of the average employee,” he The Guidance Center’s Sup- said. “From a business stand- ported Employment Job Place- point we save money on the cost ment and Retention Program of rehiring and retraining associ- The Guidance Center Offers Unique helps individuals with disabilities ates, which is a plus for the to negotiate the road to competi- store.” Vocational Training Opportunity tive employment. Services in- That thought was echoed by clude coaching on resume prepa- Greg Feerick, customer service ration and interview skills, job manager at the Westchester Ave- ARTWORKS is a socially-responsible retail store located in placement, and follow-along job nue Stop and Shop in White coaching. Plains where three other Guid- Mamaroneck, managed and staffed by adults with special needs, selling fine Judith Weber, owner of Weber ance Center clients work. He also crafts and art by people with special needs. Studios, a ceramics studio in praised the productivity of the New Rochelle, is not new to hir- workers. “We’re getting good peo- ARTWORKS is currently seeking individuals with disabilities in- ing people with disabilities. She ple who show up each and every hired a Guidance Center client day for work,” said Mr. Feerik. terested in obtaining vocational training in graphic arts, computerized de- five years ago who has been “And they give one-hundred per- sign, and sales and management skills, as well as artists with special needs working for her ever since. Re- cent to the job.” who wish to sell their art and crafts on consignment. cently, she hired two more em- The Guidance Center, Inc. is Contact Cristina Boardman for details. ployees through the program. one of Westchester’s leading

“The job coach really under- health and human services agen- Sponsored by Verizon stands my employment needs,” cies. For six decades, residents of remarked Ms. Weber. “To me, Westchester have turned to The Wednesdays, Fridays, hiring employees through The Guidance Center for assistance Saturdays & Sundays: Guidance Center’s vocational in dealing with daily life stresses 12 PM—5 PM program is an affordable way to related to early childhood devel- Thursdays: 2 PM—7 PM get part-time help on a flexible opment, academic/work perform- schedule. It also gives someone ance, antisocial behaviors, do- with a disability the opportunity mestic violence, depression, sub- 628 Mamaroneck Ave. to work and grow into a job.” stance abuse, crisis intervention Mamaroneck, NY Guidance Center vocational and other mental health issues. (914) 632-7600 x 220 services clients are also employed The center serves the community [email protected] by a number of Stop and Shop from 14 locations in Westchester supermarkets including the County including Mount Vernon, stores in New Roc City and New Rochelle, Mamaroneck, Port The Guidance Center is a health and human services organization that provides Palmer Avenue in New Rochelle, Chester, Purchase, and Mount services to individuals with disabilities.. Artworks is a Guidance Center vocational program. Westchester Avenue in White Kisco. MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 13

NAMI Corner

Providing support to families and friends of individuals with mental illness and working to improve the quality of life for individuals with mental illness.

Helpline: 1 800-950-3228 (NY Only) - www.naminys.org - Families Helping Families

By J. David Seay, J.D. our hope for the future and we believe convulsive therapy (ECT) for those few what is intended to be the first in a se- Executive Director that the state’s budget should not be people for whom there is no other ef- ries of such workshops to support our NAMI-NYS balanced by selling off our future. fective treatment. As refined and ad- 58 affiliates around the state. Also of major continuing concern to ministered today, ECT bears little re- The next day, on February 11, 2003, NAMI and its members is the availabil- semblance to the electric shock treat- NAMI-NYS held its annual Legislative ity of housing for persons with a seri- ments of 20 or even 10 years ago, and Breakfast and Conference in the Legis- ous mental illness. We applaud the Of- are endorsed by all credible scientific lative Office Building in Albany. Ad- fice of Mental Health and the Depart- organizations as safe and effective in- dressing a crowd of well over 200 ment of Health for providing additional cluding the state and national psychiat- NAMI members and friends from funds in this year’s budget proposal to ric associations, medical associations, across New York were NYS Comptrol- help fix the adult home problem by US Surgeon General and the National ler Alan Hevesi, Assemblymen Peter making more housing and other vital Institute of Mental Health. At the same Rivera, Richard Gottfried, Jeffrion Au- services available. We also salute OMH time we fully support the safeguards to bry and Harvey Weisenberg and Sena- for proposing a budget that has virtu- patient rights in existing law, and con- tors Thomas W. Libous, Velmanette ally no cuts in basic community pro- cur with the New York State Commis- Montgomery and James Brennan. Also grams and services – no small feat in a sion on Quality of Care for the Men- speaking were Office of Mental Health year with a projected budget deficit of tally Disabled and its recent study of Commissioner James L. Stone, Andrew nearly $12 Billion. But the problem ECT in New York that found safe- Sperling of National NAMI, NAMI- with the need for housing is so large guards to be adequate and that the pro- NYS Board President Michael Silver- that many good deeds are still not suffi- berg and members of the NAMI-NYS cient to make safe, adequate and afford- cedure is not being abused, misused or over-used. We feel that medicine Government Affairs Committee. able housing with support services In all of these efforts, NAMI-New should be practiced by doctors and not available to all New Yorkers who need York State continues to press its mis- the legislature. them. sion of support, education and advo- J. David Seay, J.D. NAMI-New York State’s 2003 An- NAMI-NYS also is fighting hard to cacy for all New Yorkers with mental nual Meeting and Educational Confer- secure passage of “Timothy’s Law,” illness and their families. ne of the themes of this which would provide for mental health ence will be held September 19-21, issue of Mental Health parity by requiring insurance compa- 2003, at the Four Points Sheraton

News is employment for nies, HMOs and other health plans to Rochester Hotel in Rochester, New This Detects persons with mental illness. cover mental illness the same as other York. As NAMI-NYS finally grows up O and turns 21, we will have a stellar cast NAMI-New York State has long cham- illnesses. The bill is named after young Smoke pioned employment training and sup- Timothy O’Clair of Schenectady, New of speakers, workshops, networking ported employment programs for our York, who tragically committed suicide opportunities and other events. The We Detect loved ones and others who suffer from two years ago at the age of 12 after his Keynote Speaker will be Dr. Michael F. Smokescreens a mental illness. Work can be a power- parents’ limited mental health insur- Hogan, Chairman of the President’s ful therapeutic component for a per- ance benefits ran out. We are pleased New Freedom Commission on Mental son’s treatment for and recovery from that Senator Thomas W. Libous has Health. OMH Commissioner James L. Housing discrimination mental illness, especially given the Stone will also speak, as will research- introduced Timothy’s Law in the New isn’t always obvious. newer medications that allow persons York State Senate with no less than 31 ers and clinicians from the University with mental illness to function as a con- other majority members as co-sponsors, of Rochester and elsewhere. Rochester These are the kinds of tributing members of their communi- is especially beautiful that time of year smokescreens you might run into: and that Assemblymen Tonko, Rivera ties. and others will be doing the same in the and we encourage early registration to Yet 85% of persons with mental what will be a sell-out conference. A “Sorry, we’ve changed our minds Assembly. We are particularly grateful about selling.” illness do not hold jobs. However, with for and wish to publicly thank Senator brochure will be going out soon and training and supported employment, Libous and his co-sponsors for their interested people can call us at (800) “We just rented that apartment.”

many more can work and be the pro- support of this much-needed and long 950-FACT toll-free in New York or at ductive members of society they want (518) 462-2000 to request a brochure or “It doesn’t look like you qualify overdo legislation. NAMI has been for the loan.” to be. The new “Medicaid buy-in,” fighting for such a law for at least fif- for more information. which was to have gone into effect in The national NAMI convention will teen years and we are hopeful that 2003 April and is now delayed until the sum- may be the year for parity and for be held in Minneapolis this year from st mer, should allow such persons to be Timothy’s Law. June 28 through July 1 . With a theme able to work without losing their health We are also calling for serious, fair of “Partnerships for Recovery: Con- Fair Housing coverage. This year, NAMI-New York fronting the Mental Health Crisis in our and balanced long-term planning for is the Law! State has called for an additional 1,500 mental health housing and services in Communities,” this ever-expanding supported employments slots in the New York State. We want to support national event also is not to be missed. budget, at an additional estimated cost and work with OMH in this year’s More information about it can be found at the NAMI website www.nami.org. WESTCHESTER of only $3.4 million. planning process, as required by section Other issues of immediate concern On February 10th NAMI-NYS held RESIDENTIAL 5.07 of the Mental Hygiene Law, to to NAMI-New York State include res- make sure that needs are properly as- an Affiliate Leaders’ Day which fea- OPPORTUNITIES toration of the proposed cuts to the Of- sessed, existing system capacity is tured hands-on infrastructure-building fice of Mental Health’s research evaluated and a real long-term, rational workshops on such topics as legal is- 470 Mamaroneck Ave., Suite 410 budget. These cuts – nearly 23% of the sues, including incorporation and re- total research budget – would result in plan is hammered out that seeks to meet White Plains, NY 10605 unmet needs in an effective and effi- lated matters, local fund raising, effec- the closing of the world-renowned Na- tive communications and outreach and T: 914-428-4507 ext. 306 than Kline Institute for Psychiatric Re- cient manner. NAMI-NYS opposes four bills that have been introduced in working better with the county mental F: 914-428-9455 search in Rockland County and very health systems. More than 70 NAMI serious damage to the Psychiatric Insti- the Assembly that would have the ef- WWW.WROINC.ORG leaders from around the state attended tute in Manhattan. Research is indeed fect of blocking access to electro- PAGE 14 MENTAL HEALTH NEWS ~ SUMMER 2003 POINTPOINT OFOF VIEWVIEW

mind that very rapid progress is now By Michael B. Friedman, CSW York State. Sadly, too, the attack on arbitrary, and time-consuming— access to medications has not risen to the designed in fact to discourage appeals being made regarding psychiatric medi- top of the agendas of many mental health even when they are medically appropri- cations. New drugs, generally with advocates. Of course, we have many ate. People on Medicaid should be able fewer side-effects, are introduced fre- fires to fight so as to be able to continue to get the medications their physicians quently. In theory the state’s preferred to provide people with the mental health believe are most appropriate without list could be updated every time a new services they need to lead decent lives in running a bureaucratic obstacle course. drug is introduced. But given the nature the community. But isn’t it obvious that It makes no sense to require a physician of bureaucracy and the goal to save if the people for whom we are fighting to prescribe a medication he or she be- money by negotiating quantity discounts, do not get access to the medications that lieves will be ineffective just because it how likely is it that the new drugs will work for them, little else we do will mat- is on a state’s preferred list. A physi- get on the preferred list rapidly? Those ter very much? cian’s judgment about what is likely to of us who have been advocates for high It is easy enough to understand why be the most effective drug should be quality care for people with serious men- state governments, which are experienc- questioned only if there is good reason to tal illnesses remember all too well the ing rapid growth of Medicaid expendi- believe that the physician is making an battle we had to wage in New York State tures, want to limit access to medica- error in medical judgment. In such a a few years ago to get chlozapine ap- tions. The cost of pharmaceuticals case it should be up to the state to appeal proved for Medicaid payment—even (although a relatively small proportion of to the physician to use a more appropri- though it was a drug—albeit an expen- overall Medicaid spending) is the fastest ate drug rather than to force a physician sive drug—with clear benefits over other growing element of Medicaid cost. By to appeal an arbitrary list. medications. As the experience with creating “preferred drug lists” which It is critical to be clear that there are chlozapine makes clear, states are likely favor the use of one or two drugs from sound clinical reasons for a physician to put the need to hold down costs ahead of Michael B. Friedman the same drug class, they are able to ne- choose one drug rather than another, the needs of people with serious mental

gotiate volume discounts and other fi- even if they are drugs from the same illnesses. Don’t Restrict Access nancial benefits, thus reducing the over- family including: history of response to For all of these reasons, I oppose the to Psychiatric Medications all cost of drugs. medications, avoiding the risk of precipi- establishment of “preferred drug lists,” It is important, of course, to find tating a crisis by changing medication, have made it a top priority for my mental ways to reduce spending in these eco- combinations of symptoms and side- health advocacy, and hope that more and sychiatric medications are not nomically trying times—so long as it can effects. more advocates will make it a top prior- the only critical component of be done without depriving people of the For people with severe mental ill- ity too. As I said at the beginning, if recovery from serious mental services that are critical to their well- nesses, it is also important to prescribe people with serious mental illnesses do illnesses or serious emotional being. The question is whether drug medications which patients will agree to not get access to the medications that Pdisturbances, and for some people they costs can be reduced without depriving take. Lack of willingness to take psychi- work for them, little else will matter. are not a critical element at all; but, for people of access to the medications they atric medications (usually referred to as Michael B. Friedman is The Director most people with severe and prolonged need. lack of “compliance”) is the source of a of The Metropolitan Center for Mental mental health illnesses, they are certainly It seems clear to me that the creation great many relapses as well as periods of Health Policy and Advocacy, a collabo- one of the three or four necessary condi- of a preferred drug list which restricts very low quality of life for people with ration of The Mental Health Association tions for living a satisfying life in the access to certain medications prescribed severe and recurrent mental illnesses. of New York City and The Mental Health community. Sadly, access to psychiatric by a physician invites disaster—even if a Physicians must have the freedom to Association of Westchester. The opin- medications for people who rely on procedure is created to appeal and to get prescribe medications that the patients ions expressed in this column are his Medicaid is now under attack in several exceptions made. will agree to take own and do not necessarily reflect the states around the country, including New Appeals processes are often difficult, Finally, it is important to keep in opinions of these organizations.

THE NYAPRS ADVOCACY WATCH

By Harvey Rosenthal Governor's Medicaid able to go to their local County Social applicant has both a job and a verifiable Executive Director, NYAPRS Buy-In Implementation Plan Services offices on July 1 and apply for disability (SSI and SSDI status will be New York Association of the Medicaid Buy-In. adequate, VA or Workers Compensation Psychiatric Rehabilitation Services Enrollment into Landmark disability status will require more docu- Work Incentive Program to Begin on ● In recognition of staffing shortages mentation). State staff will then make a July 1, 2003 and workload issues at many Local De- disability determination, issue a letter partments of Social Services, local DSS No Premiums Until April 2004 verifying the applicant's acceptance or offices will be playing a more limited role during the first 9-12 months of the denial into the Medicaid Buy-In program t a recent Capitol meeting of and then enter eligible individuals' infor- program's 'interim' implementation (July groups called to provide out- mation into the appropriate state and reach, education and client 1, 2003 to April 1, 2004). During that period, local social services staff will be local databases. representation in support of ● Athe implementation of the Medicaid responsible for taking applications and, This process will typically take 45 Buy-In, Governor Pataki's Buy-In imple- upon ensuring that each application has days for most applications, up to 90 for been completely filled out and that the those needing additional corroboration. mentation plans were announced as fol- lows: necessary supporting documentation has ● Applicants who are successfully en- been attached, send it on to the State rolled into the Medicaid Buy-In program ● Education and outreach to New York- Department of Health's Bureau of Medi- can expect that Medicaid will cover their ers with disabilities and the various pro- caid Eligibility Operations. vider and governmental groups that medical expenses retroactively back to ● Interagency state staff comprised the date of their application. serve or support them will be quickly developed and available by mid-Spring largely of DOH, OMH and OMRDD ● Due to delays in the establishment of to support the Medicaid Buy-In pro- personnel will then, during this 'interim' an automated premium collection and period of July 1, 2003 and April 2004, gram's implementation date of July 1, tracking system, the Governor has process each application for the Buy-In. 2003 (see below for more details) Harvey Rosenthal ● Applications must demonstrate the see Buy-In on page 21 ● New Yorkers with disabilities will be MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 15

The MHA Connection The

Coalition

Mental Health Association in New York State, Inc. 194 Washington Avenue, Suite 415, Albany, NY 12210 Report Phone: (518) 434-0439 Fax: (518) 427-8676 www.mhanys.org

By Joseph A. Glazer hospital system exceeds the demand and New and Old Amsterdam: activity centers that offer social support President & CEO, MHANYS required capacity. Downsizing is war- An Exchange of Working Ideas and volunteer work experiences, and a ranted, and utilizing the funds saved to small selection of supported employ- improve (dare we even say develop) the By Alysia Pascaris, Director ment services primarily designed for system of community-based care is uni- New York Work Exchange individuals with mental retardation and versally supported. Where we divide is developmental disabilities. Sheltered the question of which community is go- here is a common saying in workshops differ in the Netherlands in ing to lose their facility. Amsterdam: God created the that workers are paid a competitive Over the years, the role of psychiatric world, but the Dutch made the wage for their efforts. Nevertheless, hospitals has evolved. Although the Netherlands. Carved out of they remain segregated settings that of- residential buildings remain large, each Tswamp and marshland, with few natural fer little encouragement and opportunity facility actually serves many times resources and a barely navigable port, for participants to move on to regular more people on an outpatient basis than this part of the world rose to greatness employment environments. Transitional inpatient. They have become the core out of the sheer determination of its peo- employment and the volunteer work- of intensive mental health services for ple to engage in a constant and collec- ordered day is an option only for con- their communities, as well as their tive battle with the sea. Since the 14th sumers living in Amsterdam, home to large catchment areas. Communities fear century a vast system of dams, dykes the only Clubhouse in the Netherlands. that the closing of the facility will lead to and canals has added 10 percent to the Although the US and Dutch mental a drop in access to inpatient beds, outpa- country’s land mass and made it possi- health systems and their underlying prin- tient services, and continuity of care. ble for people to safely live and flourish ciples appear quite similar on the sur- And, in the absence of a plan, history below sea level. To hold back the sea, face, important differences exist. The continually bears out those fears as justi- and then to harness its power, takes Dutch do not necessarily equate ‘good’ fied. planning, endurance and teamwork. It is work and a dedicated worker with long First and foremost, it is important to no surprise then that the Dutch routinely workdays, the accumulation of overtime, note that Deinstitutionalization, rank among the most productive workers and substantial pay. Within the commu- Joseph A. Glazer long a rallying cry for mental health ad- in the world. Curiously, this intense nity mental sector, this issue for people vocates, has never included a plan. work ethic exists alongside a strong with psychiatric disabilities may be less That, at least in part explains how the commitment to volunteerism as an alter- about ‘real work’ for ‘real pay’, and NIMBY vs. NOMBY same percentage of the population native to paid employment, a robust more about participation in meaningful that occupied state hospitals in the 1950s social and health safety net including activity, whether paid or unpaid. Within is numerically equivalent to the universal health care that makes it possi- the Dutch Clubhouse for example, tran- ny time an organization tries percentage living with mental illnesses ble to live above the poverty line with- sitional employment is viewed as volun- to site a new program, caught in the criminal justice out working, and a minimum of five teer work; participants are paid a small particularly residential, for system today - 0.3%. weeks paid vacation per year. and non-competitive wage through the people living with mental ill- More recently, we need look no fur- How we work, and how we under- Clubhouse provider, not directly by the Anesses, NIMBY (Not In My Back Yard) ther than the closing of Gowanda stand the role of work in our lives, varies employer. The Dutch seem less ashamed rears its head. People from throughout psychiatric center a decade ago. Today, from place to place. The Dutch do not of not working, or of not working for the community, usually lacking suffi- people in that community will tell necessarily do work better, but they do pay, than Americans. cient understanding of the program, un- you that the county jail is the largest work differently. Their experiences But the landscape is changing in the derstanding of those to be served or psychiatric hospital in the county, might help us understand better our own Netherlands. The economic recession other attributes of the planned service there are substantial gaps in housing and hidden assumptions about the way we felt worldwide is both altering the role will rally against the proposed site, mak- services, and that Buffalo is too work, the way we use work to give government plays in aiding those most ing the argument that they don’t want it far for many people to go to see, and meaning to our lives, and the way we in need and influencing the options in their community. Largely founded in advocate for, their loved ones who are build work environments to promote available to potential workers with psy- misguided fear and ignorance, NIMBY hospitalized with critical mental health health and well-being. This is as true for chiatric disabilities. The government has has untracked many a worthy program or care needs. people with psychiatric disabilities as it adopted a policy to privatize the delivery residence. Understanding NOMBY is what has is for the population as a whole. of employment services mandated to NOMBY is a much lesser known brought MHANYS to its position regard- The system of vocational rehabilita- help all unemployed persons including phenomenon. An acronym for Not Out ing the proposed closures Governor tion programs that exists to help con- people with psychiatric disabilities. A of My Back Yard, NOMBY is a similar, Pataki has put forward. We agree that sumers with psychiatric disabilities in belief exists among some officials that albeit more educated and compassionate the infrastructure is too large, and that the Netherlands is relatively new. It was organizations operating for profit will be response to proposed dismantling of services can be provided more not until the mid-eighties that the Dutch more inclined to reach their objectives, services or facilities. This year, as in effectively and cooperatively in the com- government launched a policy of de- to find more jobs for more people, and 2001, Governor Pataki has proposed the munity. But we cannot support closures institutionalization and started develop- most important, to reduce the number of closure of state run psychiatric centers in the absence of an overarching plan, ing a system of community-based care. recipients receiving social assistance. around our state. And in the communi- for what happened in Gowanda will hap- As in the US, two government agencies, The concerns among advocates for the ties that fear new and greater gaps in pen elsewhere unless the planning and health and employment, are typically disabled sound all too familiar: the prac- the mental health services available, systems change is completed. involved in assisting the return to work tices of these privatized services may NOMBY is the first and most visceral Children's Mental Health Week is of individuals with psychiatric disabili- ‘cream’ among their clients, place peo- reaction. nearing. What are you doing to help ties. Generally, it is the health system ple in jobs that may not serve their best The demarcation line in the MHA raise awareness to the importance of this that has responded to consumers’ voca- interests, and neglect to assist those most movement around proposed closures is issue? See the Children's Mental Health tional needs creating options similar to in need, especially people with psychiat- best explained in terms of NOMBY. Toolkit which can be viewed on line at those found in New York State. Con- ric disabilities. Consumers contemplat- Virtually all of our MHAs, as well as www.MHANYS.org. Make things hap- sumers pursue vocational goals in shel- ing work for competitive wages face the MHANYS, believe that the size of the pen in your home town. May 4th - 10th tered workshops, pre-vocational and infrastructure of the state run psychiatric is Children's Mental Health Week. F transitional employment programs, day see Amsterdam on page 21 PAGE 16 MENTAL HEALTH NEWS ~ SUMMER 2003 the NARSAD report The National Alliance for Research on Schizophrenia and Depression By Constance Lieber, President world, with total funding for 2003 pro- year to find the most promising research I have been gratified, recently, by NARSAD jected at a solid $16.8 million. The lat- proposals. NARSAD expects grant re- the efforts of several families challenged est round of awards included a record cipients to play key roles in discovering by a psychiatric illness, who realize that 175 Young Investigator grants of up to the causes, new treatments and eventual research represents our best hope in con- $60,000 each to provide early career cures for mental illness. quering the devastating brain disorders. support to scientists, and 15 Distin- Young investigator awards give One extraordinary gesture came guished Investigator grants of $100,000 many scientists the career boost they from a childhood friend of a young man each to provide continued support to need to get their research off the ground. with schizophrenia who committed sui- established researchers. These are im- Countless young investigators have par- cide 15 years ago. She wrote to every- pressive numbers, and even more so layed their NARSAD awards and subse- one who knew him on the occasion of when you add the 164 Young Investiga- quent research findings into multi- tors and 40 Independent Investigators million dollar grants from the National what would have been his 40th birthday, who will be receiving second-year grants Institutes of Health. Many researchers urging them to make a donation to NAR- in 2003. NARSAD is providing funding credit NARSAD with having given them SAD in his memory. The response was for studies on depression, schizophrenia, their start. overwhelming. anxiety disorders, bipolar illness, post- Distinguished investigators funded Just recently, a successful young traumatic stress disorder and other brain- by NARSAD have made momentous woman whose sister was diagnosed with Constance Lieber based illnesses. discoveries. Two such scientists, Dr. schizophrenia organized a major fund- Since 1987, NARSAD has been Eric Kandel and Dr. Paul Greengard, raising dinner in Manhattan. She and

awarding grants for the most promising won the Nobel Prize in Medicine in 2000 her friends persuaded 200 people to at- arlier this year, the National psychiatric research based on the recom- for research elucidating the mechanism tend. They raised not only money for Alliance for Research on mendations of our Scientific Review by which brain cells communicate with NARSAD… but awareness of the terri- Schizophrenia and Depres- Council. By the end of 2003, NARSAD each other. Both Dr. Kandel and Dr. ble toll of brain disorders and the impor- sion (NARSAD) was faced will have awarded $144.5 million in Greengard had received Distinguished tance of research. Ewith a dilemma. We had received a re- grants to more than 1,600 scientists at Investigator grants, and they currently Another family in Boston is now cord number of outstanding grant pro- 212 research centers worldwide. These serve on NARSAD’s Scientific Council. working to spread the word in their posals from researchers at leading medi- numbers are a testimonial to the extraor- Recent advances in research tools town. They have also generously of- cal centers and universities worldwide. dinary growth NARSAD has experi- are aiding investigators in their quest for fered to underwrite an upcoming NAR- The quandary was how to fund all the enced since 1987, when the organization better treatments and cures, and top sci- SAD Scientific Symposium. researchers whose proposals showed distributed grants to just 10 researchers entists predict major discoveries in years The devotion of so many families such promise and innovation. Ulti- totaling $250,000. to come. Advanced brain imaging, the who have become involved in NAR- mately, NARSAD’s Board of Directors NARSAD’s Scientific Review unraveling of the human genome, and decided we could not turn our backs on a Council is composed of 75 scientists and new cellular and molecular biology tech- SAD’s mission, along with the tireless single young investigator deserving of a academic leaders in all phases of neuro- niques will enable researchers to make efforts of researchers, gives me much research grant. biological and psychiatric research. This breakthroughs that will benefit countless hope for the future. For more informa- In February, NARSAD awarded distinguished group of volunteer review- patients and their families facing mental tion about NARSAD, please call us at new grants to 190 researchers around the ers screens hundreds of applications each illness. 800-829-8289, or visit www.narsad.org.

1,695 212 20

MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 17

WORKING WITH MEDICATIONS What is a chemical imbalance?

By Richard H. McCarthy lems are taking place. Another the place where we presently cluster is responsible for a dif- M.D., C.M., Ph.D. way of understanding the brain can best find and influence the ferent behavior. In the cluster ComprehensiveNeuroScience is to understand how these chemical imbalances associated known as the striatum, dopa- White Plains, New York parts of the brain are communi- with mental illnesses. Obvi- mine is involved in the control of cating with each other. One ously, the synapse, the space movements, in the frontal lobes, kind of chemical imbalance will where nerve cells meet will be a dopamine plays a role in atten- have something to do with the very important space to under- tion and concentration, and in balance between actions that stand. the meso-limbic system dopa- are taking place in different The synapse consists of an mine plays a role in psychosis. parts of the brain. Another kind incoming nerve cell, (the pre- Clearly, if there is an imbalance of imbalance will have some- synaptic nerve cell), a small in dopamine there can be prob- thing to do with how nerve cells fluid filled space across which lems in any or all of these func- carry messages. In order to un- chemicals will drift, (the synap- tions. derstand either of these we have tic cleft), and an outgoing nerve It would be simple if all of to understand how nerve cells cell (the postsynaptic cell) that the problems were the same, work. receives the message and carries that is, too little dopamine in Nerve cells move information it forward to the next cell. The each area. Then we could give from one place to another. Each chemicals released by the in- medications that could only cell is made up of many, highly coming, transmitting, presynap- raise the level of dopamine eve- specialized parts, but to simplify tic cell are called neurotransmit- rywhere. Unfortunately, this is things, we will look at only four: ters. These message carrying not the case. Dopamine re- a part that receives information; chemicals, the neurotransmit- quirements and balance are dif- a cell body where cell metabo- ters, drift across the synaptic ferent in different parts of he lism takes place; an "axon" that cleft and attach to special parts brain. Too little dopamine in moves the message over great of the receiving, postsynaptic the striatum causes the symp- Dr. Richard H. McCarthy distances; and a transmitting cell, called receptors. When toms of Parkinson’s disease but end, the part of the cell that enough of the receptors are too much dopamine in the eople suffering from passes information on to the stimulated, the postsynaptic cell meso-limbic system we can mental illnesses or brain next cell. In general, informa- "fires" and carries the message cause psychosis. Physicians disorders are frequently tion moves only one way: from forward. When we speak of a can help minimize the resultant told that they suffer the receiving end, through the chemical imbalance we are talk- movement problems of Parkin- Pfrom a chemical imbalance in length of the cell body and axon ing about an imbalance in the son ’s disease by giving a medi- the brain. What does that to the transmitting end. Neural chemicals that carry messages cation such as L-Dopa (sinemet) mean? In order to understand transmission, i.e., nerve cell between cells such that they do which will raise dopamine levels what a chemical imbalance is, it communication, is an not perform their message car- where ever dopamine is found, is necessary to have some gen- "electrochemical" event. This rying function properly. There including in areas where it may eral idea of how the brain means that nerve cells transmit are several kinds of difficulties be normal and where we do not works. information by means of a series that could cause an imbalance. want it raised. This may correct The brain is the organ in the of both electrical and chemical The kind and amount of neu- the movement problem of Park- body that is responsible for changes. The "electro-" refers to rotransmitters that are released inson’s disease but cause psy- thoughts, feelings, and control how information moves across by the presynaptic cell can be chosis. Similarly, we can treat of virtually everything that we the cell. We can observe this out of kilter. Something can the problem of psychosis by giv- do. The brain is organized into small electrical charge that happen to the neurotransmitters ing medications such as clusters of cells, each located in nerve cells create when they as they drift across the synaptic fluphenazine (prolixin). This will different areas of the brain. carry messages when we do an cleft so that they no longer as lower dopamine levels every- Each cluster is responsible for EEG (electroencephalograph). effective. The neurotransmitters where dopamine is found in- different functions. So, for ex- Many of the medications that can interact with the receptor on cluding areas where it is normal ample, the ability to produce are used to treat seizures and the receiving, postsynaptic cell and where we do not want it speech occurs in one part of the bipolar disorder influence this in a peculiar way such that the lowered. This may help correct brain and the ability to under- "electro" part of the electro- message is interfered with. the problem of psychosis but stand speech takes place in an- chemical event. So, medications There are many other types of can cause the person to have other part of the brain. In order such as valproate (Depakote) or problems that can influence this problems with the control move- for our speech to be reasonable carbamazapine (Tegretol) modify tightly controlled and delicately ment. i.e., the symptoms of what we say must be related to the movement of messages balanced system. This should Parkinson’s disease. When this what we hear. Therefore, these across the length and breadth of not be surprising. The more happens we say that the person two parts of the brain must be the nerve cell. We believe that delicate and complicated a sys- is having side effects. able to communicate with each these medications do this by tem is, the more easily it is to Chemical imbalances are other. If this communication be- stabilizing the cell membrane disturb it. While the brain is complex and their treatment is tween the parts of the brain is which then blocks the electrical well protected, by bone and spe- not without problems. In the interfered with, there would be a passage of information and cial membranes, it is not invul- future, a few things are likely to significant impairment in our thereby slows down neural nerable. occur. We are likely to develop a ability to make both understand transmission. The "-chemical" An example of the problems better picture of how nerve cells and make ourselves understood. part refers to how messages associated with correcting communicate with each other Nerve cells perform this task of move from one cell to the next. chemical imbalances may help. and how different parts of the linking different parts of the When two nerve cells meet Dopamine is an important neu- brain work. Moreover, it is brain together by a process they do not touch but are sepa- rotransmitter that is used in likely that better medications known as neural transmission. rated by a small space called the many different cell clusters in will be developed to address the One way to understand the synapse. Most psychiatric medi- the brain. Even though each brain disorder problems that are brain depends on where prob- cations work by modifying what cluster uses dopamine as its caused by chemical imbalances goes on in the synapse. This is neurotransmitter to move, each and their treatment. PAGE 18 MENTAL HEALTH NEWS ~ SUMMER 2003

The NYSPA Report

By Seth P. Stein, Esq. certification and authorization, first re- tice at their first office visit following the formation and to improve their practices and Rachel A. Fernbach, Esq. port of injury, and health claims attach- April 14 deadline. Providers are re- where necessary. Providers are also ments. If a provider engages in any stan- quired to ask patients to sign a form indi- required to limit the amount of personal An Introduction To dard transaction by electronic means, cating that they have received the No- health information they use or release to The New Federal Law that provider is subject to HIPAA. tice. However, patients may obtain the minimum amount of information What is covered by the Privacy Rule? treatment even if they do not sign the necessary to accomplish the task at hand. form. The provider must post the Notice On Medical Privacy The Privacy Rule applies to any indi- What is the relationship between HIPAA in a prominent location in the provider's vidually identifiable health information and New York State law and practice? What is HIPAA? medical office and make a copy avail- transmitted or maintained in any form, able to anyone who asks for it. New York State law has always re- referred to by the Rule as “protected quired physicians and other health care IPAA, which stands for the Individual Rights: Under the Privacy health information” or “PHI.” Informa- providers to obtain patient consent be- Health Insurance Portability Rule, patients have certain rights with tion that has been de-identified is not respect to the health information that is fore disclosing health information to any and Accountability Act of subject to the Rule. De-identified infor- third parties for treatment and payment 1996, is a new federal law collected and maintained about them. mation includes information that has purposes, with some exceptions where Hthat creates standards for the use and This includes the right to: been stripped of certain identifying in- disclosure is permitted or required by disclosure of personal health information formation, such as name, dates, address, • Request that the provider restrict law. Under HIPAA, all state laws that that is maintained or transmitted by elec- telephone number, social security num- certain uses and disclosures of provide greater privacy protection or tronic means. In order to implement the ber, among others. health information. afford greater rights to access to records new law, the federal government created • Request that the provider communi- remain and are not affected by HIPAA. standards and guidelines that applies to What does the Privacy Rule require? cate with the patient by alternative Because New York State law provides all health care providers who bill elec- Patient Authorization: Under the Pri- means, such as making records greater privacy protections, the HIPAA tronically or transmit health information vacy Rule, providers must obtain written available for pick-up, or mailing Privacy Rule does not erode or in any electronically. These federal guidelines authorization from patients for all non- them to an alternative address, such way diminish the privacy rights that pa- are known as the HIPAA Privacy Rule routine uses and disclosures of patient as a P.O. Box. tients currently enjoy under New York or simply, the Privacy Rule. The Pri- health information. A non-routine use or law. vacy Rule went into effect on April 14, disclosure is a use or disclosure other • Request to review, or to receive a

2003. than for treatment or payment purposes copy of, the health information about that is maintained in the pro- For further information about HIPAA Who must comply that is not otherwise permitted or re- and the Privacy Rule in general, visit the quired by law. For example, an authori- vider’s files and used to make deci- with the Privacy Rule? U.S. Department of HHS website at zation would be required in connection sions about the patient’s treatment. Health care providers, including psy- http://www.hhs.gov/ocr/hipaa/. For in- with a pre-employment medical exam or • Request that the provider amend the formation about HIPAA and mental chiatrists, psychologists and social work- the release of information to a patient’s health information that is main- ers who provide mental health treatment, health care and services in New York attorney. tained in the provider’s files. will be subject to the rule if they engage State, visit the website of the NewYork Notice of Privacy Practices: The Pri- • Request an accounting of certain State Office of Mental Health at in at least one standard electronic trans- vacy Rule requires that all covered pro- action. A standard transaction means the disclosures of the patient’s health http://www.omh.state.ny.us/omhweb/hip viders provide patients with a Notice of transmission of information between two information to third parties. aa/index.htm. Privacy Practices, which is a document parties to carry out financial or adminis- that sets forth the provider's policies and Safeguards for Information: The Pri- trative activities related to health care, vacy Rule requires that all covered pro- Seth P. Stein is the Executive Direc- procedures with respect to the handling including health care claims, health care viders implement appropriate technical, tor and General Counsel of the New of confidential patient information and York State Psychiatric Association and payment and remittance advice, coordi- also informs patients of their individual physical and administrative safeguards nation of benefits, health care claim to ensure the privacy of personal health Senior Partner in the law firm of Stein & rights with respect to their own health status, enrollment and disenrollment in a information. These guidelines will re- Schonfeld LLP, Garden City, NY. Ra- information. All new and existing pa- chel A. Fernbach is an associate at Stein health plan, eligibility for a health plan, tients should receive a copy of the No- quire providers to reassess the way they health plan premium payments, referral handle and maintain personal health in- & Schonfeld LLP.

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In Silence from page 6 ment on my decision for now. Mental Health News gave me the Three years have passed since this opportunity to share my story and reach incident. I take my life easier now. I also out to others who might also wish to New York State take my medication, exercise regularly, remain anonymous. Depression does not and try to keep life’s stressors to a mini- pick and choose whom it might attack Psychiatric Association mum. The three years have also taught next. It is blind to age, race, occupation me something else about depression. It and creed. Corporate professionals are carries with it a stigma with those who chosen to the same degree as others. In don’t understand it. fact, given the stressors associated with Area II of the American Psychiatric Association Even the best-intentioned people will corporate life one could make a case that probably view you differently and may it may take an even heavier toll. The Representing 4500 Psychiatrists in New York wonder just how to approach you. Oth- triggers are definitely there. ers will just avoid you or the issue alto- If you would like to chat with me or gether. Only those that have the illness join me in helping others in similar Advancing the Scientific can really appreciate it and the power it situations please write or E-mail Mental can wield over your mind. Health News, and they will forward your and Ethical Practice of Psychiatric Medicine I have chosen to remain anonymous note to me. I promise to return any calls in this writing to underscore this stigma. on a strictly confidential basis. I hope to Others have talked to me about the establish some type of outreach program Advocating for Full Parity shame they feel or what it might do to for those like me. I’m open to your ideas their career. To all of those people I say and I’m calling it “PRIVATE PART- in the Treatment of Mental Illness you are not alone. To those that are read- NERS.” ing this, I ask that you withhold judg- A Private Partner Advancing the Principle that all Persons with Mental Illness deserve an

Evaluation with a Psychiatric Physician Employing from page 6 Medicaid Reform from page 8 to Determine Appropriate Care and Treatment I have found that an employee who Reducing coverage for these optional meets these requirements and has populations to a package similar to pri- demonstrated stability by the time he vate insurance appears to be the Admini- Please Visit Our Website At comes to me is as likely, and maybe stration's preferred option. But this ap- more likely, to be a successful employee proach would deny adults and children with mental disorders the critical inten- than one who hasn't met these require- www.nyspsych.org sive services that are only available ments, regardless of whether or not he through the public mental health system. has a psychiatric diagnosis. The Bazelon Center believes that the Bush proposal is reckless and would Dr. Laura Lustig, President needlessly put millions of Americans The New Learning Therapy Center with mental health care needs at risk. Mental Health Association in Putnam County, Inc. House Legislation from page 8 person who breaks the law relating to 1620 Route 22 Social Security or to the SSI program to Brewster, NY 10509 to explain in their solicitations that the make restitution to the trust funds or SSA provides the services free of general fund as appropriate. charge. HR 743 would also improve work - Authorizing the Commissioner to re- incentives for individuals with disabili- Promoting a vision of recovery for individuals fuse to recognize certain disqualified ties to return to work by: attorneys. - Clarifying some provisions of the and families coping with mental health issues - Establishing penalties for impeding Ticket to Work and Work Incentives any SSA employee while acting in their Improvement Act of 1999, including official capacity. beneficiary access to assistance from the ● Peer-Run Information and Referral Warmline - Expanding the current law prohibition Protection and Advocacy System for maintaining a job. ● Consumer-Drop-In-Center on the use of Social Security or Medi- care symbols, emblems, or references. - Clarifying the Work Opportunity Tax ● Peer Bridging Program - Prohibiting individuals who fraudu- Credit so that it is also available to employers who hire a beneficiary with ● lently conceal work activity from being Self-Help Groups eligible for a trial work period. disabilities who is referred from any employment network, not just the State ● - Allowing Federal courts to order a Education and Support for Family Members rehabilitation agency. ● Community Outreach and Education

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By Barbara Bernstein, Ph.D. some” violence to resolve international ren absorb the emotions of adults. It is hope that families will be focused on Director, Training and Education conflict. essential that we not burden them with summer vacation. Whatever the world MHA of Westchester How can these examples of chil- our worries. For their sake as well as situation is at that time, summer, when dren’s experiences guide us to help them our own, it is important that we take children are out of school, can be a time s the war in Iraq, now in its through unsettling and unsettled times? care of ourselves. For many, that means to focus on our families and on third week, dominates the Children’s comprehension of events limiting exposure to the minute-by- strengthening the bonds that sustain us. media and our discussions, and their worries vary with their ages, minute, mile-by-mile coverage of the Additional information about chil- concern has turned to how developmental stages, and personal his- war, doing things that nurture us, dren’s responses to war is available on Athis war affects children. tory. Most of all, children want to know spending time with loved ones, and many web sites including: The Mental I asked friends, colleagues, and edu- that they and their loved ones are safe. avoiding substance use, excessive use Health Association of Westchester, Inc. cators about children’s reactions to the Older youth want to know that the world of alcohol and dependence on food to www.mhawestchester.org, The Na- war in Iraq. I learned that children’s they will inherit will be stable and pre- relieve stress. tional Mental Health Association at responses range from appearing to be dictable. It is up to adults to reassure By the time this issue is released, I www.nmha.org, and at Mental Health unaffected to expressing fear and even but in a realistic way. We need to be hope that the war will have ended. I News at www.mhnews.org. fascination. Some children feel pro- credible and willing to have difficult tected by the distance between the discussions. War and the world situa- United States and Iraq. Others are con- tion are on the minds of many youth fused about where the war is being even if they never raise the topics or fought and whether it is far away and express concern. It is up to adults to they are safe. For some in the greater invite discussion. It may be most com- New York City area, the war has rekin- fortable to ask what peers are feeling dled the anxiety that followed Septem- and saying and about what is being dis- ber 11th. Anxiety has remained high cussed in school, rather than directly for many who live near Indian Point. about the child's feelings. As you listen Bedtime rituals are drawn out as chil- carefully to what a child says and does- dren do not want to be left alone. Other n't say, keep in mind his or her personal children, uncharacteristically ask to history—perhaps he or she has experi- A Place To Turn For Help sleep with their parents. Perhaps sur- enced trauma, the death of a loved one, prisingly, teens no longer want to be at or has a mental illness or physical illness Information and Referral home without their parents. There is an that leaves that child more vulnerable urgent need to stay together and stay than others. Children ask difficult ques- Mental Health Issues connected—children do not want to go tions and adults may not have all the Availability and Locations of Services Nationwide to school, travel on vacation, or have answers. We don’t have to, but we Educational, Financial, Legal, Social, and Other Support Services their parents travel on business. There is should acknowledge when we don’t. a heightened sense of “something in the Children are reassured by routine and air.” predictability, so maintain your child's MHA Services Our children identify with the chil- usual routines as much as possible. Child Adolescent and Adult Educational Outreach dren they see on the news—those who Young children should not see televised ● ● Counseling Vocational Services have escaped to refugee camps, and images of war. Limit your older chil- ● Individual, Family and Volunteer Opportunities those who are seen in rubble and debris. dren's exposure to the news and watch it ● ● Group Therapy Consumer Advocacy Some children identify with our soldiers: together. Discuss what you have seen, ● Senior Counseling and Support Housing Alternatives some boys, in particular, are excited your child's and your own reactions. ● ● Domestic Violence Services Rehabilitation Services about awesome weapons and their capa- Use this opportunity to affirm your val- ● ● bilities. Older youth recognize that they ues and beliefs. Give children opportu- are not substantially younger than our nities to release nervous energy in soldiers and worry about a draft. healthy ways such as physical activity. Children are inquisitive and actively This is a particularly important time to 914-345-5900 work to make sense of their worlds. help others. Whether writing to soldiers, They accomplish this based on their own sending care packages, or doing commu- experiences and the lessons and values nity service close to home, children Visit Our Website At they have been taught. Children re- benefit from contributing to others. mind us that they are taught to resolve Having a sense of purpose and mean- www.mhawestchester.org conflicts through non-violent means and ing to life beyond their own interests is ask how it is acceptable that adults and essential for children. nations resort to “shocking and awe- From the time they are babies, child- 2269 Saw Mill River Road, Bldg. 1-A, Elmsford, NY

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Buy-In from page 14 $61,870 for a household of two. A pre- The Dutch learn from us as well. The Dutch have another saying: mium (a payment back to the state to ‘Evidence-based practice,’ pioneered by never stand out in a crowd. They value provided for a moratorium on premium retain Medicaid coverage), based upon a American researchers, is gaining mo- teamwork and consensus above all else payments until April 2004, when the percentage of earned and unearned in- mentum in the Netherlands. The Indi- – entrepreneurship in the Netherlands is system is expected to be operational. come, may be required. vidual Placement and Support (IPS) a collective endeavor. North Americans

● model of evidence-based supported em- are more likely to value individuals who Local Social Service Departments will ● To be eligible for the Basic Medicaid be taking over full responsibility for ployment has taken root in four demon- stand out in a crowd, and are strongly Buy-In program, a working individual stration sites, part of an implementation inclined to use work as a measure of taking and processing applications and between the ages of 16-64 must have a study associated with the New Hamp- individual self-worth. We can’t change enrolling individuals into the Medicaid disability that meets the medical criteria Buy-In program on April 2004. At that shire-Dartmouth Psychiatric Research this, nor would we necessarily want to. for Supplemental Security Income (SSI) Center. Consistent with the essential But, if we better understand our own time, Buy-In enrollees earning between established by the federal Social Secu- principles of supported employment, IPS attitudes regarding the relationship be- 150-250% of the Federal Poverty Level rity Administration, but have too much will be expected to begin paying premi- emphasizes competitive and integrated tween work and self-worth, we might income to qualify for SSI. employment. Mental health researchers better understand the monumental pres- ums to retain their Medicaid. in the Netherlands look positively upon sures we assert on people for whom More Details on New York's ● Eligible individuals can have no more IPS, viewing it as potential leverage to work is difficult. Medicaid Buy-In Program than $10,000 of resources (excluding transform the existing mental health Alysia Pascaris is the Director of the house or car). ● The Medicaid Buy-In program for employment system to one which pro- New York Work Exchange, Coalition of vides consumers with greater opportuni- Voluntary Mental Health Agencies. She Working People with Disabilities will ● Individuals with incomes under 150% ties for integrated and competitive em- is currently on leave in Amsterdam, liv- make Medicaid coverage available to of poverty pay no premiums; individuals ployment. Can we learn from them? ing with her family. employed people with disabilities who with incomes of 150-250% of poverty are at least sixteen years of age but un- will pay premiums calculated at 3% of der the age of sixty five and whose in- earned income and 7.5% of unearned come from work previously would have income. disqualified them from coverage.

● Once the program starts, individuals ● Medicaid Buy-In enrollees who are with net incomes up to 250% of the Fed- later determined to be medically im- eral Poverty Level can be eligible, proved on a Continuing Disability Re- meaning Medicaid will be available for view but who retain a severe medical working individuals with a gross income impairment can still qualify if they are of $46,170 for a household of one and working 40 hours per month or more. F

Amsterdam from page 15 fear of losing social assistance or dis- ability payments, the consequences are potentially threatening effect of earned more deeply felt by Americans who can- income on disability pension. Although not rely on the state for essential medical American and Dutch consumers share a benefits. (next column)

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The Effect from page 1 How Can A Person Function totally overwhelmed.” must be distinguished from physical secu- Rather than challenging the content of rity, which is necessary, but not sufficient. In Spite Of Being Afraid? How Fear Works such statements, help to increase the per- Psychological safety refers to our ability to Just as the brain has mechanisms to son’s ability to monitor thoughts and rec- feel that we can regulate our emotions, as The fear reaction occurs automatically instantaneously activate the fear response, ognize how absolute and negative such discussed above. Social safety refers to our as a consequence of the brain’s threat re- other mechanisms involving thinking, statements are and how such beliefs in- ability to feel safe in a group and to experi- sponse system. This system operates with learning and planning can be mobilized to crease distress. Their confidence can in- ence an enhanced sense of connection.6 extreme rapidity, making split second “yes/ overcome learned fear responses. These crease by becoming aware of their negative Exposure to threats immediately intensifies no” decisions as to whether something is techniques can promote new understand- self-talk, challenging their assumptions a person’s need to be close to their loved or is not a threat to our survival. Failure to ings about threatening experiences, teach and substituting more positive self-talk. ones. Following the attack on the World defend oneself has greater consequences ways to restore calmness and enhance ac- Fear and trauma exposure changes peo- Trade Center, everyone felt this urge very than responding too often. We cannot tive coping, even when intense emotions ple’s expectations and affects their ability strongly. This increased “bonding and at- afford to debate whether something is dan- originally clouded thinking. These tech- to properly assess threats. tachment” serves as an antidote to danger gerous when we need to act immediately, niques allow one to: We see more threat than actually exists and trauma and can help mitigate their either by fighting or fleeing. - Acknowledge frightening feelings rather because of the tendency to misperceive intensity. Our fear response “turns on” faster than than trying to suppress them. non-threatening events as possible dangers. One maladaptive response to fear is to our higher mental functions, such as rea- - Learn techniques to calm oneself down. Our estimates of the probability of cer- “circle the wagons” and thus isolate one- son. It operates largely outside of con- tain risks shift. This causes less likely, but - Challenge self-defeating assumptions. self. In fact, withdrawal and avoidance of scious awareness, as our vision, hearing very frightening events (nuclear attack, social contact can increase distress because and other senses continually scan the envi- - Clarify unrealistic or catastrophic expec- plane crash) to be ranked as more probable it deprives one of social support, one of the ronment for potential threats. However, tations. while more likely risks (smoking, car acci- most helpful counterbalances to fear. more conscious mechanisms like reason, - Learn about the universal and natural dents), which actually cause more death (“There is safety in numbers.”) Suggest planned behaviors, and remembered dis- and harm, are ranked lower. that people build connections to family, basis of the fear response. tinctions between what is safe and unsafe, Constantly having our “guard up” and friends, and work colleagues, community can be used to override the initial response. - Develop effective ways to release ten- sion. expecting a past trauma to recur can evoke groups and religious organizations. Help The fear response is both emotional and re-living of events even though we are them recognize what makes them feel safe physical. The primary physical reactions -Increase social connections. actually safe (responding “as if” then is and to take steps to increase those activi- are a pounding heart and rapid, shallow -Recognize what makes one feel safe and now). ties. It is especially important that attention breathing. Often these physical reactions take steps to increase such activities. The tendency to expect the worst can be to physical security not override the build- become automatically associated with be- confronted by actually encouraging people ing of psychological and social safety. ing frightened, even if they result from -Learn to distinguish physical security from psychological and social safety. to discuss their “worst case scenarios.” Excessive focus on locks, guards and other other stimuli. Various relaxation tech- This helps develop perspective and pro- physical security measures may increase niques, which help to calm these physical -Learn to approach problems by breaking mote the realization that certain fear- anxiety by serving as a constant reminder reactions, can be learned. When practiced them into smaller more manageable pro- provoking thoughts are unreasonable or of danger. regularly during times of relative safety, portions. irrational. Efforts should be directed towards in- they can also help promote a sense of self- -Learn to use healthy compartmentaliza- Educating clients about the universal, creasing the range of options that are avail- control. tion. automatic, intense nature of our fear re- able in a dangerous situation by helping If fear is turned on repeatedly, a bias -Access sources of moral/spiritual support. sponse system can help to enhance control with the development of a personal safety towards overreacting to possible threats over what otherwise seems like a personal plan. This must be thought out in advance How to Promote can develop even though we may eventu- weakness. Understanding that the response and mentally rehearsed. ally realize they are non-threatening. Mo- Preparation and Resilience is rapid and occurs automatically outside Expanding personal coping options, bilizing the capacity to accurately distin- First, the capacity to elicit a counterbal- of awareness makes it more objective practicing how to act effectively under guish real threats from overreactions can ancing relaxation response needs to be rather than a personal failure of will power highly stressful conditions and knowing actually reverse learned fear responses. learned. The use of the following calming or intentions. This, combined with the un- how to connect with close family members Exposure to trauma interferes with the techniques can regulate and contain intense derstanding that fear is a product of evolu- reduces the fear response, especially in ability to properly evaluate threats causing feelings: breathing exercises, meditation, tion and shared by many species, helps to children. By increasing the feeling of con- seemingly inconsequential events to trigger progressive muscle relaxation, active visu- relieve guilt and anxiety that “there is trol and effectiveness, being prepared acts fear. something wrong with me.”5 alization of positive imagery, relaxation as a counterbalance to the helplessness How Can These Observations Be tapes , emotional and physical grounding Helping people to develop successful induced by the inability to clearly think of Helpful to Anxious/Fearful Persons? techniques. ways of releasing tension can promote a options. Once people feel they can contain and greater sense of control and counteract the When people feel unsafe there is a ten- Knowing that these reactions are auto- regulate intense emotional reactions, rather helplessness that often intensifies fear. dency to generalize it to all situations, matic and occur in everyone can help indi- than being overwhelmed by them, they can This includes: physical activity, use of rather than keeping it to a specific re- viduals to: be helped to acknowledge fearful feelings humor and sublimation, use of creative sponse. Creating an inventory of places, rather than suppress them. This counteracts non-verbal outlets: dance, drawing, paint- people and things that help one feel safe - Stop blaming themselves. Frightened ing, writing, keeping a journal, and playing can promote the realization that the lack of individuals may personalize their reac- the perception of more threat than actually exists, which can keep a person hyper- or listening to soothing music. safety is not all-inclusive and may increase tions, often wrongly concluding that they The goal is to increase the focus on participation in situations where they feel are the only person “getting so upset.” alert, jumpy and prone to interpreting in- nocuous stimuli as dangerous. those things that give pleasure and mean- most safe. Furthermore, if the individual’s fear reac- ing. It is useful to have a few different References: 1.) Le Doux, 2.) Chemtob, tion is interpreted as a sign of something Stress that they can learn to cope with fear and keep it within tolerable limits. techniques. In particular, one needs meth- 3. & 4.) Rutter, 5.) Goldman, 6.) Bloom. being inherently wrong with them, intense ods that can be done briefly and /or alone For additional copies of this document and shame can occur. Discuss their fear while using learned calming techniques to insure that the level (at work or in other public places). These other trauma-related materials, including - See that their reactions are explainable, of fear arousal doesn’t exceed the person’s can be added to other methods that require tips on self-care and secondary trauma, which can help contain feelings of being capacity to tolerate it. (See techniques planning, facilities or other people. contact: J.J. McConnell, Publications above.) Stop the discussion if too much Manager, JBFCS Marketing and Commu- “out of control.” How to Promote Feelings of Safety discomfort occurs but work toward in- nications Department 212-632-4549. Psychological safety and social safety - Reduce overestimation of potential risks, creasing tolerance levels. (Desensitization) which only magnifies the feeling of dan- Respect their fears—there are no right ger. or wrong ones. Remember we aren’t trying - Counteract helplessness by preparing to tell people “Don’t Be Afraid.” Help them recognize that constant and learning adaptive ways to cope. worry and tension is emotionally and The Center for Career Freedom Explaining that fear is a natural, univer- physically exhausting and can cause fa- sal reaction and not a personal fault can: tigue, body aches and pain. Help them recognize physical signs of ● NYS Dept of Education Licensed Business School - Promote learning to contain the often suppressed feelings and ways to tell others intense, confusing emotions that interfere how to help calm them down, especially if ● DSS One-Stop Workforce Training Provider with effective action. physical contact, such as, a hand on the

- Foster the realization that even though shoulder, a hug or holding hands can pro- ● SSA Ticket-to-Work Employment Network one can’t stop the fear from “turning on” duce soothing. there are things that can be done to turn it Help to calm distressing emotions is ● DCMH Drop-in Center/Case Mgmt./Advocacy “off.” necessary, but not sufficient unless one also pays attention to thoughts and as- - Reduce secondary reactions such as ● Microsoft Certified Office User Training Center sumptions. Confident functioning in the shame, guilt and a feeling of being “weak.” face of distress is undercut by self- ● - Reduce helplessness and feeling out of defeating assumptions, such as: “Only VESID ‘Employment Network’ Partner control by recognizing that a seemingly weak people get frightened,” “If I were inconsequential trigger can turn the fear brave, I wouldn’t be afraid,” “There’s no response on. way to feel safe,” and “I can’t cope. I feel 914-288-9763 www.Freecenter.org A SUMMER 2003 ADVERTISEING SUPPLEMENT SPONSORED BY FOUR WINDS HOSPITAL PAGE 23 FOUR WINDS HOSPITAL “Celebrating 25 Years Of Caring, Healing and Clinical Excellence”

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Mood Disorders In Children: Diagnosis and Treatment - Two Case Studies

By Joseph P. Damore, M.D. plete unless it covers information about obtaining a clear and complete history of Alexander? Medical Director both unipolar and bipolar depression. I symptoms, along with a multi- Keep in mind that in the United Deerfield Children’s Programs hold this bias for several reasons. First, generational family pedigree for affec- States, mood disorders in children have Four Winds Hospital according to many researchers— tive illness, alcoholism and substance long been under diagnosed largely be- Akiskal, Jamison and others—the dis- abuse, and suicide. cause of the psychoanalytic tradition of tinction between unipolar depression and Childhood Unipolar Depression: the 1950’s, which posited that a child’s bipolar depression is not as clear-cut as Case #1 immature superego and personality we would like it to be. A full one fifth structure would not allow the develop- (20%) of adults who walk into a psychia- Alexander is a nine-year-old white ment or experience of a mood disorder. trist’s office with neurovegitative signs male who was referred to the local emer- If one reviews the psychoanalytic litera- of major depression are in the throes of gency room for evaluation of suicidal ture at that time, it can be seen that well their first affective disturbance of bipolar thoughts. His mother reports that over up into the 1970’s this belief was still illness. These “pseudounipolar de- the past six months, but especially over posited by a substantial number of child pressed” patients will go on to have a the past three months, Alex’s school and adolescent psychiatrists. However, manic or hypomanic episode and thereby performance has deteriorated from his detailed case descriptions of depressed declare themselves as having bipolar previous level of good functioning. He children who experienced sadness, irrita- depression and bipolar illness. The num- has become withdrawn, sullen, and very bility, changes in concentration, suicidal ber is probably higher in the child and sensitive, particularly to the criticism of thoughts, hopelessness, changes in appe- adolescent populations. Barbara Geller others. He cries easily. His mother tite and sleep, and other depressive states that he has become somewhat reported in the American Journal of Psy- symptoms, have long been reported in more irritable over the last several chiatry in 2002 that of those subjects the psychiatric literature. Kraepelin, for months, especially in situations where who had a prepubertal diagnosis of ma- example, reported as early as 1921, that tasks requiring concentration are asked jor depression, one-third (33.3%) devel- mood disorders, particularly bipolar dis- Joseph P. Demure, M.D. oped bipolar disorder Type 1 by their of him. She reports that he does not ap- order, were rare, but did occur in chil- 20’s, and nearly half (48.5%) went on to pear particularly interested in sports or dren, and that a substantial number of develop some form of bipolar disorder. playing with his friends as he used to. new cases could be seen in adolescents. hildhood depression is an To make matters worse, we know that He tends to have difficulty falling asleep, In 1971, the union of European pe- important and timely topic antidepressant use in patients with bipo- and reports to his mother than when he dopsychiatrists officially recognized the facing parents and health care lar illness has been associated with tries to fall asleep, he often has bad professionals today. For the manic switching, and the development of thoughts. Alex’s mother states that his needs of depressed children and adoles- C appetite is currently very poor. It’s a cents by declaring that depression is an purposes of this article, childhood is rapid-cycling bipolar disorder. Many defined as the period between ages five authors, Bowden and Calabrese among struggle to get him to eat three meals a important illness that constitutes a sig- and twelve. I will share with you two them, are discouraging the use of antide- day. When asked about suicidality, nificant proportion of mental disorders in clinical narratives—two cases about pressants with these patients. Patients Alexander states that he often thinks of a children and adolescents. In 1975, the childhood depression. Each case will be who are diagnosed as unipolar, treated world in which he is dead, though he National Institute of mental health fol- used as a template to discuss various with antidepressants, and who then flip does not currently have a plan to harm lowed up on this sentiment, and in 1977, issues associated with each disorder. into mania or rapid cyclying don’t appre- himself, nor does he have any intention published their finding in a book entitled These cases are fictional composites ciate it, nor do their families. To avoid of harming himself at the present time. Depression in Children: Diagnosis, from my own clinical experience and are this, one must become familiar with the He reports major stressors in his life, Treatment, and Conceptual Models. designed to represent, as closely as pos- sometimes-subtle differences between including the divorce of his parents, Even though the existence of depression sible, typical children affected with these the two disorders. Working with chil- which became final six months ago, his in children and adolescents was first disorders. It is my hope that these cases dren, adolescents and adults, I have be- mother’s engagement to a new fiancée, officially recognized at this time, it was will stick in your memory and rise to the gun to rule out a bipolar disorder first, which took place several months ago, not until the 1980’s that interest in defin- surface when you encounter children and to consider a diagnosis of unipolar and many episodes of teasing which oc- ing and diagnosing mood disorders in who present with similar symptoms. depression only when I am convinced cur at school. He feels hopeless almost children and adolescents began to in- Before I begin with the first case, I’d that the symptoms reported do not repre- every day. All lab tests performed at the crease. like to share a bias. I believe that any sent the depressed phase of bipolar ill- time of the exam came back normal. discussion about depression is not com- ness. Correct diagnosis depends upon What, if anything, have we learned about see Mood Disorders page 24

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Mood Disorders from page 23 have the thoughts. Finally, somatic with bipolar disorder before the onset of maternal grandmother is currently in her symptoms may coexist with depressive puberty, the family histories revealed 80's and taking Zoloft for depression. What further became clear was that it symptoms in children. The most com- mood disorders and/or alcoholism com- There is a maternal aunt with panic at- was difficult to diagnose depression and mon symptoms are headaches and ab- ing down both the maternal and paternal tacks. There is no maternal history of mania in children because language does dominal pain. Oftentimes, depressed sides. Finally, the presence of suicidal bipolar disorder, schizophrenia, alcohol not begin to be used as an effective children are seen by the pediatrician, behavior in family members can be help- or substance abuse, nervous breakdown method of communication until approxi- who conducts extensive laboratory and ful in separating unipolar from bipolar or psychiatric hospitalization, or sui- mately seven years of age. Even today, procedural workups for these symptoms. depression. In a study by Goodwin and cidality. Alexander’s father is a 42-year- verbal communication remains the best From an epidemiological standpoint, Jamison on bipolar patients, suicides in old white male who is employed in his tool for diagnosing psychiatric disorders. Kashani et.al. reported that in 1983, 2% the probands’ generation and later gen- own computer firm. Alexander's parents Without direct evaluation of the patient, of a general population of children met erations largely occurred in people with have been in the process of divorcing for one misses the core symptoms of a mood criteria for major depression, 7% of chil- symptoms in antecedent affective disor- the last five years, and the divorce be- disorder, i.e. feelings of sadness, low self dren admitted to pediatric hospitals for der. Let’s discuss Alexander’s family came final one year ago. His father has esteem, feelings of inadequacy, and the medical reasons met criteria for depres- history. In taking a family history, I sporadic visits with Alexander. Alexan- focus is primarily on the symptoms that sion, and Ling et.al., reported that as always ask parents the following ques- der's father has been in treatment for motivated the parents to bring their child many as 40% of children in pediatric tions: I start off with mom, and I ask her "personality problems," but denies a to the clinic in the first place, i.e. irrita- neurology clinics presenting with head- age. I am interested in knowing what family history of major depression, bipo- bility, getting into fights, and other dis- aches met criteria for depression. With she does for a living. I ask her, when lar disorder, anxiety disorder, schizo- ruptive behaviors. The diagnosis of de- this information in mind, let’s go back she thinks about herself and her parents phrenia, alcohol or substance abuse, pression in children is also complicated and consider Alexander, our first case. and her grandparents, her aunts and un- nervous breakdown or psychiatric hospi- by the fact that developmental processes As a professor, in my discussions with cles, her nieces, her nephews, her cous- talization, or suicidality. Alex has one affect the way the clinical picture is pre- medical students and psychiatric fellows, ins, everybody that would ever get to- sibling, who is five years of age, and sented. Spitz and Bowlby by, in their I share that the adequate gathering and gether at a family gathering, is there any- apparently in good health. Given the classic papers, described the phenome- understanding of family history is vital one in that group that has ever been di- above family history, it is my clinical non of anaclitic depression, the depres- in determining the correct diagnosis. agnosed with, or treated for depression, opinion that the likelihood that Alex's sive reaction seen in children separated Nowhere is this truer than in the diagno- or who she thought was probably de- symptoms are related to a bipolar disor- from their primary caretakers at an early sis and treatment of depression in chil- pressed, could have benefited from treat- der are low. The family history demon- age. These children look depressed, cry dren and adolescents. A positive family ment, but never got any? I ask, in that strates few episodes of affective illness, excessively, react slowly to stimuli, and history for mood disorders is more fre- group, was anyone diagnosed with bipo- no evidence of alcoholism or substance may have sleep and appetite distur- quent in depressed children than in de- lar illness, was anyone in that group ever abuse, no evidence of suicidality. In bances. In somewhat older children, the pressed adults. diagnosed with an anxiety disorder, and I addition, there are clear-cut social and clinical picture becomes a bit easier to There are three generalizations that explain exactly what that means: social familial factors, which could contribute figure out. Preschoolers with depression are consistent across family studies re- phobia, panic attacks, Obsessive Com- to Alex's current poor performance. Fi- appear very sad, and appear slowed garding affective illness. pulsive Disorder. I ask about a history nally, Alexander's neurovegetative signs down. They have limited verbal com- Affective disorders are familial, since of schizophrenia in this group. I ask if are not so severe as to warrant inpatient munication. Mothers may describe that the rate in relatives of patients is consis- anyone in the group has had a problem treatment. Treatment recommendations their child has lost his or her spark. In tently about two or three times the rate in with alcohol or with drugs. I ask if any- for Alex, given a diagnosis of major de- this age group, not gaining weight, not relatives of appropriately chosen case one in this group has ever been psychiat- pression, would include a combination growing, and weepiness with ‘tummy controls. rically hospitalized or had a nervous of antidepressant therapy and outpatient aches’ are common symptoms. As chil- The most frequent affective disorder breakdown. I am continually amazed at psychotherapy. Prior to the initiation of dren reach the age of six or seven, their in relatives of bipolar patients is not bi- the number of positive responses to this any medication, I would obtain lab work verbal repertoire increases, and this al- polar illness, but unipolar illness. Bipo- question after a series of negative re- consisting of a complete blood count to lows them to become more accessible to lar illness is the next most frequent. sponses to the previous questions. Fi- rule out anemia, electrolytes, BUN/ be listened to and to be understood. Among relatives of unipolar patients, nally, I ask if anyone in the family has Creatinine, Liver function test, Thyroid Older children usually have no problem there is a tendency, not always signifi- attempted to kill themselves or actually function tests, to rule out hyper or hypo- admitting to symptoms such as low cant, for bipolar disorder to appear more succeeded in harming themselves. I then thyroidism, Lyme titres to rule out Lyme mood, trouble concentrating, poor school frequently than it does among controls. ask, what is the status of the marital rela- Disease, ceruloplasmin, and serum cop- performance, irritability, crying, and Similarly, alcoholism can be a key diag- tionship, and I ask about the father. I am per to rule out Wilson's disease, and a suicidal thoughts, which their parents are nostically. For example, Strober re- interested in what he does for a living… baseline EKG. A full physical exam in- often unaware of. As a society, we often ported a higher rate of affective disorder and I ask the same questions in the same cluding height, weight, blood pressure, have difficulty believing that children and alcoholism in adult relatives of pa- order. Now, it may seem as if such a and a neurological exam is also neces- can be suicidal, as childhood is typically tients with bipolar disorder or schizo- discussion would take a substantial sary. Careful, informed consent is al- equated with happiness, lack of worry, phrenia. In a study conducted by Bar- amount of time, but it usually only takes ways obtained from parents prior to the and lack of responsibility. However, it bara Geller, the rates of alcoholism were about ten minutes to gather this informa- start of any medication, and children needs to be stressed that depressed chil- higher in adult relatives of bipolar chil- tion, and this information is vital diag- should be medically cleared as well by dren can be, and often are, suicidal. dren, 20% higher, than in relatives of nostically. Alexander's family history their pediatrician. The use of SSRI medi- They may not be able to act on their sui- those children diagnosed with depression reveals the following: his mother is a 38- cations has demonstrated clinical anec- cidal impulses because they lack access only at 12%. Demetri Papolos reported year-old divorced white female who is dotal efficacy for children. to lethal means, but they certainly may that in a majority of children diagnosed currently employed as a bank teller. His see Mood Disorders on page 25

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Mood Disorders from page 24 consider other etiologies for the symp- Childhood Bipolar Depression: Her speech is slow in rate and low in toms the patient is experiencing. It is not Case #2 volume. Her thought process is organ-

Paxil is my first-line treatment choice my clinical experience that children with Anne is a ten-year-old white female ized, but markedly circumstantial. She because of its easy tolerability and favor- unipolar depression routinely require who presents to the emergency room for admits to episodes of hearing voices of a able side effect profile for this popula- augmentation strategies such as the co- "devil and an angel telling her to do bad evaluation of gradually worsening and tion. Occasionally, when Paxil has not administration of Lithium or Cytomel, as bizarre behavior. According to Anne's things or to do good things." She reports been tolerated, I have used Zoloft or is true in the case of adults. Usually, parents, Anne has become markedly mild ideas of reference—of peers at Prozac. It has been my experience that children repond to the first agent, if not school talking about her behind her back. irritable and aggressive in the classroom an improvement in mood begins to take to the first agent, to the second agent, setting. She has been disciplined for She admits to having "confusing place within the first three to four weeks and if not to the second agent, to Well- threatening other children on the play- thoughts," and reports that she often of treatment, with full effect, as seen in butrin. It has also been my experience thinks about suicide, and wishes that she ground with sticks and with sharp pen- the adult population, by four to six that in situations where mothers or first- were dead. cils in response to being teased and pro- weeks. During this time, I meet with the degree relatives are depressed, children voked. Parents report that temper tan- What can be concluded about Anne? child on a weekly basis to monitor the tend to respond to the medication that trums, often lasting hours in duration, effect of the medication and to deal with has been most helpful for the parent. Evidence that manic-depressive illness can be precipitated merely by telling her frequently emerges in adolescents, per- the psychological issues which contrib- Occasionally, in the treatment of these "No," in response to a request. She is ute to his or her difficulty in functioning. children, one may notice a profound haps even in childhood, has generated reported to be markedly moody and can Parent counseling is also scheduled dur- improvement in mood within two weeks. increasing interest in the early features go from periods of elation to periods of of the illness. The clinical presentation ing this time. Patients who show a re- I tend to be very cautious about this phe- sadness and crying despair in cycles of sponse to the medication are usually kept nomenon because in my experience, it of early onset illness differs from bipolar hours to days. Her parents report that it on the medication for one year, after tends to be a harbinger of impending illness with later onset, as does the pa- is difficult to get her to settle down for tient's experience of it. Diagnosis is dif- which time I slowly taper the medication hypomania. We know pharmacologi- sleep, and that she seldom falls asleep and discontinue it. The patient is then cally that antidepressants take four to six ficult, and bipolar illness is frequently before 11 or 12 at night. Her mother watched for the return of symptoms, and weeks for a full effect to be achieved. mistaken for conduct disorder, schizo- wakes her at 7:30 for school and reports phrenia, or ADHD. Difficulty in cor- if they recur, medication is restarted. Though some improvement may be seen waking her is like “waking the dead.” Occasionally, it is seen in practice that a at two weeks, it is usually not a robust rectly diagnosing childhood bipolar ill- When she awakes, she is irritable, op- child demonstrates a partial response to response. Other hallmarks of impending ness can be traced to several sources. positional, and nasty. Her interests in- Although bipolar disorder is a relatively an antidepressant or no response at all. hypomania include sleep disturbances, clude playing Nintendo and playing with In this situation, I tend to stop the antide- increased irritability, aggressiveness common diagnosis, many clinicians con- her dog. Her energy level is reported to pressant and switch to another agent in which is out of character for the child, tinue to associate manic depressive dis- be variable—extremely high at times and orders with a later age of onset. Many, the same class. I then give the second new interest in sexual topics, and disor- extremely low at others. Her concentra- agent a full four to six week trial. Usu- dered, racing thoughts. Any of these also wishing to avoid psychiatric label- tion is described as poor. Her appetite is ally, there is a response to the second findings should signal the clinician to ing during adolescence, tend to avoid voracious and includes a diet of junk probing and explicit questioning of ado- antidepressant. In situations where there stop the antidepressant medication. food and carbohydrates. She has ex- is a poor response to the second agent in Though it is recommended to taper anti- lescents, and fail to inquire sufficiently pressed to her mother a wish to be dead the same class, I tend to switch to an depressants, especially SSRI antidepres- into the presence of depressive sympto- with a plan to jump from the balcony of matology. Likewise, there is a tendency antidepressant in a different class, such sants, when changing to another agent or their apartment. Her mental status is as Wellbutrin. If at least a partial re- stopping them, symptoms consistent for some child psychiatrists to avoid the significant for behavior which is psycho- use of medications, and consequently, sponse is not obtained with this strategy, with impending hypomania warrant motorically retarded, irritable, and angry. I begin to question my diagnosis and abrupt discontinuation. There are no stereotypes or tics noted. see Mood Disorders on page 26

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Mood Disorders from page 25 last several hours. Marked irritability, and outrageous comments. reported that discontinuing Lithium rap- oppositional behavior, distractibility, Children with bipolar depression may idly over fourteen days led to sharp in- they are likely to choose a diagnosis that and aggressiveness are also commonly demonstrate psychotic thoughts and re- creases in suicidal risk. The risk in- does not require drug therapy. In addi- seen features. Grandiosity, carbohydrate port auditory hallucinations which are creased twenty fold in the first twelve tion, the DSM-IV criteria apply poorly cravings, and lethargy, especially upon mood-congruent. Occasionally, children months, but was only half as great fol- to the diagnosis of depression and bipo- morning awakening, are also features with severe neurovegetative signs and lowing slow discontinuation over fifteen lar depression in children. For instance, seen commonly in bipolar illness in chil- hallucinations will be misdiagnosed as to thirty days. Lithium has also been duration criteria for the diagnosis of a dren. having major depression with psychotic associated with an anti-depressant effect, depressive episode requires at least a Children with bipolar disorder tend to features. According to Dr. Maria though some studies seem to suggest two week period with five or more de- cycle from depression into mania and Kovacs, a major researcher on childhood that Depakote is equally efficacious in pressed symptoms. However, a signifi- then back again quite rapidly. Some mood disorders at the University of the treatment of bipolar depression. cant proportion of early onset bipolar may cycle over a period of days. Others Pittsburgh, the diagnosis of major de- In situations where the child is ex- children demonstrate frequent mood and may seem to alternate mood states pression with psychotic features is most periencing rapid cycling, as most do, or energy shifts that occur several times throughout the day. Because the mood often encountered in the elderly. In chil- is in a mixed state, I tend to use Depa- within a single day. By DSM-IV defini- shifts are so rapid, some children be- dren, it is exquisitely rare, and should kote first. As in the case of the treat- tion, mood states that occur less than the come trapped in the switch process and prompt the consideration of a different ment of depression, the duration of treat- required duration cannot be formerly develop what is called a Mixed State. diagnosis, and most probably a bipolar ment with Depakote depends on clinical diagnosed. It is becoming clear that At this time, they may report feeling depression. efficacy. Medication education with bipolar disorder in children requires its agitated and constantly restless with a With this in mind, let's consider parents always includes the discussion own criteria. Hypomania can be misdi- high degree of energy. At the same Anne's family history. Anne's mother is that the duration of treatment depends agnosed as hyperactivity because of its time, however, they may feel worthless a 35-year-old white female who is em- on the efficacy of the medication, and psychomotor component and cognitive and self-destructive. While mixed states ployed in retail sales. She has been di- what the child has to gain or lose by changes, such as distractibility and are not as common in adults, unless in- agnosed with depression and is currently coming off of the medication. We know shortened attention span. Several fea- duced by antidepressant treatment, they on Effexor. Her maternal grandmother that bipolar disorder is a chronic illness, tures of hypomania can aid in differenti- tend to be a hallmark of the ultra rapid was also depressed, as is a maternal and best treated by the use of prophylac- ating it from hyperactivity. It is more cycles found in childhood onset bipolar aunt. There is no maternal history of tic medication for many years. The du- episodic and characterized by rapid disorder. Parents may also report that bipolar disorder, schizophrenia, or anxi- ration of treatment with Lithium is simi- mood swings, a family history positive children with bipolar depression demon- ety disorder. Her maternal grandfather, lar to that of Depakote, dependent upon for affective illness, and episodic hyper- strate sensitivity to stimuli of all kinds. maternal uncle, and another maternal the efficacy of the medication and the activity. Manic children show signifi- Not only are they bothered by sensa- aunt are all reported to be active alcohol- cyclical nature of the illness. Newer cantly greater behavioral pathology and tions, odors, and noises, but they seem ics, and have attended rehab several medications such as Trileptal, a metabo- overall maladjustment. Their psychopa- to have great difficulty making shifts times. Her maternal aunt has attempted lite of Tegretol, Topamax, and Neu- thology manifests itself in psychosis, from one context to the other. Children suicide several times and has been hos- rontin have also been reported to be depression, aggression, excitability, with bipolar depression tend to demon- pitalized. Anne's father is a 38-year-old helpful with this bipolar disorder, rapid mood swings, hostility, inappropri- strate difficulty maintaining peer rela- retail distributor, and they have been though they are less well studied. Sev- ate affect, and disregard for the feelings tionships. Children can often be de- married for 15 years. He has been de- eral studies seem to indicate that Neu- of others. In evaluation of children with scribed as bossy, intrusive, or too over- pressed off and on since his late teens rontin seems to be a very poor mood bipolar disorder, a history of separation whelming and aggressive. Parents may and is currently on Prozac. Anne's pa- stabilizer, though it has demonstrated anxiety is common, as are rages and describe periods of intense silliness, ternal grandfather and paternal aunt are efficacy for control of anxiety symptoms explosive temper tantrums, which may giddiness, goofy behavior, grandiosity, also depressed, and there is some ques- in children with these disorders. Often- tion that her paternal aunt may actually times, clinical improvement in response have bipolar disorder. There is no other to these medications can be witnessed history of bipolar disorder, schizophre- within a two-week period of obtaining a nia, or anxiety disorder. Anne's paternal correct blood level. In situations where grandfather "drinks heavily" and there is Depakote produces no response after a a family history of suicide attempts by period of one month despite patient her paternal first cousins. Anne has one compliance and good blood levels, I will younger sister who has been evaluated opt to switch to Lithium or some other for possible ADHD. In this case, it is agent. In situations where Depakote clear the family history is markedly produces a partial response, I will often more complicated than in Alex's case add Lithium as an adjunctive treatment. (case #1). We see unipolar depression In addition to the mood stabilizing on both sides of the family, as well as medications, the atypical neuroleptics, histories of alcohol abuse, and suicidal- such as Risperdal and Zyprexa, have ity. Given these features, a diagnosis of shown promise in the treatment of bipo- bipolar depression for Anne is likely, lar mania and psychosis, either as first and the likelihood that she will have an line medications or as adjuvants to the adverse reaction to an antidepressant mood stabilizers. As with all neurolep- medication is high. Treatment of this tics, however, the risk of long term se- disorder is more complex and requires quelae, such as tardive dyskinesia, thorough psychoeducation for the par- weight gain and lipid and glucose me- ents, who need to understand clearly the tabolism abnormalities are real concerns, difference between unipolar and bipolar and the risks of these conditions must be depression. In addition, informed con- weighed against the benefits of pro- sent about mood stabilizing medications longed treatment. As in the case of Hiking needs to be obtained, and the substantial treatment of unipolar depression in risks, both short term and long term, childhood, treatment of bipolar depres- must be explained clearly. I tend to be- sion requires the presence of a therapist gin treatment of these children with a as a consistent and abiding presence to mood stabilizing medication such as the patient and to the family. Medication Depakote or Lithium. If the child is must be managed by a doctor, and is not markedly suicidal, Lithium is the first the complete answer. Individual and line of treatment, as it is the only mood family therapy are essential components stabilizer clinically and statistically as- of therapy, particularly as it applies to sociated with a decrease in suicidal be- the treatment of children and adoles- havior—approximately a sevenfold re- cents. duction of suicide attempts and fatalities Joseph P. Damore, M.D. is the Medi- in patients diagnosed with bipolar disor- cal Director of the Deerfield Children’s der. This is a major consideration when Programs at Four Winds Hospital in discontinuing Lithium after long-term Katonah, New York and Assistant Pro- maintenance therapy has been consid- fessor of Psychiatry (Courtesy) at Weill ered for a patient. Ross Baldessarini Medical College at Cornell University. MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 27

Mental Health Treatment in the Context of Ongoing Threat

By Randall D. Marshall, M.D. veteran who had managed with sub- in 1,400,000. Nevertheless, most per- Director of Trauma Studies and threshold PTSD for many years with sons give no thought to driving every- Services, New York State Psychiatric moderate success, presented with full day. Such facts can be extremely com- Institute, Associate Professor of Clinical PTSD after 9/11 and sought treatment forting to persons who want to use their Psychiatry, Columbia University College for the first time. Most clinicians I have rational capacity to overcome fear. A of Physicians and Surgeons spoken with in community trainings good example is the following: if a per- have similar stories. son witnesses someone killed by light- Eun Jung Suh, Ph.D. Instructor of Clinical Psychology, In each case, the personal implica- ning, this fear will likely seem greatly Department of Psychiatry, tions of these new political develop- exaggerated. By analogy, the fact that ments appeared to be the source of millions witnessed the attacks of 9/11 Columbia University College of Physicians and Surgeons symptoms. Each patient felt more vul- led to a collective irrational fear re- nerable than before because of fears of sponse related to flying. witnessing 9/11-like events again he fact that terrorism is psycho- 5. Encourage conscious decisions about logical warfare has direct im- (patient 1), fears of being killed by daily behavior and risk appraisal that plications for the mental health bioterrorist or other attacks, or evoked are not influenced by exaggerated memories of being constantly in danger community. Although the loss fears—Since anxiety is a normal reac- Tof life on 9/11 is tragic and appalling, the in Vietnam (patient 3). tion to the perception of threat, new re- consequences for the nation and for Our center has provided training in ports of attacks, arrests of alleged terror- trauma-focused psychotherapy to over greater New York extend far beyond the ists in the U.S., and hypothetical scenar- actual destruction of life and property. 500 clinicians in the greater New York ios such as bioterrorism will inevitably Because of the attacks, it is now docu- area in the past 1 and a half years. We produce anxiety in most. However, are frequently asked for advice as to how mented that hundreds of thousands of functional disability in our patients (and persons developed PTSD and depressive to handle the many fears expressed by in ourselves) will largely depend on our symptoms in New York and across the our patients. Some basic guidelines response to such emotions. If a patient Randall D. Marshall, M.D. culled from our experience are below: country; our community and state was does not go to work every time there is a

plunged into recession, bringing with it 1. Don’t underestimate the effect of ter- new potential danger reported on the attacks, and are saturated with apocalyp- all the mental health risks and suffering rorism fears and the war on our pa- news, she will soon lose her job. If a tic fears from anxious and depressed of unemployment; and our nation has tients—One of the great embarrassments patient keeps his children from school, patients. waged 2 wars. The nation is being of the mental health field is the way in his family and children will suffer How can we continue to work in this drained of billions of dollars for security which trauma histories were minimized (particularly since the New York data new environment? The field of trauma and defense. Regardless of one’s politi- or interpreted as fantasy in the past. We suggests that children with anxiety reac- has always emphasized the important cal viewpoint, we are all trying to adjust make the assumption that the current tions are greatly influenced by their par- role of ongoing psychological support to a new uncertainty about our safety situation in the U.S. is affecting every- ents’ reactions to the current situation). for clinicians working in this area. Such from random attacks on civilians from one, and research as to the vulnerabilities In other words, our task is partly to pro- support is necessary because maintaining terrorists. to PTSD in adults demonstrates un- mote resilience in the face of adversity, an empathic capacity requires a sensitiv- Prior to 9/11, a patient wanting to equivocally that psychiatric patients are rather than to treat anxiety. ity that makes us vulnerable to absorbing discuss politics in session might have particularly at risk for developing sig- Confronting the feared situation in some of the affect expressed by our pa- been seen as defensive intellectualiza- nificant symptoms after trauma. By ex- turn leads to habituation to the anxiety tients. This maxim is no longer an ab- tion. I believe that perspective is no tension, patients may also be vulnerable fairly rapidly in most persons. stract, theoretical recommendation for longer tenable. It is worth noting that to symptom exacerbation under our cur- 6. Encourage patients to limit unneces- clinicians but a necessary way of life. many of our theories and maxims about rent conditions. It is the rare patient who sary exposure to anxiety-provoking cues therapeutic process were developed in is entirely unaffected, and this may in Attending our Trainings such as “what if scenario” media specu- the states during peacetime, or certainly fact be a manifestation of social isola- or Referring Patients lation—In addition to this basic principle during a time in which we were not tion, alienation, or extreme avoidance. (which has actually been extensively If you would like to attend our inten- physically threatened by attacks on civil- 2. Be willing to discuss these fears with covered in the media), patients having sive trauma-focused psychotherapy ians for political reasons in North Amer- your patients—If the patient senses that clinically significant catastrophic reac- trainings, please call 1-800-LIFENET to ica. Furthermore, the theoretical frame- we are dismissive of their worries, or are tions to news coverage are probably per- schedule your attendance. Trainings are work of traditional psychotherapy is made anxious by such discussions, the sonalizing the information and imagin- free of charge and sponsored in part by rooted in a now obsolete perspective, opportunity to work with such fears ing catastrophic scenarios as if they are the United Way 911 Fund. with its roots in the culture of individual- therapeutically may never present itself. certain or highly likely. We are studying a wide range of ism, that most symptom manifestations therapeutic approaches for all the anxiety can be entirely explained from the indi- 3. Make sure you are clear about your 7. The basics of self-care should be con- own conclusions as to the risks present sciously maintained—This public health disorders and provide treatment at no vidual’s personal history, character, and cost in this context. If you would like defensive structure, with little credence in the current situation—If we as mental message from (Federal Emergency Man- health practitioners have not consciously agement Agency) and Project Liberty more information or wish to refer a pa- given to environmental events. It is our tient, please call us at 212-543-5367. experience that many persons are having considered our own reactions to the cur- still applies to worried patients, and to genuine and powerful reactions to cur- rent situation, and made conscious deci- ourselves. Although it may seem con- Anxiety Disorders Clinic, Trauma rent world events that are not idiosyn- sions as to how we are going to live in crete and obvious, these reminders are Studies and Services, New York State cratic but rather best understood in terms the context of these new threats, it will beneficial to most patients because they Psychiatric Institute (NYSPI) Columbia of an interaction between the individ- be all the more difficult to work with reinforce common sense practice, sup- University College of Physicians and ual’s place in his or her culture, psychi- patients on these topics since the discus- port healthy coping strategies, and divert Surgeons. The New York State Psychiat- atric vulnerabilities, and prior life ex- sion will evoke uncertainty and anxiety attention away from anxious worries. ric Institute: Founded in 1896, the New perience. in ourselves. The basics of self-care include eating, York State Psychiatric Institute (PI) con- A patient with a serious anxiety disor- 4. Engage the patient in a realistic dis- sleeping, avoiding exhaustion, limiting tinues to make vital contributions to our intake of alcohol and other substances, der that is in full remission, who lives in cussion about the threats in day-to-day understanding and treatment of psychi- New York but did not see the Towers life—The tendency to focus on new po- exercise, restorative activities, and social atric disorders, and is ranked among the attacked on 9/11, recently presented with interaction. tential threats in the environment and best psychiatric research facilities in the an exacerbation of old symptoms, some exaggerate their risk appears to be al- world today. Noted for its research on new symptoms, and vivid dreams of a Being Mental Health Providers anxiety, depression and suicide, schizo- most universal. The risk of dying of in an Uncertain Time large plane being forced to land because cardiovascular disease in the U.S. is ap- phrenia, and child psychiatric disorders, of a kidnapping. All these symptoms proximately 1 in 2; of being killed in a Clinicians are also worried. We are PI is at the forefront of research dedi- coincided with the war in Iraq. Another long automobile trip, 1 in 14,000; of members of the community too, and cated to developing better and more effi- patient, after watching two days of news being killed by a tornado, 1 in 450,000; have families whose safety concerns us cient therapies and medication treat- coverage, awoke with a full-blown panic of being struck by lightning, 1 in daily. In addition, many of us working ments, as well as to unraveling the attack that had been in complete remis- 1,900,000; and of being killed in a plane in this area have heard countless tragic brain’s mysteries. For more information sion. Yet another patient, a Vietnam crash in the year 2001, approximately 1 and fearful stories related to the 9/11 please visit our site at www.nyspi.org. PAGE 28 MENTAL HEALTH NEWS ~ SUMMER 2003 New York State’s Wall of Stigma and Discrimination Beginning to Crack Thanks to Timothy’s Law Campaign

Staff Writer organizations, service providers, unions, Mental Health News hospitals and professional organizations. These representatives made their com- ments in a press release: even weeks before his 13th "It is too late to save Timothy's life, birthday, Timothy O'Clair but that doesn't mean other children and completed his suicide. The families in New York should be forced S youngest of three children in to suffer the same fate," Paige Mac- his Schenectady family, Timothy hung Donald of Families Together of New himself in his bedroom closet on March York State said. 16, 2001. Referring to a recent actuarial study Two years later, on March 18, 2003, that shows the cost of parity in mental his parents, Tom and Donna O'Clair, health and chemical dependency benefits took part in a press conference in Albany would be minimal, Joseph Glazer of the to announce Timothy's Law Campaign Mental Health Association in New York (TLC), a campaign to finally end health State said, "It would have cost $1.26 per insurance discrimination against persons month to save Timothy O'Clair. For with mental illness and chemical de- pennies a day, our children and families pendency in New York State. could be getting the full complement of At press time, Timothy's Law is about mental health and chemical dependency to be introduced into both houses of the services." state legislature, the first time the same "Not only would there be minimal "parity" bill has been introduced into premium costs, but studies have shown both houses. The bill has garnered 32 that equal mental health benefits raise majority cosponsors in the Senate and 50 Tom O'Clair speaking at the press conference productivity and lower overall health cosponsors in the Assembly. Initially costs," J. David Seay, Executive Director submitted on April 2nd, the bill is “on sues. By age seven, he was becoming seven out of his annual 30-day allotment of NAMI-NYS said. "With Timothy's hold” at the request of the Senate leader- easily frustrated and developing a seri- for inpatient services. Law, everybody wins. ship, which asked for time to seriously ous temper. By the time he was eight, his Because the insurance would not pay The O'Clairs were also joined by Jes- review it. family and his school knew he needed for desperately-needed residential care, sica Lynch, the reigning Miss New York Key sponsors of Timothy’s Law in the help. Tom and Donna finally had to "share" City, who began to suffer from depres- Senate are Thomas Libous, Chair of the Over the years, Timothy was diag- custody of Timothy with the state, and Senate Mental Health Committee, nosed with Depression, Attention Deficit pay child support. sion while in the third grade. She de- Patricia McGee, Chair of the Senate Al- Hyperactivity Disorder, and Opposi- When the O'Clairs were able to ac- scribed how, at the age of 14, she was cohol and Substance Abuse Committee tional Defiance Disorder. cess care and services, they found the admitted to a psychiatric hospital weigh- and Hugh Farley, the senator who repre- At the press conference, with Donna treatment they attained to be high qual- ing only 79 pounds, and how, after the sents the district the O'Clairs reside in. at his side, Tom O'Clair described how ity. The problem was that it was limited number of days her insurance would pay Key sponsors in the Assembly are Paul their son was systematically denied ac- and sporadic, available only as insurance for was up, the hospital found that she Tonko, who represents the district the cess to the health care he needed. While and the family budget allowed. had been "magically cured," and released O'Clairs reside in, and Peter Rivera, the family's health insurance allowed For more than five years, the O'Clairs her, even though she still weighed 79 Chair of the Assembly Mental Health only 20 outpatient visits a year for Timo- struggled to obtain the care their child pounds. She said she was appalled that Committee. thy's psychiatrist and psychologist com- desperately needed while trying to make such practices were still happening. The bill was written with the input of bined, Timothy needed weekly visits to ends meet. Even after Timothy's death, Speaking at the Press Conference, a coalition of 25 organizations, including his psychiatrist to monitor his medica- the family continued to pay child support Assemblyman Tonko he said he would NAMI-NYS. It seeks equal benefits for tion and twice-a-week visits to his psy- to cover his stay at the residential pro- do his utmost to pass Timothy's Law. mental health and chemical dependency chologist. gram -- $226 out of every paycheck -- "I will implore my colleagues to open services for health insurance polices Even the visits the insurance covered and they were still paying for the "extra" their doors so they can open their written in New York State, contingent took their toll. While the family's co- days of his last hospitalization. The fam- hearts," he said. "We need to change his upon federal limitations. payments for both physical and mental ily had to go to court to get the child devastating discrimination, and we're Commenting on the legislation, health services were $10 per visit ini- support garnishment stopped. going to make this happen. We're going Senator Libous said, “No family should tially, mental health visits quickly "If Timothy had diabetes or cancer to bring about Timothy's Law, so we have to experience the pain and suffering jumped to $35 each. our health insurance would have pro- don't artificially restrict and deny the of the O'Clairs. Working together, we Once the insurance was used up, Tom vided unlimited coverage. Instead, sim- care that is needed." can ensure the best possible mental and Donna were left to fend for them- ply by the nature of Timothy's illness, NAMI-NYS urges all of its members health services and coverage for all New selves, paying for care they could not our coverage was limited," Tom O'Clair to actively participate in the Timothy's Yorkers so we can prevent tragedies like afford. said. "We are confident that had Timo- Law Campaign, and challenges its affili- Timothy's before they happen." Meanwhile, Timothy grew steadily thy received the services he needed, he ates to advocate for Timothy's Law with Timothy was a typical boy. He worse. Two hospitalizations occurred, would be with us now." their legislators and Governor Pataki as climbed trees, brought home stray ani- each limited to a week by the health in- At the press conference, the O'Clairs they have never advocated before. mals and played the piano. Problems surer. For the latter hospitalization, the were joined by representatives of the Show your appreciation for the legis- began to develop in his life as he grew, family paid out-of-pocket for three extra TLC coalition, which currently consists lators who support this law, and generate however, beginning with attention is- days, even though he had used only of 25 organizations, including advocacy support for it in your community.

“If Timothy had diabetes or cancer our health insurance would have provided unlimited coverage. Instead, simply by the nature of Timothy’s Illness our coverage was limited. We are confident that had Timothy received the services he needed, he would be with us now.” Tom O’Clair MENTAL HEALTH NEWS ~ SUMMER 2003 PAGE 29

You Can Crack the Wall of Stigma and Discrimination Together We Can Bring It Down

With a record 32 Senators and 50 Assembly members agreeing to sponsor Timothy’s Law, this year’s movement to end mental health and chemical dependency insurance discrimination in New York State has made more progress than any efforts in years past.

Senators Assembly Members Benjamin Hikind Balboni Marchi Bing Jacobs Bonacic Maziarz Bradley Karben Brennan Koon DeFrancisco McGee Canestrari Lafayette Farley Mendez Clark Lavelle Cohen McEneny Flanagan Morahan A. Cohen McLaughlin Fuschillo Nozzolio M. Colton Millman Cook O’Donnell Golden Padavan Cusick Ortiz Cymbrowitz Paulin Hannon Rath DiNapoli Pheffer Hoffman Robach Dinowitz Powell Eddington J. Rivera Johnson Saland Englebright P. Rivera Larkin Skelos Galef Sanders Gianaris Seddio LaValle Spano Glick Sidikman Libous Trunzo Gottfried Stringer Grannis Sweeney Little Velella Green Tonko Greene Towns Maltese Volker Grodenchik Weinstein Marcellino Wright Gromack Weisenberg

To show your support for Timothy’s Law, please: Call, write or e-mail your State Senator and Assembly member, if they are a sponsor of Timothy’s Law, to thank them for their support. Educate your communities about why the law is needed. Hold events (be sure to include your Legislators) and get the message out through your local newspaper, television and radio. For more information on why New York State needs Timothy’s Law, and for links to the latest "calls for action" as it goes forward, go to: http://www.naminycmetro.org/TLC.htm, www.mhanys.org., and www.ftnys.org Now under construction: www.timothyslaw.org

This advertisement was paid for through donations from: Coalition of Voluntary Mental Health Agencies, Center for Urban Community Services, Association for Community Living, New York Presbyterian Hospital, New York State Psychiatric Association, Ellis Hospital, Law & Public Policy Consulting, Samaritans Suicide Prevention Center, Mental Health Association of Westchester, Mental Health Association of NYC, Mental Health Association in New York State, National Alliance for the Mentally Ill in New York State, Schuyler Center for Analysis and Advocacy, NASW - NYS Chapter, Mental Health News, National Alliance for the Mentally Ill of New York City PAGE 30 MENTAL HEALTH NEWS ~ SUMMER 2003

Human Development Services of Westchester

Creating Community

• Human Development Services of Westchester serves adults and families who are recovering from episodes of serious mental illness, and are preparing to live in- dependently. Some have had long periods of homelessness and come directly from the shelter system

• In the Residential Program, our staff works with each resident to select the level of supportive housing and the specific rehabilitation services which will assist the person to improve his or her self-care and life skills, with the goal of return- ing to a more satisfying and independent lifestyle.

• The Housing Services Program, available to low and moderate income individu- als and families in Post Chester through the Neighborhood Preservation Com- pany, includes tenant assistance, eviction prevention, home ownership counsel- ing, landlord-tenant mediation and housing court assistance.

• Hope House is a place where persons recovering from mental illness can find the support and resources they need to pursue their vocational and educational goals. Located in Port Chester, the Clubhouse is open 365 days a year and draws mem- bers from throughout the region.

Human Development Hope House Services of Westchester

930 Mamaroneck Avenue 100 Abendroth Avenue Mamaroneck, NY 10543 Port Chester, NY 10573 (914) 835 - 8906 (914) 939 - 2878

Opportunities to Heal Grow and Recover Putnam Family & Community Services is:

Welcoming Accessible Offering professional treatment Open Mon-Thurs 8am-9pm in a healing environment Fri. 8am-6pm - Sat 9am-5pm

Affordable Caring PFCS does not deny treatment to Our services treat anyone because of inability to pay each person as a whole

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Prevention, treatment, rehabilitation and self help including: Mental health and chemical dependency counseling for all ages Psychiatric evaluations and medication management Crisis Intervention Recovery and rehabilitation through Continuing Day Treatment Advocacy and linkage through Case Management

1808 Route Six Carmel, New York (845) 225-2700 Mental Health News - New York City Section: Summer 2003 Page 31 The Mental Health News New York City Section

The Workplace Center of Columbia University is Promoting Successful Employment Outcomes for Consumers

By Sheila H. Akabas, Ph. D., Lauren B. Gates, Ph. D., research communities. We are supported in this be- ify workplace structures and systems for consumers Suzanne Weidberg, MSW, Virginia Oran-Sabia, MSW lief by the resources from both the New York State and providers. Although Unions have the potential to Office of Mental Health (NYS OMH) and the New make connections between consumers and providers York City Department of Health and Mental Hygiene of vocational services and the workplace, results of ordon wants to get a job and keep it. He (NYC DHMH). Recent initiatives, carried forth by the study indicated that these connections often are is 34 years old, diagnosed with schizo- the Workplace Center, open new opportunities for not made. phrenia. Gordon is bright and seems well consumers through enhanced vocational services. Based on study findings, the Workplace Center G put together so he can usually get hired. The WORC© Program, developed by the Work- developed training curricula and an educational video Because of his mental health condition, however, he place Center and funded in part by NYC DHMH, is a to help providers of vocational services and consum- easily becomes confused and uses abusive language systematic approach to help providers of vocational ers learn how to access these workplace supports and when overwhelmed. As a result, Gordon has been services support consumers in making life long con- to help EAP professionals and Union representatives fired from many short-term jobs. Gordon has asked nections to work in a way that best meets their career rally their expertise and knowledge in new ways to his counselor to help him find work, but the coun- interests, builds on their strengths and promotes their support working consumers. selor feels that Gordon is not ready for work because well-being. It is integrated into an agency through a Evaluation of the Performance Based Con- of his inability to keep a job. Can there be another comprehensive consultation process. To date, 19 tracting Demonstration: To promote integrated, ending to Gordon’s story? What can Gordon’s coun- agencies have participated in the WORC© Program competitive employment for consumers, the NYS selor do to help him find a job and maintain it? throughout New York City. OMH is funding a cutting edge demonstration pro- This situation is typical of many consumers who The first Program component, Individual Assess- gram, the Performance Based Contracting (PBC) are ready and able to work but do not have the sup- ment and Workplace Intervention, begins with identi- Demonstration. It reimburses providers of vocational ports they need to make long-term connections to fying and resolving the potential barriers to employ- services once they successfully help consumers reach employment. The Workplace Center of Columbia ment that need attention in order to insure successful specific employment outcomes such as securing a job University believes that access to competitive em- work outcomes. At the same time, this assessment or achieving job retention at three, six and nine ployment is a civil right, the accomplishment of helps consumers identify a career path and select a months. The program’s six milestone structure is which warrants attention from the provider and job along that path. Because some consumers may developed from evidence based supported employ- experience symptoms or side effects of their medica- ment technology that includes rapid placement into tions that can interfere with job performance, this jobs, individualized job planning and consumer self- Mental Health News component also helps identify the need for workplace determination of a career path. Seven mental health Metro-New York Leadership Committee accommodation and guides negotiating these accom- agencies throughout New York State are providing modations with employers. vocational services through the PBC Demonstration Peter Campanelli, President & Chief Executive Officer The second component of the WORC© Program, and the Workplace Center has been selected by the Institute For Community Living Career Clubs, is groups that offer consumers the in- State to evaluate its effectiveness. Amy Chalfy, Mental Health Director - Bronx District formation, support and feedback essential throughout Preliminary findings indicate that the program JASA the employment process. Each session includes the reaches those consumers who often have difficulty Kenneth J. Dudek, Executive Director opportunity for mutual support and presents content sustaining employment, promotes rapid placement in Fountain House that covers such topics as how working affects bene- permanent, competitive jobs for a significant propor- Mary Guardino, Founder & Executive Director fits, consumer rights under the Americans with Dis- tion of participants, and encourages provider agencies Freedom From Fear abilities Act, and developing a disclosure plan. With to adopt evidence based practices to achieve employ- Mark D. Gustin, M.B.A., Senior Associate Director this information, consumers are empowered to make ment outcomes. Evidence also suggests that provid- Kings County Hospital Center employment decisions that best meet their needs and ers are expanding their definition of work readiness Mary Hanrahan, Director, Treatment Services to carry them out with or without provider support, and embracing competitive employment as a realistic New York Presbyterian Hospital - Payne Whitney Division according to their own choice. goal for a more varied group of consumers. Rhona Hetsrony, Executive Director Through the third program component, the Initial findings also begin to identify areas that North Shore LIJ Health System - Zucker Hillside Hospital Neighborhood Labor Market Strategy, providers se- pose challenges to effective service provision through

Joseph Lazar, Director, New York City Field Office cure work opportunities by establishing a network of the PBC approach. These include coordination of New York State Office of Mental Health on-going relationships with local employers. Net- service systems to resolve barriers to employment

Margaret E. Moran, C.S.W., VP of Admin Services work development helps providers gain an under- posed by nonvocational issues; staff stability to en- Behavioral Health Svcs. - St. Vincent’s Catholic Medical Centers standing of how to work with consumers to meet sure that consumers do not lose momentum toward

Evelyn J. Nieves, Ph.D., Executive Director employer needs and helps to increase employer un- their employment goals; effective benefits counseling Fordham-Tremont Community Mental Health Center derstanding of consumers as qualified workers. to help consumers overcome their hesitancy to secure Utilizing EAPs and Unions as natural supports: work because of fear around the impact of work on Evelyn Roberts, Ph.D., Executive Director NAMI - New York City Metro EAPs and Unions are largely untapped sources of their benefits; adequate job development efforts to support at the workplace, often poorly understood by provide a pool of possible employers with jobs that Phillip Saperia, Executive Director consumers and mental health providers alike. The will meet consumers’ interests and abilities; and post- Coalition of Voluntary Mental Health Agencies Workplace Center, funded in part by the New York placement supports that include accommodation at Alan B. Siskind, Ph.D., Executive Vice President & CEO Work Exchange of The Coalition of Voluntary Men- the workplace in order to promote retention. The Jewish Board of Family & Children’s Services tal Health Agencies, studied what EAPs and Unions PBC Demonstration will continue for two more Giselle Stolper, Executive Director currently do to help consumers in New York City years, supporting NYS OMH’s commitment to an Mental Health Association of New York City maintain work. EAPs are a benefit offered by many employment outcome and permitting further research Jonas Waizer, Ph.D., Chief Operating Officer employers to help their employees with personal of factors that best support successful employment F.E.G.S. Behavioral & Health Related Services problems that might interfere with job performance. for consumers. Joyce Wale, Assistant Vice President - Behavioral Health Results of a survey confirmed that EAPs provide a Enormous advances have been made toward open- New York City Health & Hospitals Corporation wide range of services that would be helpful to con- ing the world of work to consumers. These initia- Peter Yee, Assistant Executive Director sumers but typically the services are not targeted to, tives help identify approaches that are most effective Hamilton - Madison House or utilized by, them. and bridge the gap between research and practice.

committee in formation Unions understand the culture of the workplace For more information, please contact the Workplace and have unique knowledge and skill needed to clar- Center, (212) 854-5173. Page 32 Mental Health News - New York City Section: Summer 2003 Job Links Recovery and Employment Continues its Success The Journey Back

By Michele Fontaine, Coordinator tiated a close collaboration with By Minnie Berman, Program Manager rehabilitation and treatment services. Job Links Fountain House in June of 2001. and Julia Blydenburgh, FEGS After Julia accomplished her housing The idea was “born” from the Manhattan IPRT Consumer goal through the IPRT program, she knowledge that some of our clients felt free to explore what she wanted he award winning Job pursuing permanent and competitive ulia Blydenburgh, 56, can to achieve next and chose to pursue a Links supported employ- employment didn’t have enough of a look back and see how men- vocational goal. Surveys indicate that ment program of Project work history to do this successfully. tal illness--Bipolar Disorder, the majority of consumers with per- hospitalizations for suicidal Renewal, Inc. has been in The original plan was that referrals sistent mental illness ranked employ- Jdepressions, manic episodes and sub- Texistence since July of 1999. Our ment as an important personal goal. could be made to Fountain House’s mission is to provide vocational re- sequent homelessness caused the un- Since Julia entered the FEGS highly acclaimed transitional em- raveling of her life since July 2000. habilitation to homeless individuals Manhattan IPRT program in January ployment program with the under- This pleasant woman went from be- 2002, she has not only gained greater with a mental health background. standing that after one or two transi- ing a middle-class wage earner to stability in her mental health condi- Our ultimate goal is to mainstream tional employment experiences, the living in a shelter with frightening tion and found permanent housing these disenfranchised individuals by client would return to Job Links to uncertainty about her future. But but she also recently completed train- placing them in competitive, main- continue their pursuit of a competi- since 2002, when she began the ing as a Peer Advocate and is work- stream and permanent employment. tive job, this time better equipped to FEGS Manhattan Intensive Psychiat- ing part-time for the Mental Health We are currently in our fourth do so. At the same time, clients at ric Rehabilitation Treatment program Voter Empowerment Project. year, and we have made a total of 81 Fountain House that have been doing and Counseling Center, Julia has “My job is to visit mental health placements in various industries. ‘te’s’ for a long time and that have moved into a studio apartment in programs and educate consumers on Some of these industries have been been difficult to place competitively, midtown Manhattan and started a how important it is for them to vote business services, health services, would be referred to Job Links for part-time job as a Peer Advocate in on the issues they feel are important food services, maintenance, clerical, supported employment. Clients the Mental Health Voter Empower- for their lives. I help them to register entertainment, mailroom, security would uniquely remain on both ment Project. to vote and make them aware of their and retail. At the time of this writ- caseloads simultaneously during this Ms. Blydenburgh was a Brooklyn need to be heard and how their vote girl who was educated in Catholic ing, Job Links has served 184 home- collaborative effort benefiting by can make a difference. I have also schools. After high school she decided to apply for part-time office less individuals with a mental health two solid teams working closely to- worked as a secretary for Eastman work through FEGS Work Services history. gether towards the client’s voca- Job Links has had a number of Kodak. She gave birth to her only Supported Employment Placement tional health. son, Adam in 1975 and stayed out of success stories since we began in program.” Our goal for the future is compli- the work force for two and a half When asked why work is impor- 1999. Perhaps the greatest success cated and challenging. The current years to raise her son, living in a tant to her, Julia had much to say. has been mainstreaming challenging economic picture has had a big part quiet suburb in West Babylon, Long “I’m really looking forward to mak- clients into the competitive job mar- to play in all this as well as the long- Island and then Queens. Temporary ing money so that I can afford to buy ket. Most of our clients have had range impact of 9/11 on the city and office jobs afforded her the opportu- presents for Christmas like I used to numerous hurdles to cross over such on the overall mental health of our nity to spend the summers with her be able to give. I also would like to as the following: severe and persis- clients. Since we began in July of son. “When Adam turned 6, I got a go out to dinner and a movie. I feel tent mental health issues; numerous 1999, our clientele has needed more full-time permanent job at the IRS as like I’m ready to take on more re- hospitalizations for these mental intensive, vocational supports par- a tax preparer. Eventually, I had to sponsibility and learn more. The fa- health issues; major medical prob- ticularly in the long term. Meeting get a night job at the IRS so I could vorite part of a job for me is the lems as serious as HIV/AIDS, kid- programmatic goals for our funding be home to make sure my son got to learning process. I like to get into ney failure and cirrhosis of the liver; source has been difficult primarily school and did his homework. The every “corner” of what it takes to be little to no marketable skills; exten- from our third year to the present. job at the IRS meant I didn’t get good at the particular job I’m doing. sive learning disabilities and cogni- However despite all these odds, Job home until 2 a.m., and it was hurting It makes me feel so proud when I am working and responsible. I’m also tive dysfunction often undiagnosed Links remains optimistic and my marriage. My husband I never and left untreated. Perhaps Job saw each other. thinking of one day going back to strongly committed towards main- college to continue my education.” Links most challenging area has streaming one of the most disenfran- Over time things got worse; Julia been with the homeless piece. Up to and her husband separated. Julia be- Julia continues to attend the FEGS chised populations in the city via the Manhattan Intensive Psychiatric 50% of our clients upon entering the gan to be plagued by self-doubts and world of work. We hope to continue Treatment program (IPRT) part-time program were still living in the shel- felt increasingly stressed and dis- our collaboration with Fountain turbed at her job. “I was at work and where she has made many close ter system. The remainder had a House, which is doing quite well, I couldn’t make simple decisions. I friends and serves as a role model to recent homeless history as early as and we constantly look for other had to quit.” She became reclusive her peers. She volunteers as a peer 2-3 months prior to admission. At creative collaborations and ideas to and suicidal. A friend helped her to counselor on the IPRT Consumer the point of discharge from the pro- help “link” our clients to the overall get outpatient psychiatric treatment, Warm Line and tutors peers in read- gram, 36% were still in the shelter community. but the medications were not work- ing and writing skills toward GED system and had been for the duration ing. Her mood swings were severe preparation. of their vocational activity- a tough For information on Job Links, and by May 2001 she signed herself “FEGS has been extremely sup- venue to work out of when one is please contact Michele Fontaine, into St. Lukes-Roosevelt Hospital portive, and now that I’m back in the looking for competitive work in this Coordinator at 212-620-0340, ext. and was diagnosed as bipolar. After world I’d like to give back all the current market! 388 or by e-mail at mich- her discharge, she was referred to favors I’ve received. I’m finally get- In addition to this, Job Links ini- [email protected]. FEGS Manhattan IPRT and Clinic for ting my life back.”

Send a Message of Hope To Someone With Mental Illness With a Subscription to Mental Health News Visit Our Website www.mhnews.org For Details Mental Health News - New York City Section: Summer 2003 Page 33

FEGS L.I.F.E. Program: Building Careers in Human Services

Staff Writer work with each year, and I am able to Mental Health News see the progress that they are making in their jobs and how they are able to “Two Workers Tell their Stories” find successful employment after their internships. It gives me a great feel- ing of satisfaction to see their success ccording to Ed Brown, Di- and know that I am part of it. Most rector of the L.I.F.E. Pro- every person went on to employment gram at FEGS: “People in and/or school and improved their recovery have skills, abili- situation. I was able to support them ties,A and insight that are essential to in their process and assist them to transforming the "helping process." discover the strengths and resources They provide a powerful supplement in their recovery experiences." to a wide range of professional reha- Helene, now Supervisor at Careers bilitation, treatment, and recovery- in Human Services at FEGS/LIFE, oriented services." was diagnosed with Schizophrenia in Careers in Human Services, is part 1990. "I have come to realize, of the L.I.F.E. Program, a consumer- through my tenure with the LIFE Pro- run multi-service program of FEGS' gram that I am also an abuse survivor Long Island Division. Funded as a and experience periodic PTSD symp- Transitional Employment Program toms. The LIFE Program is a very through the New York State Office of important place to me. It is a place Mental Health's Special Vocational that has allowed me to grow, at my initiatives, CHS offers mental health own pace, as an individual as well as consumers paid work experience and an employee. When I first began teaches them how to work in the Hu- working at five hours a week that was man Service arena, using their own all I could handle. I slowly increased recovery as a tool to help others. my hours until I was working 15 In 1986, Sandra was diagnosed hours a week. with depression and anxiety; she also After a few years, when the posi- had brief psychotic episodes. Sandra's tion became open for a full-time cleri- story exemplifies the benefit of work cal worker, I felt ready to take that in a recovering person's life. step and I applied for it. In the two "The experiences I had growing up years I have worked in this capacity, I with my father were extremely abu- have grown a great deal. When the sive. My father was a Holocaust sur- position became open for the Coordi- vivor who became sadistic with his nator of Careers in Human Services, I family in all areas. I remember when felt confident in applying for it. The I had my first psychotic breakdown, I LIFE Program has been both suppor- was very fearful that my husband was tive and encouraging for me, a place Hitler, my father was Mengele, and where my recovery is primary. I feel that they were ready to kill me at any I have developed tremendously in this moment. Over the years psychotropic nurturing environment and I am very medicines and treatment have helped grateful to be successful as a full-time me a great deal. Working and reha- FEGS employee with the LIFE Pro- bilitation services have also helped gram." me to focus and concentrate better. The Transitional Employment Pro- "In the summer of 1998, I took a gram is unique because it pays people risk and became an IPRT Program in recovery while they transition from participant at FEGS. The structure, a difficult past to secure jobs in the social atmosphere, and groups that Human Services arena. FEGS Ca- were offered helped me to become reers in Human Services believes peo- more stable. Slowly my depression ple in recovery have unique expertise lifted. Helene, a friend and peer at the that can increase the success, skills, IPRT, started working part-time at the and resources they bring to Human LIFE Program, I decided to try too. I Services work. Careers in Human was hired as an Assistant Case Man- Services is a year-long Internship Pro- ager at Catholic Charities, escorting gram where people work ten hours a people to doctor's appointments, to week in a Human Service environ- Social Security for Medi- ments, receive training, and partici- caid/Medicare, for Food Stamps, pate in a weekly support group to clothes shopping, etc. In December share their successes and struggles in 1999 I was asked if I would like to be the workplace. a Job Coach. I could have stayed on The program outcomes are impres- at Catholic Charities, but I decided sive: 70% - 80% of all participants instead to stay with FEGS /LIFE be- transitioned to full or part-time work cause I still had anxiety and stress and in the Human Services, 10% - 20% found the LIFE environment helpful. pursued advanced educational goals, I liked the staff and colleagues, and I and 5% have transitioned to perma- had friends at LIFE. I decided to take nent part-time or full-time work in the position as Job Coach with Ca- other fields. After seven years, we reers in Human Services. believe this project has yielded tre- "Being a Job Coach is wonderful. mendous results, as Sandra and I have nine to twelve consumers to Helene's stories show. Page 34 Mental Health News - New York City Section: Summer 2003

Small Business Defies Challenging Economic Times

Staff Writer the first time) to develop career paths illness, physical disabilities, mental ployees associated with the com- Mental Health News in employment. Gina Genovese, retardation, felony records, drug and pany. The partnerships are built and Business Manager of the company, alcohol histories, as well as language maintained on a win-win objective. stated, “Many of our employees barriers. Over the past twelve Consumers get quality, real work hese are difficult times for work part-time and realize there may months, Phoenix has maintained a training and the opportunity to gain small businesses in New be times where their hours need to be 60% retention rate for individuals employment in Phoenix while the York City, and that means reduced from a particular site, but employed twelve months or longer. partner agencies these trainees are difficult times for individu- there are usually opportunities to The national average for the popula- associated with gain a committed alsT with disabilities to find employ- work on different sites or projects to tion to obtain and retain employment employment resource and a future ment. The war has the economy make the hours up.” “This flexibility is 10 to 15% based on employment experienced service vendor with an stalling after a brief increase in in- allows stability, diversity in skill de- research done by Anthony and extensive knowledge of mental vestor confidence at the beginning of velopment, and continuity of their Blanch, 1987; Salyers and Muesur, health organizations. One of the ar- the New Year. The jobless rate in employment, which increases their in press. “Because the majority of the eas of expertise for Phoenix is con- December, according to The New marketability when they choose to workforce has a history of disability sultation and services for agencies as York Times, increased by 1 percent leave Phoenix.” there is an understanding and sensi- they prepare for state and city regula- to 8.4 percent in NYC, exceeding the All about Team tivity, but there is not a compromise tory audits. “We can help agencies national average; the small business in the quality of our work.” Ms. assess the maintenance and janitorial has to create and remain flexible The success of Phoenix is meas- Genovese added, “Everyone is ex- needs for residential programs, day when designing and finding creative ured by the success of its employees. pected to do their job; we hire people treatment centers and residen- ways to increase and sustain revenue Over the last six years, Phoenix has not based on their past but based on tial/treatment facilities for the men- streams while adhering to opera- modeled the company after Japanese their personal commitment to work.” tally retarded/developmentally dis- tional fiscal control and vision. automobile manufacturing practices This ideology has served Phoenix abled. Our consultants can help Phoenix Recycling and Maintenance of the seventies like Honda and Toy- well. agencies plan service needs and costs Inc., a janitorial and renovation com- ota and technology corporations of How to Get into Phoenix for an entire year. Many times this pany located in Brooklyn has over the eighties like Microsoft and Ap- cost is lower than that of the compe- the last six years developed a solid ple. These companies learned from These concepts of teamwork and tition.” Ms. Genovese adds, “We business strategy based on competi- the fall of the American auto and assertive communication become understand the tight maintenance and tive service and pricing. Phoenix has iron ore industries during the oil cri- familiar to ICL consumers early on janitorial budgets agencies face so a solid track record with for-profit sis of the mid-seventies that cost ef- as they prepare for employment we work to develop a strategy that companies and not-for-profit mental fectiveness and company growth are training. Phoenix has partnered with makes sense and can save money health agencies and a consistent, reli- impacted positively when employees the agency’s Vocational and Reha- throughout the course of a year.” able and dedicated workforce of em- and management both share vested bilitative Services Department and Future Vision ployees with mental health disability interest and direct input in how prod- provides a 90-day, paid janitorial histories that has shown Phoenix ca- ucts/services are produced and pro- training internship. Individuals inter- Phoenix is faced with a number of pable of enduring this challenging vided. This team concept can im- ested in this field of work get the challenges as it looks to the future as economic trend as well as being a prove product quality and maintain it opportunity to work along side Phoe- a growing small business. The most company with growth potential. via company pride, employee devel- nix employees, learn the same tasks clear is the reality that Phoenix must Phoenix was founded in 1997 by opment investment and employee and skills and show their desire and increase the number of outside for- the Institute for Community, Inc. respect. In keeping with this team commitment. “Most of our employ- profit contracts to balance the num- (ICL) a not-for-profit agency that attitude, Phoenix utilizes “work clus- ees are selected from our internships ber of not-for-profit and ICL con- provides services and opportunities ters.” This means that two or three because we have a better sense of tracts it has. Currently Phoenix still to individuals with mental health, janitors work side by side with a what they can do.” Ms. Genovese provides a large amount of services physical and developmental disabili- cluster manager. They arrive as a states, “They also have a clearer un- to its parent agency. Ms Genovese, ties to improve their quality of life team, work as a team, and trouble derstanding of what we expect and “The more Phoenix can do outside of and participation in their communi- shoot as a team. Each employee car- the people they will be working with. ICL, the better understanding we ties as residents and contributors. ries his/her own weight, with the su- It helps them become comfortable as have of our competitiveness in the As a for-profit subsidiary of ICL, pervisor acting as a liaison between new workers and introduces them to market.” The other challenge is in- Phoenix is charged with realizing in the team and the client. Each cluster and reinforces the teamwork attitude creasing the complexity of work the daily practice one of the agency’s can provide services to two or more we work to instill in all of our em- company does and increasing the goals of providing real career oppor- facilities each day. Each supervisor ployees.” Paula Rivers, Director of tunities for individuals with disabili- is expected to participate as a full the Vocational Department, supports skill level of all employees. One of ties in the employment of their working member of these teams. So the notion that the arrangement sup- the possibilities for rapid growth po- choice. Phoenix began, as do most everyone is important to the goal, ports consumers. “The partnership tential for the company is to merge affirmative businesses, small; with and no one person is greater than the has been very successful; Phoenix is with an existing company, preferably 10 employees working part time and whole. The team attitude is pervasive major employer of ICL consumers. one that specializes in areas of floor three ICL contracts in providing resi- throughout Phoenix: Each individual Over the last five years the best re- care and installation or construction dential janitorial and recycling ser- worker has the ability to contact Ms. tention rate of all the businesses we and renovation. This type of merger vices. Phoenix learned early to un- Genovese on a daily basis with any place consumers in comes from this is always a risk because in many derstand its strengths, improve on and all concerns they may have. relationship. Our people do better as cases two different processes and weaknesses, and learn its customers’ This ability to communicate on all workers.” philosophies are combined, and time and patience are required to allow needs. Phoenix has grown to 45 full supervisory levels is important for Partnerships That Work and part-time employees, (95% indi- individuals with disabilities to feel collaboration and unity to find a sta- viduals with disabilities or employ- part of and not isolated from an ef- Phoenix has also developed a ble foundation. Ms. Genovese noted, ment barriers), over 30 contracts in fective band of contributing equals. number of partnerships with not-for- “Growth as a company and growth all five boroughs and over one mil- Over the past six years, Phoenix profit agencies throughout the six as an employer continues to be our lion dollars in revenue. More impor- has shown impressive numbers in years: Community Access, Center major focus. We hope to continue to tant to ICL and Phoenix than break- employee diversity, retention and for Urban Community Services, and provide our employees the best ca- ing even at the end of the year is the career advancement opportunities. Fast Track To Employment. These reer opportunities possible while de- commitment of not laying off em- The workforce consists of people partnerships have supported business livering quality services to our cli- ployees who are striving, (many for with severe and pervasive mental growth and the quality of the em- ents.” Mental Health News - New York City Section: Summer 2003 Page 35

Page 36 Mental Health News - New York City Section: Summer 2003

JBFCS Addresses Employment Needs for People with Mental Illness

Staff Writer Historically, services for the mentally ment but also assists in their psychiatric were hired to assist in locating commu- Mental Health News ill have primarily focused on the psychi- recovery. As part of their treatment pro- nity job resources and working with the atric needs of consumers. As individuals gram, consumers learn a wide range of Department of Labor. The job developer ne of the most prevalent and have moved from state institutions into office and vocational skills including the meets with clients in groups and in indi- misunderstood disabilities in community and self-sufficient living fundamentals of computers, working in a vidual sessions to measure each client’s the United States is mental over the past twenty-five years, more professional kitchen and office clerical work readiness. The peer counselors are O illness. Mental illness, in all and more social service programs incor- duties. The skills that clients develop in an essential part of the project, escorting its various forms, is more common than porated daily living and vocational skills the program help them manage stress in consumers to appointments and inter- cancer and diabetes combined with more into treatment and rehabilitation. all aspects of their lives, not just job- views, and conduct work readiness than five million Americans experienc- The Jewish Board of Family and related. groups. Each staff member at the Coney ing an acute episode at some point in Children’s Services (JBFCS) is a leader Dror Nir, Director of Bronx REAL, Island CSS Project addresses the issues their lives. One out of five families is in the development of programs for the explains the multi-layered goals of the of interviewing skills, resume writing affected by a severe mental illness, bipo- mentally ill, offering extensive psychiat- vocational training program. “Our pro- and proper appearance for interviews lar disorder, schizophrenia, or major ric treatment and rehabilitation programs gram,” he says, “helps people with se- and jobs. depression of a family member (Source: and a range of housing options. As treat- vere mental illness manage their illness JBFCS’ Coney Island CSS Project is NAMI) While significant progress has ment has evolved, so have JBFCS’ pro- in a way to find more meaning in their a success in many ways. Clients learn to been made in the fields of mental health grams, which today include innovative lives.” think beyond the limits imposed by their diagnosis and treatment, the challenges vocational education and training pro- In 2002, JBFCS introduced a program illnesses and consider different ways to of daily living continue to confront those grams. at their Coney Island CSS Project to help obtain skills and employment. Clients suffering with mental illness. As the The JBFCS Bronx REAL people with mental illness secure local set a variety of goals with their counsel- U.S. moved away from mass institution- (Rehabilitation and Education in the Art employment. The Coney Island CSS ors, such as how to prepare for work, alization of the mentally ill, the chal- of Living), provides a range of suppor- Project consists of four Continuing Day which can include obtaining interview lenge became how to help people living tive and rehabilitative services for adults Treatment (CDT ) Programs and three clothes or practicing typing. Accom- with mental illness become self- who have been diagnosed with a psychi- Mental Health Clinics which help con- plishing such a goal is a success in itself sufficient. Training for and securing atric illness. Bronx REAL clients are sumers who have serious and persistent and helps build the individual’s self- employment were key elements of this individuals with diverse backgrounds but mental illness. Approximately 400 cli- confidence. “With their newfound skills challenge. share a common struggle against the ents are helped each year through these and confidence, consumers are able to Those with a serious mental illness symptoms of mental illness. The clients programs. venture into areas of the community face the greatest barriers to employment of Bronx REAL are functioning at many The New York Work Exchange, un- where they would not have gone without and the highest degree of stigmatization different levels and are thus exposed to der the auspices of the Coalition of Vol- the vocational training and personal de- in the workplace. The unemployment several types of vocational training. untary Mental Health Agencies, devel- velopment programs “ said Bob Ferrer, rate for this population is reported to be Psychoeducational groups, support oped a program called the “Ways To Director of Coney Island CSS Project. as high as 70-90%. The majority of peo- groups, pre-vocational, internships and Work” which is being implemented at The agency’s ability to provide a ple with a mental illness want to work externships are vital in helping these the Coney Island CSS Project. The pro- wide range of vocational programs grew and recent surveys report that approxi- clients feel successful and satisfied with gram provides grant money for hiring out of their commitment to respond to mately 70% of those with significant their lives. and training staff and technical assis- the changing needs of mentally ill cli- psychiatric problems rank work as im- Begun in 1999, the vocational train- tance and equipment to prepare mentally ents. Today, vocational education and portant goal for themselves (Source: ing program at the Bronx REAL not only ill client for the workforce. placement are an essential part of treat- Matrix Research Institute, 1995). helps consumers prepare for employ- Peer counselors and a job developer ment and support services. Mental Health News - New York City Section: Summer 2003 Page 37 New York Works Success Story

By: Nicole LaCorte-Klein gathering research data and statistics that keep more of her SSI check each month. Account.” This was the next step in NY WORKS Program Coordinator show that coordination of both benefits One of the first questions she posed to achieving her goal of financial independ- advisement and employment counseling her Benefits Advisor was, “What will ence. Elena believed that the SSI re- he New York WORKS project, lends to individuals returning to and happen to my residence payments once source limit of $2,000 was not realistic if a Social Security Research and maintaining employment. The New my SSI check decreases?” one was aspiring to financial independ- Demonstration program funded York WORKS project is funded through At Libby House, a community resi- ence. An “Independence Ac- by the Social Security Admini- the end of 2003, however, a two-year dence, Elena’s SSI check was sent di- count” (IDA) would allow her to take Tstration, began in 1998. One of twelve extension has been requested. It is our rectly to an Entitlements Coordinator. advantage of an $8,000 savings-from- states funded, New York decided to de- hope that the approved Social Security She never saw or knew the amount of earnings limit. Each month Elena desig- sign its project for individuals with an work incentives will one day be avail- the original check and did not even know nated about $250 for direct deposit from Axis I diagnosis that receive SSI or eligi- able to ALL SSI recipients. The follow- the amount of her monthly rent. Elena earnings into her IDA. ble for 1619b, the Medicaid Program for ing story is reported from one of the told her Benefits Advisor that she A year after entering New York SSI recipients. Benefits Advisors working with a New wanted to be informed about rent and WORKS, Elena moved out of her sup- The unemployment rate for individu- York WORKS participant who is cur- benefits transactions so that she would portive housing residence and into her als with mental health disabilities is rently utilizing the New York WORKS be sufficiently knowledgeable to reach own apartment. With the money that she close to 90% yet individuals want to waivers. her future goal of independent living. has saved, a little over $2,000, she has return to work! The New York WORKS Elena was a reserved, rather passive, Elena and her Benefits Advisor purchased a bed, a couch, and plans to project addresses barriers to returning to 28 year-old woman when she enrolled in worked together each month calculating buy kitchen items for her new home. work such as health care benefits, fear of the New York WORKS project. She had her SSI check from her gross earnings, Without support from her Benefits Advi- losing your SSI check and obtaining recently begun a part-time job as Out- then figuring out how much she would sor and the knowledge that she has the training and job placement assistance. reach Worker for Project Liberty for need to pay to cover her rent. She IDA as a safety net, Elena stated that she The New York WORKS project has which her main responsibility was to learned that she could receive a maxi- would not have felt sufficiently confi- obtained special Social Security work assist people in need of mental health mum of $980 from SSI each month dent to move out of supportive housing. incentives that allow participants to and accompanying services. Working based on her living situation. Her rent/ Each month Elena continues to meet make and save more money without the twenty hours per week at $10 per hour, program fees totaled to $759, which left with her Benefits Advisor to review risk of losing their SSI or Medicaid she grossed about $800 per month. her a difference of $221 per month. This budgeting and provide documentation of Benefits. Working participants also Elena felt that the special rules and work was the calculation for the maximum her wages and account information. have the opportunity to save above the incentives she would be entitled to under amount of SSI. Since Elena was work- Elena has also recently applied for her $2,000 resource limit that SSI recipients New York WORKS would help her to ing, her SSI check usually came out to own computer through the Beaumont are subject to. Working closely with its become financially independent. She about $800 per month. Once the rent Foundation. Since her main goal has partners, New York WORKS offers also believed that the project offered the was subtracted, she was left with a sti- been accomplished, Elena has set a new Benefits Advisement and Employment necessary support system to assist her pend of $42. goal for herself: To always be proactive Coordination to enrollees residing in along the way. Elena immediately began After Elena understood how to instead of passive, to obtain full-time New York City and Erie County reporting her wages to her Benefits Ad- budget her income and SSI to figure out employment and to continue saving. (Buffalo) New York. The New York visor to take advantage of the New York her rent, her Benefits Advisor encour- For information please contact Ms. WORKS project is in the early stages of WORKS 3-for-4 waiver allowing her to aged Elena to open up an “Independence Klein at (212) 986-2966 x234.

Fordham-Tremont Community Mental Health Center

is a dynamic organization providing comprehensive outpatient mental health treatment through our multi-disciplinary teams. Our employees receive competitive salaries and an excellent benefit package. We currently have openings for the following:

PSYCHIATRIST – BC/BE (Adult or Adolescent)

CLINICAL SUPERVISOR - NYS CSW or Psych PHD (Adult Programs)

CLINICIANS - NYS CSW or Psych PHD (Adult & Children's Programs)

Spanish is a plus. Part-time positions available. We value diversity in the workplace.

Mail resume to: H.R. Dept., Fordham-Tremont CMHC 2021 Grand Concourse, Bronx, NY 10453 or FAX to: (718) 466-2115

FTCMHC is an affiliate of St. Barnabas Hospital and is an aa/eo employer.

Jewish Association for Services for the Aged Serving Older New Yorkers and Their Families Since 1968

● Licensed Geriatric Mental Health Clinics in the Bronx and Manhattan ● In-home Psychiatric Assessment and Treatment ● Case Management ● Social Adult Day Care and Caregiver Support ● Supportive Senior Center Style Programs for Individuals in Mental Health Treatment

JASA is committed to improving the quality of life of all older New Yorkers and supports individuals in their homes and communities with 81 programs located in NYC and Long Island For Further Information Call (212) 273-JASA Page 38 Mental Health News - New York City Section: Summer 2003 mha mental health association of new york city

Can Cognitive Remediation Services Improve Employment Outcomes for Individuals with Psychiatric Disabilities?

By Barbara A. Cohen mental illness. Vocational service pro- serious mental illness, schizophrenia in series of exercises to strengthen weak Director of Work Services viders for people with mental illnesses particular, on cognition. In their excel- muscles. Remediation interventions can MHA of New York City have long recognized that many of their lent handbook "Dealing with Cognitive be provided on an individual basis or in participants have difficulties paying at- Dysfunction Associated with Psychiatric a group. They may involve pencil and ocational services for indi- tention, remembering and processing Disabilities," Drs. Alice Medalia and paper, or the use of a computer. viduals with serious mental information, planning, problem-solving, Nadine Revheim define cognition as A typical computer-assisted cognitive illnesses are still relatively and dealing with novel situations. Ser- "…thinking skills, the intellectual skills remediation exercise designed to im- new. Most began by adapting vice providers viewed these problems as that allow you to perceive, acquire, un- prove attention might provide a com- Vservice models designed for the develop- secondary to other symptoms like psy- derstand and respond to information. puter simulation of a conveyer belt car- mentally disabled. They offered services chosis, as medication- related, or related This includes the abilities to pay atten- rying manufactured objects through a characterized by lengthy vocational as- to institutional stays. It was thought that tion, remember, process information, quality control checkpoint at a certain sessments, extensive, and sometimes they would go away or significantly im- solve problems, organize and reorganize speed. A participant would be required perpetual, pre-placement training, shel- prove when people recovered, when information, communicate and act upon to repeatedly identify flawed items on tered employment, or, not infrequently, their medication dosages could be low- information." the conveyer belt and remove them by no employment at all. With experience, ered or newer medications tried, or when The cognitive problems observed in clicking a mouse. An computer-assisted vocational service providers made modi- they became fully integrated into a com- individuals with mental illnesses are now exercise targeting attention and reaction fications, and new models emerged, such munity or an employment setting. recognized as primary symptoms of time might require a participant to stop a as Individualized Placement and Sup- Program administrators have re- mental illness, caused by the way mental moving clock hand at designated times. port, which emphasized integration with sponded to these issues in a variety of illnesses impact the brain’s ability to clinical services, job matching, on-the- ways. They've sought to place their par- receive and process information. The Integration of Cognitive Remediation job training, and competitive employ- ticipants in low- demand environments result is that many people with mental and Supported Employment Services: ment. As a result, program placement and matched them with entry-level jobs illnesses have impairments in cognitive A Research Project rates improved. that required repetitive work and mini- skills such as attention, memory, the mal decision-making. Such environ- ability to process and respond to infor- The Mental Health Association of Why is a 50 percent Placement Rate ments have been perceived as more suit- mation rapidly, to think critically, to New York City, Goodwill Industries, Considered Realistic? able, regardless of the educational back- plan, organize and problem-solve, and in and the Institute for Community Living grounds of the participants, given their some instances, to quickly coordinate are participating in a cognitive remedia- A 50 percent placement rate is widely observed limitations. They’ve provided eye-hand movements. Most, if not all of tion research project sponsored by the used as a standard for supported employ- job coaches, sought accommodations these skills, are important to successful New York Work Exchange and funded ment programs, appearing in perform- from employers, and taught an array of workplace functioning. It is now known by the New York State Office of Mental ance-based contracts and service quality compensatory strategies such as partial- that these cognitive skills can be im- Health. This research project, led by Dr. goals. Yet, why has the bar been set so izing tasks, note-taking, use of recording proved, facilitating the type of learning Susan McGurk, Assistant Professor, De- low? Why is it acceptable that 50 per- devices, alarms, checklists, and use of required in the workplace. partment of Psychiatry, at the Mount cent of the individuals that a program reminders to prioritize tasks and to per- Sinai School of Medicine, will help to serves don't become employed? And form sequential tasks. Sometimes these What Is Cognitive Remediation? determine whether combining cognitive for those that do get employed, why do strategies worked, quite often they didn't. remediation services with supported em- so many terminate employment in the Even after months on a job, partici- Cognitive rehabilitation services have ployment services will improve the abil- first six months? pants continued to have difficulty main- been widely used to treat the cognitive ity of individuals with mental illnesses to As any supported employment pro- taining attention and focus, organizing impairments of traumatic brain injury acquire and maintain employment. Spe- vider will tell you, the reasons are both and mobilizing themselves to get a task patients. In recent years, they have been cific cognitive skills targeted include complex and numerous. Some are sys- done, following instructions, absorbing made available to consumers of mental attention, memory, motor speed and temic - limited funding and the associ- information, mastering new tasks, and health services in a small number of in- problem solving, all believed to be ated difficulties of recruiting and retain- setting priorities. Frequently participants patient and outpatient facilities. Cogni- linked to successful employment out- ing qualified staff, the seemingly differ- could not increase the speed at which tive rehabilitation services may involve comes. Supported employment program ent goals of the vocational rehabilitation they were performing certain tasks. Al- remediation, which uses techniques to participants who choose to enroll in this and mental health treatment systems, in though employers tolerated slower work directly improve a targeted skill, com- research project will receive an initial which some clinicians are wary of work speeds in the first months of a job, they pensatory strategies which teach alter- neurocognitive assessment in the areas as a potential destabilizing factor. Other expected employees to increase their nate ways to perform a task, for example of attention, problem-solving, motor factors often cited include societal speed as they gained experience on the using mnemonic devices to compensate speed, learning and memory and reading stigma and the increasingly competitive job. And when that didn’t happen, termi- for poor memory, and adaptive ap- level. As a result of this assessment, par- job market, which requires people to be nations often resulted. In addition, some proaches which modify an individual's ticipants, employment program staff and more versatile and to work harder and people felt stuck in jobs they were ini- environment, for example, using a watch the research team will jointly develop longer. Individuals and their families tially happy with but then felt limited by. alarm to remind someone to take their priorities and goals for an individualized fear the loss of benefits, the potential for Yet they were fearful about moving on medication. service plan. A supported employment relapse, and stigma in the workplace. because they were already having diffi- Cognitive remediation interventions staff member, trained in cognitive reme- Lack of belief in self-efficacy and fear of culties in their current job. consist of an array of educational and diation techniques, will provide three failure also come into play. training techniques designed to improve computer-assisted cognitive remediation But another reason is that, until re- Mental Illness and Cognition a broad range of thinking skills. They sessions for forty-five minutes to an hour cently, vocational service providers have involve a series of highly specific exer- each week for approximately eight not been able to integrate into their pro- Over the past several years, numerous cises that help the brain to practice and weeks. Throughout the eight- week grams what the latest behavioral science articles have appeared in the behavioral strengthen certain cognitive skills, just as research tells us about cognition and science literature regarding the impact of physical therapy may involve a specific see Remediation on page 41 Mental Health News - New York City Section: Summer 2003 Page 39 Pathways to Housing Provides Consumer Choice: Housing First...Employment Next By Annora Karas MS, CRC model. Pathways to Housing, today, has Director, Vocational Services approximately 75 tenants employed as and Human Resources receptionist/clerical workers, mainte- nance workers, messengers, building repair people, nutritionist assistant, he right to a place to live, the medical clerk and activity leaders at the right to a job and the right to six ACT team office sites located in East choose them both are values and West Harlem, Queens, Brooklyn and that fuel the passions of crea- Westchester County. Cleaning/moving Ttive and dedicated Pathways to Housing teams have been developed to provide staff! Pathways staff work together with cleaning services for tenants who need their tenants—formerly homeless men and want a little extra help around the and women who have coexisting psychi- house or when a tenant moves in and out atric and substance abuse problems—to of an apartment. Driver assistants, stock develop equal opportunities and a life clerks and cashier/sales associates work with possibilities. Pathways to Housing at the Pathways Thrift Store in Jamaica Inc., a progressive, community based, Queens. All tenant workers are em- not for profit organization established in ployed at $5.25 hr. during an initial 1992 by its visionary leader Dr.Sam three-month introductory work period. Tsemberis, founded the agency on the Following a satisfactory evaluation of belief that the cure for homelessness is a work performance, at the end of this place to live. People living on the street time, a salary increase is awarded. Most cannot contemplate matters such as treat- tenant workers currently earn $6 hr.and Employee, Manager and Assistant Manager at the Thrift Store ment, recovery and employment when some who do more difficult and grueling they are waging a war for daily survival. work can earn up to $10-12 an hour. lic. Pathways Thrift Store can only pro- newspapers featuring discount coupon Pathways treats homelessness by giving Thrift Store: A Social Enterprise vide regularly scheduled part time em- campaigns (b) distribution of flyers by people apartments of their own. Once ployment for 9-12 workers and this job our own tenants on the sidewalks of Ja- housed, Pathways Assertive Community October 2002 heralded the opening of is highly coveted among the tenants. It is maica Avenue and (c) publicity derived Treatment (ACT) services, provided by a Pathways Thrift Store, our first Social certainly, we feel, an empowering em- from a human interest article about the team of professionals reach out and ac- Enterprise located in the busy shopping ployment opportunity. thrift store published in a local newspa- tively work with these tenants to address district of Jamaica, Queens at 92-10 Donors and shoppers alike quickly per. basic psychiatric, medical and human 147th Place, off Jamaica Avenue. The embraced Pathways Thrift Store! What From the very beginning Pathways needs, in a respectful and consumer Thrift Store is an entrepreneurial project have been some of the reasons for the Thrift Store has been responsive to the driven way, for as long as each tenant with a social purpose and is operated as early success that established this thrift needs of the community, providing a desires. Once housed safely, with basic a business that expects to be self- store as a credible social enterprise busi- place to shop that offers quality, gently human needs met and psychiatric and supporting and, indeed, generate a profit. ness? We believe that the overreaching used, personal and home furnishings at substance abuse problems addressed, Pathways Thrift Store offers quality reason has been that donors and custom- very low prices. A loyal customer fol- Pathways found that many of the tenants goods at very low prices to residents in ers, alike, have been treated equally with lowing was developed by giving the wanted to work. If the cure for homeless- surrounding communities. The store also respect and appreciation, a basic Path- community what it wants. Pathways did ness is a place to live then why is the provides both transitional employment ways practice that has governed all of not attempt to walk in the footprints of cure for unemployment not a job? Path- for tenants seeking to enter the main- our operations. This practice in concert other thrift stores e.g. developing inven- ways believes that it is! stream job market and primary employ- with a (1) focused donor solicitation tories of antiques or exclusive designer Vocational Initiatives ment for others. While providing a sup- plan, (2) defined advertising campaign clothing. Although valuable, costly and portive work environment, the manager and (3) customer driven merchandising, collectible merchandise has been do- Tenant Worker Program of the store, a person who has both a have been the building blocks of our nated and sold, the mainstay of Path- Driven by consumer choice, Path- business and clinical background, ex- early success. way’s business has been the sale of mer- ways modeled their first vocational ini- pects his staff who are tenant workers to Practical and operational keys to our chandise, at very low cost, that residents tiative, Pathways Tenant Worker Pro- report to work on time, fulfill the de- successful donor solicitations included of the surrounding communities need gram, on the housing first principle and mands of the job in a professional man- (a) developing a targeted mail campaign and want and can afford. We believe that gave tenants who wanted to work a job. ner, provide customer friendly service which is repeated at defined intervals, is the primary reason that the community Keeping with the housing first model, no and maintain appropriate work behav- (b) responding to donors requests for has shopped Pathways and have sent requirements for medication compliance, iors. Allowances are not made for sloppy pick up of large donations in a timely their friends and relatives to shop as abstinence or sobriety were established. work and abusive conduct. Accommoda- manner and (c) the small business, cus- well. tions are made for those who want to tomer friendly, respectful approach of When most vocational programs were Mainstream Competitive Employment administering interest inventories, evalu- work and need guidance and support to the thrift store employees. Pathways ating skills, abilities, motivation and realize this goal. Thrift Store. has been the fortunate re- Some of Pathways tenants are work- training people for employment, Path- Pathways Thrift Store is an attractive, cipient of increasingly large donations ing competitively in the community. ways’ tenants were earning better than clean, and welcoming place to work and from many new donors. Among mer- Often these are people who are highly minimum wage and performing neces- shop. The interior and windows are chandise donated, in addition to clothing, resourceful, have more recent work his- sary work in jobs which would have decorated seasonally; there are warm shoes, accessories, toys, books, home tories and have found their own jobs. been otherwise filled through traditional smiles to greet you and a dish full of furnishings, collectibles, and costume Some people are former tenant workers staff recruitment measures. Tenant candy to taste. Customers quickly learn jewelry, have been many unique items of who were, with support from the ACT worker jobs, when available, are sched- that the thrift store is not only a relaxing furniture and fur coats as well as artwork team, able to secure and maintain com- uled for 20hrs or less a week dependent and courteous place to shop, but also a and electronics. On any given day a full petitive employment. Many of them de- upon the position and tenant choice. Jobs place to visit, browse and engage em- house can be furnished and a large fam- veloped the confidence and gained the are often shared and per diem “back up ployees in friendly conversation. Path- ily clothed for all seasons at Pathways work experience to enter the competitive slots” have been created to allow tenants ways is educating the community about Thrift Store. No small accomplishment job market in the Pathways Tenant to “try” rather than commit. What Path- mental illness. Tenant workers are sell- for a 6- month-old fledgling business Worker Program. We are very proud of ways staff shortly discovered was (1) ing more than merchandise; they are with the heavy New York City competi- all of these people and seek to assist oth- nothing succeeds better than a “try” and “selling” their abilities and making tion for donors! ers in this goal –if they chose to do so. that most who tried succeeded (2) the friends with the community. As employ- Practical and operational keys of a Staff from Columbia University, School demand for jobs began to snowball; the ees, tenant workers are honing social defined advertising campaign that estab- of Social Work, Work Opportunities for motivation to work is often proportional skills, realizing self worth and develop- lished the thrift store as a visible com- Rewarding Careers (WORC) Program, is to the reality of getting a job, and (3) ing the social confidence (so often lost in munity presence included (a) creative peer success serves as a strong role the illness process) to relate to the pub- and repetitive advertising in many local see Pathways on page 44 Page 40 Mental Health News - New York City Section: Summer 2003

MENTAL HEALTH NEWS ~ SPRING 2003 PAGE 41

Recovered Therapist Treating Eating Disorders

Judy Scheel, Ph.D., Director conflict that caused the eating disorder derstanding of psychological theory is solid training, experience, and supervi- Center for Eating Disorder Recovery can identify these vulnerabilities and necessary because an eating disorder is sion should not be treating patients with triggers before the symptoms reappear, not a here-and-now disorder. It is based eating disorders. rguments for and against re- and seek appropriate help. Full recovery on historical or recent past conflicts, Another positive aspect that a recov- covered practitioners treating is possible. The psychological depths which are relived/relieved in the present ered therapist can offer her/his patient is patients with similar diagno- the practitioner plumbs during her/his through the symptoms. the first hand knowledge in conveying ses have appeared in the lit- recovery, the longer the recovery period, The major positive use of the recov- hope, in knowing that there is freedom in Aerature (Renfrew Perspectives 2002) and and the ability to listen to warning ered clinician as practitioner is that the recovery and in opening the window for are ripe topics for annual conferences. signs/triggers before symptoms develop recovered clinician is more aware of the a patient to see the possibilities in life. Often practitioners who are in recovery are keys to long-term recovery. subtle communication cues of the pa- from substance abuse (i.e. drug and alco- A potential risk, which perhaps super- tient. The eating disorder speaks vol- L. Hall (Full Lives, 1993) poignantly hol) treat substance abusers. Eating dis- cedes all others, is the practitioner who umes; the goal in recovery is to enable described her recovery this way. orders, however, are often not viewed limits her/his theoretical framework to a the patient to express verbally what s/he “Healing my abusive relationship with within a substance abuse model; there- ‘gut’ understanding of how to treat an has used the symptom to convey. The food forced me to look at every fear, fore, etiology and treatment of eating eating disorder, or utilizes an under- therapist can make pivotal links between every pain, every barrier that I had disorders is different, and some of the standing or techniques found to have the patient’s symptomatology as meta- erected to keep myself from living and issues regarding recovered practitioners been helpful to her/him during her/his phors and can link responses to the pa- loving fully. What’s more, the very act providing treatment are different as well. own recovery. The scope of this practi- tient’s unconscious motivations or un- of eating [normally] had become some- The risks for patients treated by indi- tioner’s practice will be narrowly de- derlying/unexpressed emotions or con- thing positive – an affirmation of my viduals recovered from Anorexia Ner- fined interpretations and understandings flicts. These critical connections gener- self-worth and growth as a person.” vosa, Bulimia or Binge Eating Disorder about the particular eating disorder diag- ally are identifiable by the well-trained, Judy Scheel, Ph.D. is the Director of can be potentially significant. Issues nosis learned during her/his own recov- well-versed professional whether the Center for Eating Disorder Recovery include identification with the patient, ery, whether the interpretations apply to professional has had a history of an eat- (CEDaR) with offices in Weschester and which can cloud professional judgment, the patient or not. (This is different than ing disorder or not. These connections, relapsing of the practitioner, and the over identification with the patient.) however, may be more readably accessi- Rockland County, NY, and is President practitioner’s lack of adequate training For instance, the treatment of eating ble to the recovered practitioner than the of Eating Disorder Foundation, Inc., or insufficient theoretical knowledge. disorders includes the use of the symp- moderately trained one or the one who (EDF), a not for profit which provides If the practitioner over identifies with tom as a metaphor for the individual’s has not had a history of an eating disor- prevention & educational programs the patient, the professional can lose conflicts. If the recovered clinician un- der. In either case, a practitioner without about eating disorders. her/his professional distance and regard derstands this – “fat is a metaphor for and respond to the patient as a mirror negative emotions that are projected on image of the practitioner. Eating disor- to the body,” for instance – but does not We’re Also on the Web: www.edrecoverycenter.org ders develop for a multitude of reasons understand the roots of the negative CEDaR is here to help those who struggle with eating and are as unique as the sufferer. A emotions or how the emotions came to disorders. Our compassionate staff is specifically trained practitioner who attempts to fit the pa- exist in the individual, the clinician may in treating eating disorders. We are happy to speak to tient into the practitioner’s own histori- be unable to make the connections to the doctor’s groups, organizations and hospitals about eating cal mold is as inappropriate as believing patient’s use of the symptom as a meta- disorder treatment. For those already under the care of a that all individuals who suffer with Ano- phor. In fact, if the clinician does not therapist, we can provide additional support through our rexia Nervosa are perfectionists and understand key psychological theories groups and nutritional care. Call to schedule a visit, or to rigid. (i.e. psychodynamic theories, including ask about our varied groups, including our new Intensive What happens if the eating disorder object relations/attachment theory or 10-Week Group for Individuals Suffering with Bulimia. practitioner relapses? Is s/he ‘fit’ to han- cognitive behavioral theory) the clinician dle the needs and treatment of the symp- can perform the tasks of recovery but tomatic or distressed patient? A practi- will miss the essence of the disorder and tioner who provides eating disorder the issues that brought the individual to Center for Eating Disorder Recovery, P.C.

treatment ought to have her/his own re- the disorder in the first place. Eating covery well integrated and be able to disorders develop in response to a his- 1075 Central Park Ave/Suite 412, Scarsdale • 914-472-4019 identify when/if s/he may be headed for tory of psychological unrest, which ex- 67 South Bedford Road, Mt. Kisco • 914-244-1904 relapse. A recovered practitioner who is isted long before the first symptoms of 99 Main Street, Nyack • 845-348-7660 undergoing stress or re-experiences the the eating disorder emerged. A full un-

Remediation from page 38 in areas of weakness. The Project’s out- comes will help to determine the bene- period, participants will be monitored fits and feasibility of making these ser- Fall 2003 Issue Theme: and periodically evaluated for skill im- vices available to supported employment Understanding and Treating Adolescent Depression provement. They will then be followed participants on a larger scale. for two years to determine how helpful these services are in reaching their em- Note: For more information on cognition Winter 2004 Issue Theme: ployment goals. and mental illness, read “Dealing with This research project brings impor- Cognitive Dysfunction Associated with The Crisis of Suicide in America tant, previously unavailable, resources to Psychiatric Disabilities, A handbook for supported employment participants, with families and friends of individuals with the potential to significantly improve psychiatric disorders”, written by Alice Spring 2004 Issue Theme: their employment outcomes. Neurocog- Medalia, Ph.D and Nadine Revheim, Eating Disorders: The Conflict Within nitive assessments, a costly service nor- Ph.D. and sponsored by the New York mally not available to participants, will State Office of Mental Health. This pub- provide insight into individuals’ cogni- lication is available on the New York Summer 2004 Issue Theme tive strengths and weaknesses. Com- State Office of Mental Health’s website puter-assisted cognitive remediation www.omh.state.ny.us/omhweb/ Understanding and Treating Sleep Disorders services will help individuals to improve resources Page 42 Mental Health News - Fairfield County Section: Summer 2003 Mental Health News - Fairfield County Section: Summer 2003 Page 43 Mental Health News Fairfield County Section Greenwich Danbury BRIDGEPORT Stamford Ridgefield Norwalk

Southwest Connecticut Mental Health System Forges Model for Employment Services

By Rebecca Allen, MSW, CCM cial independence, provides ing on their role in the workplace bility, desirable both for services Director of Rehabilitation Services meaningful activities and facili- and take pride in the duties for and spending, was already evident

tates constructive contributions to which they are responsible. They in practice at Bureau of Rehabili- society. A job provides a person tation Services, Fee for Service job plays a significant have worked through the initial a chance to learn and grow. For fear that employment will impact (FFS) funding mechanism. role in our lives. It is those with a mental illness, being FFS allows a consumer to re- one of the reasons we their entitlements and see that it is a part of the workforce increases all achievable. ceive only the services that he/she wake up in the morn- their self-esteem and contribution requires at a given time. As needs Aing, helps us put food on the ta- The understanding that occu- to the community in which they pational responsibility and ac- change, the services adjust in ble, and broadens our support sys- live. kind. For example, when a con- tem. This is no different if you countability promote personal The feedback from consumers growth, and the motivation that sumer is successful at a job and have a disability. Employment is requires minimal follow-along a vital component to recovery and seeking employment and those follows, are steps in the right di- already employed is unanimous. rection. However, the gap be- supports, the FFS allows that the Southwest Connecticut Men- funding to continue. Over the last tal Health System (SWCMHS) They want and need a paycheck tween motivation and achieve- and they need a job that matches ment is a large one and precisely year, Goodwill Industries and recognizes that importance and is Kennedy Center have been work- discovering ways to further pro- their interests. They recognize where the competitive employ- that it takes a good deal of effort ment strategies of SWCMHS can ing with SWCMHS in rolling out mote employment in the lives of the FFS program. By working people that we support. to find a job and they are ready to assist. In order to help consumers as they pursue their employment together with the FFS method of The daily grind provides many embark on that adventure. Those reimbursement, the Department of opportunities. It promotes finan- who are employed enjoy reflect- interests, SWCMHS contracts with local private non-profit or- Mental Health and Addiction Ser- vices is able to utilize the same Mental Health News Fairfield County Leadership Committee ganizations to provide support for them in competitive employment. amount of funding to serve more Chairman & Medical Editor people. The array of services includes ca- David Brizer, MD, Chairman reer exploration, job seeking and In the next fiscal year Norwalk Hospital Department of Psychiatry developing, job placement, and SWCMHS will continue to maxi- Committee Members job coaching supports. mize the flexibility of FFS. Addi- Two years ago, an interagency tionally, more efforts will be ap- OmiSade Ali, MA, Director Consumer Affairs William J. Hass PhD, Executive Vice President plied to the promotion of employ- Southwest Connecticut Mental Health System Family Services Woodfield collaboration of vocational pro- ment services through the educa- Orestes Arcuni, MD, Chairman Lynn Frederick Hawley, MA, Executive Director viders began meeting to assess the Danbury Hospital Department of Psychiatry Southwest Regional Mental Health Board tion of consumers, clinicians and employment services opportuni- Alan D. Barry PhD, Administrative Director Florence R. Kraut, LCSW, President & CEO ties in the community. Under the other natural support systems. Norwalk Hospital Department of Psychiatry Family & Children's Agency SWCMHS is the first local joint sponsorship of the Chief Ex- Alexander J. Berardi, LCSW, Executive Director Remi G. Kyek, Director Residential Services mental health authority in the KEYSTONE Mental Health Association of Connecticut ecutive Officer of SWCMHS and state that has implemented this Selma Buchsbaum, Member Charles Morgan, MD, Chairman the District Director of the Bureau Southwest Regional Mental Health Board Bridgeport Hospital Department of Psychiatry of Rehabilitation Services, the model for delivering long-term employment services. SWCMHS Douglas Bunnell, PhD, Director James M. Pisciotta, ACSW, CEO providers, which included con- The Renfrew Center of Connecticut Southwest Connecticut Mental Health System and all the providers cooperating tracted private non-profit organi- Joseph A. Deltito MD, Clinical Prof. Psychiatry Selby P. Ruggiero, LCSW, Associate Director zations, The Workplace, Vet- in this project are dedicated to & Behavioral Science, NY Medical College Clinical Services, New Learning Therapy Center eran’s Administration, etc., began seeing consumers involved in Steve Dougherty, Executive Director Marcie Schneider, MD, Director meaningful employment. Laurel House Greenwich Hospital Adolescent Medicine meeting to assess what was cur- rently being provided and what SWCMHS is a Local Mental Richard J. Frances MD, Medical Director Janet Z. Segal, CSW, Chief Operating Officer Silver Hill Hospital Four Winds Hospital needed to be improved. It was Health Authority of the Connecti-

Stephen P. Fahey, President & CEO Bruce Shapiro, MD, Chairman of Psychiatry concluded that there needed to be cut Department of Mental Health Hall-Brooke Behavioral Health Services Stamford Hospital a union of funded and required and Addiction Services. It covers

Susan Fredrick Thomas E. Smith, MD, Medical Director services based on individual need fourteen (14) cities and towns in Family Advocate Hall-Brooke Hospital that was flexible in nature and lower Fairfield County and serves Carla Gisolfi, Director Edward Spauster, PhD. President & CEO would provide the opportunity for nearly 5,000 different people an- Dr. R. E. Appleby School Based Health Centers LMG Programs more consumers to be employed nually. Margot O’Hara Hampson, APRN, Manager Wilfredo Torres, MSW, Site Director Greenwich Hospital Outpatient Center F.S. DuBois Center while remaining within the cur- Rebecca Allen may be rent budget allocation. That flexi- reached at (203) 551-7504. Page 44 Mental Health News - Fairfield County Section: Summer 2003 Searching for Meaning in Recovery

OmiSaide Ali, MA, LADC, CCS Fairfield County and surrounding areas. received on the units where they visit. Regional Director, Consumer Affairs She is going to visit with a woman strug- She proudly looks on as consumers who gling with symptoms related to bipolar might ordinarily be isolative, fearful and ental illness affects many disorder and an eating disorder. She uncommunicative with others come out individuals and families in understands. She has been there. of their rooms when the dogs enter the Connecticut. Although The young woman, L., a consumer of units. She is presently working on an- many forms of mental services in GBCMHC for over ten years, other program like the one in Bridgeport Millness involve genetic and biological is now in recovery from her psychiatric for the F.S. DuBois Center, one of the factors, recovery is possible. As we be- symptoms and wanted to give something programs of SWCMHS in the Region. gin to acknowledge that recovery can back to the facility and its staff who have In Conclusion and should be expected, we must also helped her gain the health she so desper- In an article entitled Recovering Our begin to recognize the important role ately wanted. She has found a way to do Sense of Value After Being Labeled by that can be played by people who have that through a program called PRO noted psychologist and consumer, Pat had first hand experiences with mental (Peers Reaching Out). PRO is a creation Deegan, Dr. Deegan writes of her feel- illness. These “consumers” of mental of the Office of Consumer Affairs of the ings of loneliness and isolation, even health care by virtue of their personal SWCMHS. In Greater Bridgeport, PRO when surrounded by well-intentioned knowledge can make powerful and utilizes consumers as human services doctors, nurses and mental health profes- meaningful contributions to the quest for trainees to work with consumers being sionals. For Pat, the power of recovery recovery for others afflicted by psychiat- treated on the Inpatient Units where one OmiSaide Ali is in someone saying, “I’ve been where ric disorders. third of consumers receiving services you are today. I know the feeling. I’m It only makes sense for those seeking emergency psychiatric have no family or friends with whom to care. Yale-New Haven Hospital, interact on a meaningful level. here to tell you there is a way out and The Recovery Model, a philosophy of that your life does not have to be about through the South Central Behavioral In the Stamford/Norwalk area, PRO service delivery being implemented in Health Network, has an active Peer En- accepts referrals from the private, not- being in mental institutions. I’m around the State of Connecticut through the De- gagement Program operating in the Psy- for-profit agencies in the service area. if you want to talk.” Pat further states partment of Mental Health and Addic- “the great thing is that I have learned chiatric Crisis Unit of its Emergency SWCMHS is the Local Mental Health tion Services, cites meaningful employ- Department at Yale. Hospital staff is Authority in Region I, Lower Fairfield that it is possible to live a whole and ment as playing a major role in the re- pleased with the level of competence of County. These referrals are for consum- healthy life and still have a disability.” covery process. Programs that are con- She explains that once a consumer be- the Peer Engagement staff and have ers who are either elderly or shut-ins sumer driven and that employ people in found consumer workers to be invalu- who are living with a mental illness and lieves that he or she is the illness with recovery create a win-win situation for able in assisting them with their work. benefit from the visits and companion- which he or she has been diagnosed, all involved. then there is nothing left of the person to A Team has been hired to replicate ship the PRO consumers provide. Southwest Connecticut Mental Health this highly successful program in the The PROs, by virtue of their status in fight for recovery. Consumers trained to System (SWCMHS), a community- Emergency Department of Norwalk recovery and their personal knowledge work with other consumers act as role based agency operated by the Depart- models and are examples of recovery for Hospital. In Lower Fairfield County, of mental illness, are uniquely qualified ment of Mental Health and Addiction consumers are hired as Human Service to do this work—work that requires sen- those still struggling. Services embraces the Recovery Model Trainees and a number of them have sitivity, empathy and the ability to be Consumer-run initiatives, peer sup- and has developed several programs that port groups and educational programs already become interested in obtaining firm and to set boundaries when neces- employ and train consumers as Human certificates through the MERGE pro- sary. such as the MERGE program make good Service Trainees. gram at Housatonic Community College. The consumers who receive services sense. They serve two purposes; to build a strong, well-trained workforce of per- PEP (Peer Engagement Program) MERGE provides training for men and from the PROs are impressed with the sons with tremendous insight into brain In the final stages of planning, the women desiring to enter the behavioral level of understanding and insight they health care field. have into the problems related to their chemistry disorders that can have devas- Peer Engagement Program is modeled tating consequences and they act as a after the Ellis Hospital program in Training for the Peer Engagement illnesses. The PROs who work with profoundly important component of the Schenectady, New York. The Ellis pro- Program will begin by late spring and other consumers are able to help them the staff will be ready to begin work by see the road to recovery while acknowl- process of recovery by providing mean- gram places consumers into the Emer- ingful activity for those living with and gency Department of its hospital to work early summer. It is hoped that teams edging their own accomplishments. in recovery from these disorders. with other consumers who need urgent will be established eventually in all hos- Pet Therapy pital emergency departments in Lower The consumers being trained to work evaluation and/or treatment of psychiat- A consumer in recovery leads a with other consumers serve as warm, ric symptoms. It has been demonstrated Fairfield County. woman with a dog on a leash onto the insightful and poignant examples of eve- that the presence of the consumer- PRO (Peers Reaching Out) elevator on the ground floor of rything that is good about the Recovery workers in the hospital emergency de- A young woman rides the elevator to GBCMHC. The dog is one of two regis- Model in the State of Connecticut. partment reduces the feelings of fear and the sixth floor of GBCMHC, the Greater tered Pet Therapy dogs that visit regu- OmiSaide Ali is the Regional Direc- anxiety common among consumers be- Bridgeport Community Mental Health larly on the inpatient units at GBCMHC. tor of the Office of Consumer Affairs for ing evaluated during emergency situa- Center, and rings the bell outside of a set Stevie and his owner, Virginia Steven- the Southwest Connecticut Mental tions. The Peer Engagement Staff work of heavy locked doors. The sixth floor is son and Mitzie and her owner, Dolores Health System, a program of the Depart- as part of the Emergency Department PICU I, or Psychiatric Intensive Care O’Neal, are part of a program run by P., ment of Mental Health and Addiction Team, offering an empathetic ear, talk- Unit, one of the inpatient units in the a consumer of services at GBCMHC. P. Services, State of Connecticut, and may ing with families, making phone calls, nine floor facility that serves the indi- keeps a schedule of the visits and makes be reached at either (203) 551-7434 or getting blankets or something to drink gent, uninsured and underinsured of certain that Stevie and Mitzie are well (203) 388-1593. Visit Mental Health News on the Internet at: www.mhnews.org Support the Vision of Mental Health News with a Charitable Contribution This Year

Pathways from page 39 Look for Pathway Career Clubs & Path- located consulting resources in the area structures that would, both, maintain the way Job Banks - -coming soon to an of floral design and the Florist industry. integrity of a social enterprise business currently providing training and techni- ACT Team site near you! Pathways Florist is expected to provide and invite private investors. Pathways, as cal assistance for twenty selected Path- employment in floral design, cashiering, always, will be brainstorming and plan- ways staff to enrich and expand their The Future –Pathways Florist sales, messenger, maintenance and tele- ning, along with our tenants, in a mean-

current vocational expertise, to develop marketing for 6-10 part time employees. ingful, problem solving, consumer Future plans include the development jobs in the local labor market and place Pathways needs fiscal support to realize driven and respectful manner to make of a second Social Enterprise business, and support tenants in competitive em- the establishment of this business and is the future, Pathways Florist, a reality. Pathways Florist, at a designated, vacant ployment. We are currently poised to actively pursuing funds through private store in East Harlem. The business plan hire an experienced job developer to foundations and corporations and re- For more information, contact Path- work with those tenants who want jobs. has been developed and Pathways has searching alternative legal business ways to Housing at (212) 289-0000. Mental Health News - Fairfield County Section: Summer 2003 Page 45

Getting To Work

By David Brizer, M.D., Chairman among Persons with Mental Illness: A Department of Psychiatry Review of the Literature, asks “Why are Norwalk Hospital we still sending people to pre-vocational programs?” Her intensive study of the rue fans of Fyodor evidence shows that “skills training and Dostoyevsky’s work may sheltered workshops don’t work. What know his more obscure novel, does is getting people right into the The House of the Dead. The work force.” The author of the NIMH- Tbook is a first person account of a mis- funded study states categorically that as erable decade spent in a Siberian gulag a society we “underestimate the skills under the harshest conditions known to among people with mental illness. man. The narrator, who describes some Many of those in treatment work at ex- of the lowest and most despicable inter- ecutive-level positions.” actions imaginable, declares that un- Dr. Lynn Warner (Rutgers Institute equivocally, beyond all questioning, for Health, Health Care Policy and Ag- stands one privation above all: depriv- ing Research), co-author of the paper, ing a man of his right to work. commented on the short-term political Dostoyevsky pictures in exquisite and perspective. “Given the current budget painful detail the kinds of work that situation, it’s uncertain what the inmates will do in order to stay sane. [political] priorities will be. The direc- The convicts will shovel snow from tion that social service supports is tak- daybreak to dusk. They will gladly if ing is more toward ad hoc supports than you will believe pile rocks one upon lasting ones.” The social scientist is another, take down the resulting mound, especially concerned about employment and at a site just a little further removed, prospects for the dually diagnosed start to build once again. All in the (addicted and mentally ill) patients. name of dignity. “What kind of jobs will be available for If you visit or have had the ill fortune them when employment rates are so of spending time in some of the more low?” she asked. deteriorated state hospitals, you are One point of view of course is that soon enough struck by the sheer weight having to work is itself a sure sign of of time and pointlessness in these mental illness. places. The residents of these living If you must work, though, the idea is mausoleums shamble up and down the to succeed to the point where your in- endless seeming corridors, scanning the come outstrips your doctor’s! walls, looking into the rooms, for dis- Towards that end, there are a number cards, for eye contact, for cigarette of employment resources worth know- butts. Many are functionally ‘lifers,’ ing about in Fairfield County. These committed to asylum ostensibly for agencies pull for the mentally ill, some treatment. Essentially they are ware- providing not only job guidance and housed, placed in custody for their pro- training, but a fuller range of services tection and ours, under the aegis of such as public entitlement access. The medical treatment. With too few excep- Human Services Council (Elaine Ander- tions, they do not work. son, Director) in Norwalk is one of One of the great ironies of mental these. Keystone House (Alex Berardi, health reform is that the so-called Director), also in Norwalk, provides ‘moral treatment’ of the insane— supervised housing as well as a host of substituting sobriquets and supportive essential support services for both sub- words for shackles—also brought about acute and chronic mentally ill patients. a politically correct distaste for ‘forcing’ Keystone Inc. (contact person Thais the patients to work. Gordon) offers employment opportuni- Rob a person of meaningful activity, ties for those only able to tolerate work- of the opportunity to be creative—even ing a few hours a week, including posi- if only with a hillock of jagged stones— tions with local merchants in house- and you have at the same time stripped cleaning, retail and landscaping. them of their dignity, their self-worth, The department of psychiatry at Nor- and even their humanity. walk Hospital has a large and highly Yes, medical treatment including effective team of case managers, many diagnosis, pharmacology, and humane of whom are registered nurses, who psychotherapy, have made significant actually go out into the field, making inroads in suffering. Yes, many more home visits, supervising medication people are able to live and function out- administration, and hooking patients up side the diocese of the sanatorium. with other kinds of social service func- Nonetheless, it is naïve to imagine that tions they need. QUIP (Search for weekly or even daily visits to the case Change) offers free computer training, manager, the social worker, the psychia- job assessment, resume assistance, on- trist, will remove the strata of social and line job searches and job coaching. financial and existential baggage that Laurel House in Stamford (Steven comes with being mentally ill. Dougherty, Director) supports clients Those who have or are still strug- through their clubhouse and consumer gling with psychiatric illness, unless advocacy programs. They also offer acutely or massively impaired by symp- some scholarships to Norwalk Commu- toms, need to spend their lives pursuing nity College. This is the short list of meaningful activity. They need to work. community resources. As we advocate Dr. Donna McAlpine, co-author of for more mental health dollars at every the study ‘Barrier to Employment level, the list will grow. Page 46 Mental Health News - Fairfield County Section: Summer 2003 Updates in Addiction Psychiatry and Pain Management Discussed at Silver Hill Hospital Seminar Staff Writer The group aspect, which functions a Mental Health News little like weight watchers, was very ef- fective. As members reported whether or he latest developments in Ad- not they had had alcohol or drugs in the diction Psychiatry and Pain past week, emphasis was placed upon Management were discussed by “sticking with the program, no matter five prominent experts in the what” for those who had lapsed. Tfield at a recent seminar at Silver Hill Research on Healing Through So- Hospital in New Canaan, a nationally cial and Spiritual Affiliation was pre- recognized behavioral health and sub- sented by Marc Galanter, M.D., Profes- stance abuse treatment facility. sor of Psychiatry, New York University In his introduction, Dr. Richard Fran- Medical Center. He noted some parallels ces, President and Medical Director of between the religious cults of the 1970’s Silver Hill Hospital, said, “The field of and the 12 step programs of Alcoholics Addiction Psychiatry has advanced tre- Anonymous. Both groups caused a re- mendously since the American Academy markable change of behavior in partici- of Addiction Psychiatry was established pants, the stabilization of people who From l to r: Barry Kerner, M.D., Physician-in-Chief, Silver Hill Hospital, J. David Haddox, D.D.S., M.D., Vice President Health Policy, Purdue Pharma, L.P., Roger D. Weiss, M.D., Associate Professor in 1985. There have also been many ad- were very depressed and a considerable of Psychiatry, Harvard Medical School, Richard J. Frances, M.D., President and Medical Director, vances in Pain Management.” decrease in anxiety and the use of alco- Silver Hill Hospital, Richard N. Rosenthal, M.D., Chairman of Psychiatry, St. Luke’s-Roosevelt “However, in cases of Dual Diagnosis hol or marijuana. Hospital Center, Marc Galanter, M.D., Professor of Psychiatry, New York University Medical Center (patients with both psychiatric disorders His studies indicated that what the and addiction to alcohol or drugs), we two groups had in common was commit- more than one.” ance is the state of adaptation through need to work on learning about the inter- ment to a higher power with a transcen- “The biggest problem, the lack of an exposure to a drug that induces changes action between addiction, psychiatric dent idea, and the social cohesiveness of integrated system, is due to a lack of in the body which diminish the drug’s problems and pain management. Addic- being part of a group. He said, “People attention and research in dual diagnosis, effect over time. When patients ask for tion can cause pain and alleviate pain for have very different ideas of what spiritu- and training of health care professionals. an increase of dosage there are many patients suffering from Dual Diagnosis. ality means. But today there is a trans- What’s often missed in a psychiatric different diagnoses possible other than We really need to get pharmaceutical formation of the sectarian religious diagnosis is the drug or alcohol disorder. addiction or diversion (intent to sell the companies to step up to the plate in de- views of the past to a more generic all Doctors must ask patients about alcohol drug). The effect of the drug could be veloping medications that help patients inclusive, ecumenical view. This is simi- or drug use and type and amount of diminished through tolerance, a progres- alleviate the problems of Dual Diagno- lar to AA which is all inclusive and more medication taken. Many primary care sion of the disease, development of a sis,” said Dr. Frances. powerful than most medical counseling. doctors believe that alcoholism cannot new disease, pain due to increased func- Integrated Group Therapy in the The idea of spirituality can be translated be treated effectively and so they ignore tional activity (over-exercising), or emo- treatment of substance abuse and into a movement like AA, and such 12 it Recovery is non-linear – like the stock tional distress. Physical dependence is mood disorders was discussed by Roger step programs are very important be- market, there are many ups and downs, not an addiction; sometimes the nervous Weiss, M.D., Associate Professor of cause people feel alienated from society but if patients stay with the treatment, system gets used to having a drug around Harvard Medical School and head of and this is an opportunity to become they recover over time. In integrated and suffers from withdrawal symptoms. McLean Hospital’s program in alcohol engaged in a group and share a commit- treatment for schizophrenia and sub- Doctors should get patients to define and substance. Patients with psychiatric ment. stance abuse, such as Silver Hill pro- expectations and explain that “making disorders are most likely to have sub- The importance of an integrated vides, the patients do better in retaining me feel better” is not making a patient stance abuse disorders, especially those system in treating psychosis and ad- sobriety, said Dr. Rosenthal.. feel like they did at 18. Doctors should with bi-polar diagnosis (manic depres- diction was stressed by Dr. Richard Recent Developments in Pharmaco- also explain the big difference between sive) and schizophrenia. Rosenthal, Chairman of Psychiatry at St. therapy (the use of drugs as medications patients taking pain killers on their own People with psychiatric problems are Luke’s Roosevelt Hospital and Professor in treating addiction and psychiatric dis- versus taking them in a very structured likely to self medicate, using drugs or of Psychiatry at Columbia University. orders) were described by Henry Kran- situation monitored by a doctor. alcohol to stimulate their level of hyper- He said, “There is a disconnect between zler, M.D., Professor of Psychiatry at the All people suffering from untreated mania, or to relieve symptoms of depres- mental health delivery systems and pro- University of Connecticut Health Center. addictions abuse drugs, but all people sion – as a means of escape because they fessional training programs. Clinicians He stressed the importance of matching who use drugs are not suffering from cannot tolerate anger or pain. Addiction are typically undereducated in one of the patients to treatment, saying, “Treatment untreated addiction. Pseudo addiction is can also cause or worsen psychiatric two domains: addiction and psychiatry. for alcohol dependence clearly works, a misinterpretation of the patient by the problems. Patients with both addiction and mental although not for everyone and maybe not doctor, caused by untreated pain which Recent research indicates that the illness are almost always under-treated. forever.” Twelve steps programs are the doctor thinks is inappropriate drug- most successful treatment is Integrated Although half the population never has most effective, especially if combined seeking behavior. Group Therapy which addresses both the any mental disorder in a lifetime, a ma- with motivational enhancement therapy New trends in pharmacology de- psychiatric and the addiction problems. jority of the people with disorders have or cognitive behavioral therapy. There scribed by Dr. Haddox include are medications designed for alcohol rehabilitation which either reduce the “developing a potent analgesic that is not pleasurable effects of drinking or cause an opiate, and efforts to design a drug unpleasant reactions if combined with a that cannot be tampered with to get a drink. There is a relationship between quick high – making it undesirable to the negative moods and drinking. We need population that would try to use it inap- to be creative in prescribing medications propriately.” with therapy. Medications are primarily In his concluding remarks, Dr. Fran- used in alcoholism treatment to prevent ces said, “If we don’t administer to our adverse effects of alcohol withdrawal, pain suffering patients, whether psycho- but some medications , such as solterex- logical or physical, we are not doing our one and antabuse show beneficial effects job.” in preventing relapse. There is a growing interest in producing these products. Silver Hill Hospital provides a full The Interface of Pain and Addic- range of behavioral health and sub- tion was discussed by David Haddox, stance abuse treatment for adults and D.D.S, M.D. and Vice President, Health adolescents, from inpatient and partial Policy for Purdue Pharma L.P. He said, hospital to halfway houses and outpa- “Pain Management becomes entwined tient programs. with addiction when controlled sub- For further information, call (203) stances are utilized in pain care. Toler- 966-3561, Ext. 2509. Mental Health News - Fairfield County Section: Summer 2003 Page 47 PAGE 48 MENTAL HEALTH NEWS ~ SUMMER 2003

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