MENTAL HEALTH NEWSTM YOUR TRUSTED SOURCE OF INFORMATION, EDUCATION, ADVOCACY AND RESOURCES SPRING 2005 FROM THE LOCAL, STATE, AND NATIONAL NEWS SCENE VOL. 7 NO. 2 Understanding And Treating Co-Occurring Disorders
Staff Writer 700,000 of these individuals have co-occurring disor- Mental Health News ders. More then two million youth under the age of 18 are arrested each year, half of whom will have contact with the juvenile justice system. A high percentage of ne in every five adults, or about 44 million these youth experience both serious mental health and Americans, experiences some type of mental substance-abuse problems. disorder every year. Moreover, five percent The presence of co-occurring mental and substance- O of Americans have a severe and persistent abuse disorders is complex, as the illnesses interact mental illness, such as schizophrenia and schizo- with, and exacerbate, one another. Emerging research affective disorders, major depression, and bipolar disor- suggests that mental disorders often precede substance der. According to the U.S. Surgeon General, the United abuse. It is also the case that alcohol abuse, drug abuse, States spent more than $99 billion for mental, addictive, and withdrawal can cause or worsen symptoms of men- and dementia disorders in 1996. Indirect costs of all tal illnesses. Substance use can also mask symptoms of mental illness in 1990, the most recent year for which mental illness, particularly when alcohol and drugs that estimates are available, totaled $79 billion dollars. are abused are used to “medicate” the mental illness. These costs include those associated with lost produc- care, including inpatient hospitalization. Many are at One disorder may interfere with an individual’s ability tivity and premature death. increased risk of homelessness and incarceration. to benefit from –– and participate in –– treatment for Many individuals with serious mental illnesses have Of an estimated 600,000 people who are homeless another disorder. Dysfunctional and maladaptive behav- a co-occurring substance-abuse disorder. Estimates sug- on any given day, approximately 25 to 30 percent have iors can be attributed to either disorder. Individuals with gest that up to seven million adults in this country have a mental illness. As many as one half of all people who untreated mental disorders are at increased risk for sub- a combination of at least one co-occurring mental health are homeless and have a serious mental illness also stance abuse. Similarly, individuals who abuse alcohol and substance-related disorder in any given year. have a substance-abuse disorder. The number of per- are at increased risk for experiencing mental disorders. In comparison to individuals with a primary mental or sons with co-occurring mental health and substance- While there is a good deal of variability from person substance abuse disorder, individuals with co-occurring abuse disorders who are also involved with the criminal to person and no single set of co-occurring disorders, disorders tend to be more symptomatic, have multiple justice system is reaching epidemic proportions. About health and social problems, and require more costly 10 million adults each year enter U.S. jails, about see Understanding on page 38 A Consumer’s Heroic Path To Recovery
By Lucee Martyn and Lucee’s story is, unfortunately, an all know that it’s not their fault, and that Patricia Maher-Brisen, APRN, BC too familiar refrain amongst consumers. turning to drugs and/or alcohol wasn’t NAMI-NYC Metro In at least half of all individuals with a the best way to go.” biochemical disorder, there exists addic- After her inpatient rehabilitation, Lu- tion and subsequent substance abuse. cee was sent to a halfway house for ike many consumers, Lucee The line between the two is very often women with addictions. “The supervisor Martyn has had a life marked blurred. there helped me realize my humanity, by the challenges of addiction. Without realizing her addiction, Lu- and that I could have a good life. I As a NAMI-New York City cee’s best friend told her that she was an stayed at the halfway house for three MetroL peer mentor, she is comfortable alcoholic and that she should go to Alco- years. We had to go to church every speaking about her dual struggles with holics Anonymous (A.A.). Then, at the Sunday. Although I was not a religious mental illness and substance abuse. “I age of 19, she went to Smithers Institute person, and began going reluctantly, I started drinking heavily at the age of (now The Addictions Institute of New learned how to develop a relationship 13,” she says. “I started drinking to for- York), where she was their youngest with God, as I understood him to be.” get about my life, which included two patient. “I was told that I would never Eventually, this relationship brought her years of repeated sexual assault by make it in a New York City rehab. So great comfort, “because it was on my someone close to my family. I thought with the clothes on my back, I was sent terms.” Grateful for the strength her drinking was harmless, but eventually it to Rhode Island, where I stayed at a re- newfound spirituality gave her, Lucee became an addiction. Eventually, I drank hab center for two years.” sought to become a minister. She soon everyday, because I would shake without Lucee Martyn It was there she realized that she did- enrolled in a ministry school where she the alcohol. At the age of 16, I was hos- n’t want to drink anymore, but knew that was able to counsel people about sub- pitalized for six months due to ‘major would hear, and that the voices would- the road to recovery would be long and stance abuse. “Two months before my depression with psychotic features.’ I n’t stop unless the drinking did. But painful. “I was determined to fight, ordination, however, I was asked to continued to drink in the hospital by once I was back home, I knew I would because I knew that if I didn’t I would leave, because I became sick again with having visitors smuggle it in for me. have to face my rapist, and because die. I wanted to live because I wanted major depression and the voices were The hospital staff told me that the al- drinking was my known escape, I used to help other teenagers that had experi- cohol was intensifying the voices I it to help me cope.” enced sexual assault, and to let them see Heroic Path on page 20
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PAGE 2 MENTAL HEALTH NEWS ~ SPRING 2005 Mental Health News Advisory Council
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MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 3 Table Of Contents
From The Publisher Cover Story: Co-Occurring Disorders
4 About Trains And Teddy Bears 1 Understanding And Treating Co-Occurring Disorders 1 A Consumer’s Heroic Path To Recovery Letter To The Publisher 18 Finding Treatment For Co-Occurring Disorders 5 Psychiatric Diagnosis: The Lesson Of Yogi’s Pizza 25 Integrating Treatments At MHA Of Westchester
Feature Story 25 DCMH Helps Individuals With Co-Occurring Disorders
6 Tragic Tsunamis Create A Mental Health Disaster 29 Turning Patchwork Services Into Cohesive Whole 29 A Plan For Integrated Treatment Mental Health NewsDesk 31 Best Practice In A Dual Recovery Program 8 Study Shows Women Need Integrated Counseling 32 Harm Reduction vs. Abstinence Approaches 8 Morahan Appointed Chair Of Prestigious Committee 34 Everyone Deserves Treatment 8 Lepore New Vice President Behavioral Health 37 Addressing Both Mental Health And Substance Abuse 9 MHA-NYC Launches Suicide Prevention Lifeline 9 Mutant Gene Linked To Treatment Resistant Depression In The News At Mental Health News
28 Salud Mental Premier Inspires Latino Community Columns 28 Campaign 2004 Raises Vital Funds 10 Point Of View: Key To Restructuring Long-Term Care 11 A Voice Of Sanity: A Deadly Game of Ping Pong Four Winds Hospital Spring Supplement
12 NYSPA Report: The Medication Warning Debate 21 Lessening Anger In Our Youth 13 Mental Health Lawyer: The Rights Of Parents 22 Spring Calendar Of Events At Four Winds
14 NARSAD Report: Multiple Diagnoses In Children many thanks to our readers, contributing writers 16 NAMI-NYS Corner: Legislative And Budget Priorities and to our many advertisers for their support 17 MHA-NYS Connection: Nix On Preferred Drug Program without which this publication would not be possible
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Our office hours are from 9-5 (M-F) at (914) 948-6699 David Brizer, MD, Addiction Recovery Service Andrea Kocsis, CSW, Executive Director New York Presbyterian Hospital Human Development Services of Westchester Our e-mail address is [email protected] Please visit our website Peter C. Campanelli, PsyD, President & CEO Peg E. Moran, CSW, VP, Administrative Services Institute for Community Living Behavioral Health - St. Vincent Catholic Medical Centers
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PAGE 4 MENTAL HEALTH NEWS ~ SPRING 2005 From The Publisher: Two Commentaries One About Trains and One About Teddy Bears
By Ira H. Minot, CSW, Founder According to a 2003 National Insti- Well that’s just what happened this it is sold out. She said the company is and Publisher, Mental Health News tute of Mental Health report, risk factors Valentine’s Day, thanks to the Vermont “truly sorry if we hurt anybody with this for attempted suicide in adults include Teddy Bear (VTB) Company’s “Crazy bear” but added that freedom of expres- depression, alcohol abuse, cocaine use, for You Bear.” The 15-inch bear is sion was at stake. She said the bear got and separation or divorce. Risk factors dressed in a straitjacket and comes com- “the highest favorability rating” from for attempted suicide in youth include plete with commitment papers that in- customers, and that she consulted with depression, alcohol or other drug use cludes the symptoms “can't eat, can't the Vermont Teddy Bear board of direc- disorder, physical or sexual abuse, and sleep, my heart's racing.” tors and the radio stations that advertise disruptive behavior. As with people who the bear before deciding to keep it. die by suicide, many people who make “We're not in a position to be told what serious suicide attempts also have co- we can and cannot sell,” she said. occurring mental or substance abuse So, Robert consulted with her board disorders — the theme in this issue of (who want her to sell bears), and she Mental Health News. consulted with radio stations that adver- If we lived in a society that placed a tise the bear (for money). So why higher premium on mental health care should we still be upset? We all know and mental health education, then per- that radio stations are never insensitive haps Alvarez, and thousands of others about disabilities or emotional topics. with symptoms of suicidal behavior, Only a few weeks ago, a local New York would be in treatment and out of harms City radio show kept airing a parody way. But we do not live in a society that song about Tsunami victims, and another places a high premium on understanding area station made fun of the Deputy mental illness or that provides compre- Governor of New Jersey’s wife who hensive mental health care. suffered from depression. Mental Health Parity legislation, Thanks to weeks of advocacy and which would oblige health insurance outcries, VTB finally agreed to stop sell- Ira H. Minot, CSW companies to cover mental health treat- ing their straitjacketed bear on Thursday, ment at the same level as other medical February 3rd. But being the marketing illnesses, still hasn’t become a national gurus that they are, upon visiting the priority. Tragically, funding cuts to men- VTB website (February 5th) I found that Train Tragedy: tal health systems across the nation are a Crazy About You Bear the bear is still there in full regalia only regular occurrence. In fact, every year saying that it is now “Sold Out.” What a Taking The Nations Pulse we see programs for medication cover- Protest over the bear came quickly clever spin by VTB. On Suicide and Mental Illness age, supportive housing, child, adult and from The National Alliance for Mentally Thankfully, this campaign has been a eldercare face the budgetary chopping Ill (NAMI), whose “Stigma-buster’s” big win for the power of advocacy by block. This leaves thousands of people, campaign regularly monitors insensitivi- many in the mental health community. he scene of a recent deadly every day, in every major city and small ties toward people with mental illness in But in the final analysis this entire train derailment in Glendale, town in the United States, suffering from the media and corporate world. Calling flap is greater than a soul-less company California lit up the newspa- untreated mental illness. It’s no wonder the bear “A Real Heartbreaker,” NAMI trying to make a buck at the expense of pers and television news chan- that eventually someone with an un- Vermont raised a protest, which received people with mental illness. It’s about a nels.T The tragic loss of 11 commuters treated mental illness, like Juan Alvarez, national media coverage, rightly claim- nation that fails to recognize people suf- and injury to over 200 occurred when will attempt suicide. ing that from a company associated with fering from mental illness with the same Juan Alvarez, intent on suicide, parked We are making some strides in the caring and comfort, the bear came as a respect and compassion as people with his car on the tracks. With the train ap- direction of becoming a more sensitive distressing surprise. other serious medical illnesses and proaching, Alvarez changed his mind nation, as evidenced by initiatives like VTB did issue an apology, stating physical disabilities. and left the vehicle — saving his own the National Suicide Prevention Lifeline they did not intent to offend anyone and It comes down to the fact that we as a life — but now facing the consequences at 1-800-273-TALK, which is being that they recognized the serious nature of community must continue fighting to of taking the lives of others. spearheaded by the Mental Health Asso- mental illness. However, even after a call the nation’s attention to our illness’ We never heard of Juan Alvarez be- ciation of NYC (see page 9). But much January 22 article in The New York importance and seriousness. Just be- fore this incident and, had he tried (or more needs to be done because, as a Times, which called for the company’s cause mental illnesses do not show up on succeeded) in taking his life in a less whole, our nation continues to stigmatize CEO to resign from the board of trustees X-rays or cat scans, and just because public manner, I suspect we never people with mental illness, as revealed in of the largest hospital in the state of Ver- having depression or bipolar disease would. However, Juan Alvarez repre- my second commentary below. mont, VTB continued to sell the bear on doesn’t require us to use crutches, is no sents a stunning national statistic, which its Web site. reason why people who suffer from this warrants the attention given to the derail- According to the Associated Press, debilitating disease should be discrimi- ment, but never gets it. Vermont Teddy Bear: (January 29), Vermont Teddy Bear Co. nated against. The statistics for suicide are stagger- President Elisabeth Robert said, “The We must speak out against continual ing, yet for some reason they are not Spreading Stigma - Not Love bear is meant as a funny Valentine’s Day yearly funding cuts to already strained newsworthy. Consider that suicide is the This Valentine’s Day greeting and has been popular among mental health community services. We 11th leading cause of death in the United customers. We made a very difficult must elect government officials and de- States, and among the young, it is the decision not to withdraw it from the mar- cision makers who support our mental 3rd leading cause of death. In 2001, ould you be happy to ket,” she said. “I listened to customers, health agenda at the local, state and na- 30,622 Americans completed suicide — send or receive a teddy from a lot of feedback from our employ- tional level — not those who simply buy one every seventeen minutes; eighty per bear that was dressed in ees. These people are Vermonters who their way into office. day. Seventy-five percent more Ameri- a straightjacket? Would really don't like to be told what to do.” We wish to thank you for your W Mental health advocates have called for continued support and readership, cans die by suicide each year than by you—knowing that the straightjacket homicide. Moreover, for every com- represents a perpetuated stereotype of the company to stop selling the bear, which makes Mental Health News an pleted suicide in the U.S., there are five a false image linking mental illness calling it “tasteless,” and saying it stig- important tool in the fight against people hospitalized each year for a non- with violent behavior? Of course not. matized people with mental illness. Gov- stigma and discrimination towards fatal attempt, and an estimated 22 emer- And if a national company hawked ernor Jim Douglas called the bear insen- people with mental illness. gency department visits for less lethal such an item and you, or a friend, or a sitive and inappropriate. Robert said the Please continue to send us your com- self-harming behaviors — totaling al- member of your family suffered from a company had planned the bear as a one- ments and suggestions by e-mail to most 700,000 hospital admissions annu- mental illness, wouldn’t you be time offering for Valentine's Day and [email protected]. ally for non-fatal suicidal behaviors. shocked and outraged? that it will continue selling the bear until Have a great spring! □
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 5 Editorial To The Publisher
The State of into 4 disorders or 40,000 disorders; number of categories used, but to re- however, there is a balance struck in the member the heterogeneity of the pres- Psychiatric Diagnoses Regarding DSM-IV system where there is an at- entations encountered within a given Co-Morbidity: tempt to make meaningful categories category — like all the different breeds with the shared features, and done in of dogs within the category of canine. The Lesson of Yogi’s Pizza such a way that clinicians and research- In co-morbid medical conditions, it is ers can make reasonable predictions re- usually indicated to treat each condi- By Joseph A. Deltito, MD garding the course of these disorders, tion optimally and vigorously. When treated or untreated. In psychiatry, for the apparent co-morbidity is between the most part, we lack the diagnostic two psychiatric conditions it often is here exists a logic used in mak- tests used in other fields of medicine that more useful to conceptualize the con- ing psychiatric diagnoses that are required to both present and confirm dition as a variant of a parent disorder is not always obvious to pa- specific diagnoses. A diagnosis of ane- that should be treated vigorously, tients or their families. In the mia, diabetes or leukemia can be quickly which will then lead the “associated” UnitedT States and many other countries, established by blood tests performed in phenomena to also improve. We know the foremost recognized system for mak- the laboratory. It is leukemia because we that people with schizophrenia will ing psychiatric diagnoses is through the can see the leukemia in the blood cells also, at times, have mood symptoms of use of the “Diagnostic and Statistical retrieved from the afflicted individual. depression. We usually do not make a Manual of Mental Disorders: Fourth Since we do not have this type of hard separate diagnosis of depression and Edition” (The DSM-IV). The goals of evidence in psychiatry, we must rely on then treat with antidepressant medica- this system of classification are to pro- symptoms and descriptions, which, after tions, but we treat the underlying vide (1) clear and unambiguous defini- time, begin to present as recognized syn- Joseph A. Deltito, MD schizophrenia more vigorously with tions of psychiatric disorders such that dromes for the purpose of correct psy- pharmacologic treatments aimed at that there would be agreement between clini- chiatric diagnoses. monia, or thyroid disease plus osteopo- condition. In patients with depression cians and researchers as to how to clas- A common misconception regarding rosis, the course of the disease and the we often encounter features of anxiety. sify disorders, and (2) there would be an the use of the DSM-IV system is that it treatments chosen may be altered. Simi- Once again, we usually do not concep- enhanced knowledge of the nature of classifies individuals (e.g., patients, sub- larly, co-morbidity of psychiatric disease tualize these individuals as having these disorders. jects, people). It does not attempt to clas- with other medical conditions may pose both an anxiety disorder and depres- Technically, the ability of a system to sify people, but the disorders that people the same considerations, such as in sion, but realize some individuals with be agreed upon by all of those using it is have. For example, it does not attempt to someone with bipolar disorder who also depression may have prominent symp- called “reliability,” and the fact that a describe the difference between Suzie has cancer, or someone with schizophre- toms of anxiety as well. The treatment system captures the truth about how and Jane, but the difference between nia who also has coronary artery disease. of such individuals is usually the more these disorders are manifested is called schizophrenia and bipolar disorder. In When we talk about co-occurring or vigorous treatment of depression, not “validity.” An ideal system of classifica- the DSM-IV system, there is no assump- co-morbid psychiatric conditions, we the current treatment for depression tion has a high degree of both reliability tion that each diagnostic entity is abso- enter into a realm that is much more with a treatment for anxiety added. and validity. A common error that is lutely distinct from other disorders with complex and not necessarily so obvi- Certainly there may be times to con- often made is to assume that, because no overlap. There is also no assumption ous as to its significance. For example, ceptualize a patient as suffering from there is high “reliability,” then there that all people diagnosed with a given we might entertain that a given indi- two distinctly different psychiatric must be high “validity.” Over the course condition share all the same features as vidual might suffer from bipolar disor- disorders afflicting them simultane- of Western Civilization, there was strong each other. It should be recognized that der plus attention deficit disorder. ously. Having anorexia nervosa does agreement among the scholars of the two people given the same diagnosis What is not clear is that it truly makes not “protect” someone from having co- time that the world was flat, not round: may not share many similar features, just sense to postulate that two different existing obsessive-compulsive disorder they had good “reliability” but terrible that they share some key features. We disorders co-exist, or are we dealing (OCD), yet in most cases it makes “validity.” Similarly, there have been may classify both a Chihuahua and a with a variant of bipolar disorder with sense to recognize that individuals ways of conceptualizing psychiatric dis- Great Dane as canines (dogs), but we features of sustained and significant with anorexia nervosa regularly have orders in the distant or recent past where also recognize how much they differ problems with attention. In this case, a features of OCD. The point here is that there was great agreement among clini- physically. Classifying canines by differ- conceptualization whether we are deal- the way we think about psychiatric cians, which have proven simply not to ent breeds can be important for a variety ing with true co-morbidity or merely diagnoses is “utilitarian,” and very be true, and which currently has little or of reasons, such as choosing the family another variant of bipolar disorder is often depends on what practical pur- no validity. For example, 40 years ago, pet, or choosing a dog to do certain jobs, crucial, for it may influence the way a pose it serves. In psychiatry, as op- many professionals agreed that the cause like being a guard dog or a hunting com- clinician decides to treat the patient. I posed to internal medicine, apparent of several major psychiatric disorders, panion. At other times, any type of dog believe most of what is called co- co-morbidity or co-occurrence does such as schizophrenia, was the result of is all that’s needed for the purpose of morbidity or co-occurring disorders not have the same significance and “poor mothering.” Obviously, this con- studying parasitic diseases that affect when involving two or more psychiat- meaning. cept has not stood the test of time. All of dogs. Like Yogi’s Pizza, sub- ric conditions reveals primarily an arti- Yogi was not very hungry that eve- the evidence gathered by researchers classification into many or few catego- fact in the way in which we classify ning, so he chose to eat six, not eight, regarding the course of schizophrenia ries is arbitrarily determined based on disorders, as opposed to truly repre- slices of pizza. The number of separate has certainly failed to support this posi- the given need we wish to serve. senting the pathophysiologic existence diagnostic categories we use in psy- tion. Therefore, a core concept regarding In recent years, there has been much of two or more separate and distinct chiatry is simply dependent on which the DSM-IV system is that it changes as attention focused on individuals with disorders. We come back to Yogi’s purpose it serves; the categories are we gather information through valid psychiatric diseases who may suffer Pizza! If we have a limited number of arbitrary, and serve for the purpose of research, which over time should in- from multiple psychiatric disorders con- psychiatric categories, we will de- enhanced understanding of psychiatric crease the reliability and validity of this temporaneously. When psychiatric disor- scribe the psychopathology in an indi- illness and its treatment. The concept system. ders occur in individuals who are also vidual by using more than one diag- of co-morbidity in psychiatry is differ- There is a story told about Yogi afflicted with addictions to alcohol or nostic category. If we have an expan- ent than it is in other disciplines of Berra, the famous baseball player, that illegal substances, the term “dual diag- sive number of categories, we can de- medicine. he once went into a pizzeria and ordered noses” is used. When one psychiatric scribe this individual by using subsets a “large pie.” He was asked if he wanted disorder co-exists in a person having of the larger categories. In this theo- Joseph A. Deltito, M.D. is a Clini- it sliced into six pieces or eight. He re- other psychiatric or medical disorders, retical condition, we might have a cal Professor of Psychiatry at New plied, “I am not that hungry. Cut it into the term “co-morbidity” is used. The category of “bipolar disorder with fea- York Medical College and has an of- six.” So, much like Yogi’s pizza, the concept of co-morbidity in medicine is tures of sustained problems with focus fice practice for psychopharmacologi- amount of pieces that we cut all of the an important one, as the existence of and attention.” Yogi’s Pizza can be cal consultations and forensic psychia- psychiatric diagnoses into is an arbitrary multiple disorders in one individual may divided into one, two or thousands of try in Greenwich, Connecticut. He is a decision, which is based on the practical alter the course of that disorder or slices. Its division is arbitrary and frequent contributor to Court TV. Dr. issues that we need to serve. We could change the way we might treat it. There- serves the purposes of the one doing Deltito serves on the Clinical Advisory divide all of the psychiatric conditions fore, if someone has diabetes plus pneu- the division. It makes sense to limit the Board of Mental Health News. □
PAGE 6 MENTAL HEALTH NEWS ~ SPRING 2005 Tragic Tsunamis Create A Mental Health Disaster
By Cynthia R. Pfeffer, MD families to support those relatives in However, there are significant differ- Professor of Psychiatry need. Such families must depend on ences between the aftermath of the tsu- Director, Childhood Bereavement strangers for support. This is a major namis and the terrorist attacks on Sep- Program, Weill Medical College issue for the orphaned child survivors. tember 11, 2001. A most striking differ- of Cornell University Child welfare laws that were enacted in ence was that children were directly in- these countries in order to help protect volved in the terror of attempting to save children from various types of abuse, themselves, and thousands succumbed to atural disasters have occurred especially foreign pedophiles, are not the ferocious destruction of the tsuna- since antiquity. Earthquakes clear. How will it be possible to ensure mis’ forces. Additionally, personal pos- and their consequences are the safety of such orphaned children? It sessions, homes, and entire families were N among the most feared natu- is imperative that clear and understand- wiped out, leaving very little with which ral events. On December 26, 2004, a able solutions be constructed within the to rebuild, or few relatives from whom major earthquake deep in the Indian cultural framework of this region. to gain family support. The extent of Ocean––and its consequential tsuna- The United States was confronted resources, including trained, skilled pro- mis— reached the shores of India, Indo- with a major disaster caused by the ter- fessionals to assist with treating the nesia, Kenya, Malaysia, The Maldives, rorist attacks on September 11, 2001. physical and psychological wounds of Mauritius, Somalia, Sri Lanka, Sumatra, From a mental health perspective, there the survivors, is limited. Also, socio- and Thailand without any warning. In are many similarities –– but great differ- cultural and religious factors about cop- some communities, legend says that ences –– between the aftermath of the ing with loss have distinct regional char- “when the ocean is disruptive, one 2004 tsunamis and the September 11th acteristics. This region of the world is should run for their lives.” Those who terrorist attacks. Much has been learned very far from the countries that offered understood this legendary statement in the United States about the families aide. There are even more factors that knew about the history of the prior de- Cynthia R. Pfeffer, MD who were directly affected by 9/11, and have made the relief effort complicated; structive brutality of the ocean. The re- this knowledge can, and should, be ap- the safety of people in some of the af- cent tsunamis in December 2004 killed He managed to save his life by hanging plied in assisting the tsunami survivors fected regions has been compromised an estimated 150,000 people. Most were onto the luggage rack of the train com- with their recovery. because of ongoing civil war – notably residents of these countries, and others partment he was in. His father also man- Both events occurred suddenly and the Sudan – and there are severe restric- were tourists. Besides the destruction to aged to survive, but the boy’s mother without warning. The devastation was tions on who can administer relief aide – the physical environment, the likelihood and siblings did not. After burying their immense and traumatizing for those who American marines are not allowed in of illness and additional loss of life family, he and his father must now forge survived. Intense stresses were experi- certain countries. among survivors reached unthinkable their future together, living with the pain enced by those attempting to avoid in- The outpouring of international sup- proportions. It was a social, economic, of their loss. There is tremendous adver- jury and death. Various degrees of physi- port was immediate and aided by exten- health and environmental cataclysm that sity that surviving families must face. As cal injuries occurred among those who sive, consistent media coverage. World stimulated massive global efforts of aide. a result of the vast destruction, many survived. For a sizable number of the leaders and national and private organi- The ravages of the tsunamis were survivors have no possessions, and, until bereaved, their loved ones have not been zations mobilized to provide financial publicized worldwide through extensive, these countries can rebuild, there are found or identified, and the hope to find aide and organized shipments of needed round-the-clock media coverage. Ap- very few opportunities available to earn missing loved ones persisted. The efforts supplies to treat injuries, dispose of the proximately one-third of those killed a living. Their futures remain grim and to find them were overwhelming and dead, and organize living situations for were children –– and thousands of other filled with worry. exhaustive. The most common method displaced and orphaned children. Quite children became orphans. International Mental health needs are clear. With used to identify the deceased was DNA early in this amazing and extensive offers of aid and assistance were enor- families losing multiple relatives, be- sampling. There were many 9/11 stories aide process was the recognition of the mous. Initially, the most critical goals reavement is extensive and complex. of survival tinged with traumatic mo- major emotional toll suffered by the were the prevention of widespread dis- Loss of personal possessions and lack of ments and outcomes, and shock per- survivors. Appraisal of specific needs eases, such as cholera, most often caused financial plans for the future has in- vaded all of those who survived. for those who have suffered from this by contaminated drinking water, air- creased the levels of grief and anxiety. The world again recognized the signs disaster is required to in order to en- borne illnesses from thousands of de- The trauma is obvious and the suffering of bereavement: intense emotional ex- sure the development of effective composing bodies, and preventing lethal is severe. Avoidance of hopelessness is a pressions of sadness and anger; survivor strategies for intervention. infections among the thousands of in- great challenge. One father said, “I lost guilt; fears; feelings of helplessness; A number of principles learned from jured survivors; therefore, relief efforts my wife and my children. Why should I feeling hopeless about the future; wish- the events of other natural and manmade concentrated on providing sanitary food want to live?” The intense guilt of sur- ing to die; sleeplessness; inability to fo- disasters may guide current efforts for and water, distributing clothing and pro- viving this disaster after so many rela- cus attention on current tasks for sur- assistance to the tsunami survivors. Key viding shelter. However, as more and tives died is a pervasive phenomenon. vival; the need for support from others; to this is the utilization of public health more shocking footage of these deadly One mother cried, “I was holding my the importance of talking about loved principles that involve: waves was shown around the world, it two children but the water was pushing ones and the circumstances of their loss. became apparent that the enormous men- us along and I could not hold onto both One guiding factor for many bereaved • Identification of the degree of tal health needs of these survivors was children. I lost my daughter.” The pain, parents was to resume life in order to emotional suffering among the equal to their physical survival. Depic- disfigurement, and loss of physical func- comfort and support their surviving population; tions of the intense shock and grief tioning due to severe injuries have com- grief-stricken children. etched on the faces of children and plicated the experience of many survi- Once again, the world recognized the • Development of prevention strate- adults reached us 24/7 on our televisions vors. They are at an extremely high risk signs of traumatic reactions, involving: gies for those who are at risk for and daily papers. Among the many sur- for depression, hopelessness, and re-experiencing through recurrent emotional problems, and treatment vival stories was that of a family living thoughts of death. thoughts and images; nightmares; feel- strategies for those who do suffer in Banda Aceh. The father, seeing the Mental health intervention is further ings of reliving the events as if they were emotional problems. “ocean wall” approaching, yelled to his challenged by many factors, including occurring again; avoidance that mani- three teenaged children to escape on the the lack of trained mental health profes- fested as withdrawal and shock; and hy- A key issue is assessment of popula- family motorcycle –– and that was the sionals who are knowledgeable about the per-arousal, which manifests as itself as tion needs, including the extent of psy- last time those children saw their parents cultural ways, in this region of the world, both poor sleep and startling to sudden chological problems and the degree of alive. A family member, who lives in a of enduring the loss of loved ones. Inter- sounds or events. manpower available to intervene. Be- distant town, offered to care for the teen- ventions to assist survivors in coping The world also recognized reac- cause affected countries may have dif- aged sister, but she refused to leave her with death and destruction are badly tions of people suffering from catastro- ferent contextual and sociocultural brothers behind, and their fate has not needed, but there are insufficient num- phe, involving depression, anxiety, factors, it is expected that interven- been determined. In yet another amazing bers of experienced professionals with and impairments in conducting com- tion needs will vary. Because it will be story, a child miraculously lived through the knowledge that is needed to organize mon, everyday activities. The risk of necessary to utilize tsunami survivors in the tsunami horror. The train on which and administer such interventions. The developing psychiatric disorders is assisting with the assessment needs of the he, his family, and hundreds of others fact that so many families lost multiple acutely increased, and often for were riding was destroyed by the waves. relatives further reduces the resources of lengthy periods of time. see Tragic Tsunamis on page 40
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 7
PAGE 8 MENTAL HEALTH NEWS ~ SPRING 2005
MENTAL HEALTH NEWSDESK
Government Study Highlights Need for Integrated Counseling For Women with Substance Abuse and Mental Disorders and Trauma
By SAMHSA grated services that involved the violence with substance abuse disorders, United States Department of Health women themselves in treatment deci- “holistic…collaborative, (and) coordi- and Human Services (USDHHS) sions cost the same as usual care and nated” services are needed, as well as stud- produced better outcomes, making the ies on collaborative, linked social service The Substance Abuse and Mental services cost-effective. programs. The study results confirm clini- Health Services Administration “The nature and impact of trauma cal recommendations in TIP #25 that treat- (SAMHSA) just released study findings remains too often misunderstood or ne- ing substance abuse issues without ad- showing that women with mental disor- glected,” explained SAMHSA Adminis- dressing a woman's history of violence is ders, substance abuse disorders, and his- trator Charles Curie. “Many women suf- ineffective, and that all clients in substance tories of violence (trauma) can improve fer tremendously as a result of misdiag- abuse treatment programs should be as- when treated with counseling that ad- nosis, mistreatment, absence of inte- sessed for domestic violence and child- dresses all three of their service grated care and a lack of a voice in their hood physical and sexual abuse. needs. Women who have a voice in their own treatment. The WCDVS results The WCDVS went further by ad- own treatment report better outcomes provide a roadmap for recovery for dressing the interplay of not only sub- than women who do not. women with co-occurring disorders and stance abuse disorders and trauma in the The findings come from the trauma histories.” lives of women, but mental illness as Women, Co-occurring Disorders and According to SAMHSA’s National well. The WCDVS also demonstrated Violence Study (WCDVS), a five-year Survey on Drug Use and Health in 2003, the empowerment and healing that study conducted by SAMHSA of over an estimated 4.2 million persons 18 and comes when a woman is directly in- 2,000 women with co-occurring mental older met diagnostic criteria for both volved in her own care and recovery. At and substance abuse disorders and serious mental illness and a substance the systems level, women with co- trauma histories. The study was not Women in the study who received use disorder (dependence or abuse) in occurring disorders and trauma histories randomized, but rather, women who fit counseling that addressed all three the past year. Of these, 2.0 million were often receive services that are frag- the study eligibility criteria were re- aspects of their lives together im- male and 2.2 million were female. mented, less comprehensive, and more cruited into a group receiving inte- proved more than women in usual The study builds on recommendations institutionally based than what they grated services, or a group receiving care. Women’s symptoms also im- from SAMHSA's Treatment Improvement need. The WCDVS also addressed these usual care, which treated mental proved when they participated in the Protocol (TIP) #25, “Substance Abuse issues in the study's guiding principles: health, substance abuse, and trauma planning, implementation and delivery Treatment and Domestic Violence.” TIP issues in isolation from each other. of their own integrated services. Inte- #25 noted that to treat victims of domestic see Study on page 20
Morahan Appointed Chair of Mental Health Lepore New Vice President Of and Developmental Disabilities Committee Behavioral Health Center At Medical Center
Staff Writer Staff Writer Mental Health News Mental Health News
enator Thomas P. Morahan ominick F. Lepore, MS, (R-C), New City has been CTRS, has been appointed appointed to chair the prestig- Vice President of the Behav- S ious New York State Senate ioral Health Center (BHC) at Mental Health and Developmental theD Westchester Medical Center in Val- Disabilities Committee. halla, New York. “I’m honored that Senator Bruno has “After a ten year hiatus from Psychia- appointed me to help oversee a signifi- try, my main efforts are to enhance the cant part of our State’s mental health core mission that drives the Westchester and developmental disabilities responsi- Medical Center. That mission is to provide bilities. I look forward to working with quality care in a compassionate manner the State Office of Mental Health, State and simultaneously be the lead educators Office of Mental Retardation and Devel- for our internal and external customers. opmental Disabilities, the Commission BHC’s contribution to the financial viabil- on the Quality of Care, and the Develop- ity of the Medical Center has also become mental Disabilities Planning Council to a priority in assessing all aspects of our
ensure that all patients get the best pos- Thomas P. Morahan services (Inpatient, Outpatient, Assertive Dominick F. Lepore sible care,” Senator Morahan said. Community Treatment (ACT) and the “Mental health issues are critically entire state, and I’m confident that he Comprehensive Psychiatric Emergency served for four years as an Assistant Vice important to the people of New York will also do an outstanding job leading Program (CPEP),” Lepore said. President in the office of Quality Clinical State, and Tom Morahan’s understand- the Mental Health Committee.” No stranger to the Westchester Medical Resource Management and Regulatory ing and commitment to this issue make The Senator has been widely recog- Center, Lepore served as a Certified Affairs at the Medical Center. him highly qualified to serve as chair nized as an advocate for mental health Therapeutic Recreation Specialist (CTRS) According to Mr. Lepore, “I am and leader of the committee,” Senate and those with special needs. In recogni- and Supervisor, and then as Director of pleased to be back to my roots in psychia- Majority Leader Joseph L. Bruno said. tion of his work, Senator Morahan was Recreational and Expressive Therapies at try and wish to express my highest confi- “Senator Morahan has always demon- awarded the Joseph R. Bernstein Memo- the Medical Center’s Psychiatric Institute. dence that we will continue to place the strated his dedication and leadership, rial Award by the Rockland County Prior to his new position as head of the consumer first and foremost when provid- both to his local constituents and the Mental Health Association. □ Behavioral Health Center, Mr. Lepore ing the care for their complex needs.” □
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 9
MENTAL HEALTH NEWSDESK
MHA of NYC Launches National Suicide Prevention Lifeline 1-800-273-TALK
Staff Writer line, emphasizes the importance of com- vices. “For many people, crisis hotlines Mental Health News bining nationwide access with local exper- serve as an entry point into the mental tise. “It is critical that callers to the Na- health system,” said NASMHPD Execu- tional Suicide Prevention Lifeline get help tive Director Robert Glover. “By ex- he Mental Health Association as soon as possible. A single phone num- panding the National Suicide Prevention of New York City (MHA of ber, available nationally, makes it easy for Lifeline into underserved regions and by NYC) and its partners, the Na- anyone to call from anywhere in the coun- linking crisis centers to a national data- tional Association of State try and get connected to certified local base of mental health resources, we can MentalT Health Program Directors crisis centers that are best equipped to help get people the help they need and reduce (NASMHPD), Columbia University and nearby callers access geographically con- suicide in this country.” Rutgers University, recently announced venient services and support.” the launch of the federally- funded Na- Dr. Draper continues, “We are pleased Lifeline Deemed National Priority by tional Suicide Prevention Lifeline, 1- that eight New York crisis and support President’s New Freedom Commission 800-273-TALK. hotlines are participating in the network to The National Suicide Prevention serve persons in distress across the State. The national hotline network is part Lifeline is a network of local crisis cen- Callers can reach them by using the local of the National Suicide Prevention Initia- ters located in communities across the hotline numbers they already know, or by tive (NSPI), a collaborative, multi- country that are committed to suicide dialing the National Suicide Prevention project effort led by the U.S. Department prevention. Callers to the hotline will Lifeline at 1-800-273-TALK.” of Health and Human Services’ Sub- year $6.6 million grant from SAMHSA’s receive counseling, support and referrals Regional participating hotlines in- stance Abuse and Mental Health Ser- Center for Mental Health Services, awarded from staff at the closest available crisis clude: Crisis Services of Buffalo, Long vices Administration (SAMHSA) that to the MHA of NYC. center in the network. Island Crisis Center of Bellmore, Suicide incorporates the best practices and re- The MHA of NYC was selected to “The purpose and promise of this Prevention and Crisis Service of Tomp- search in suicide prevention and inter- manage the development of the National national suicide hotline is to be there for kins County, Ithaca, Covenant House vention with the goal of reducing the Suicide Prevention Lifeline due in part people in their time of greatest need,” Nineline of New York City, HELPLINE incidence of suicide nationwide. to the organization’s extensive experi- said Giselle Stolper, Executive Director of the Jewish Board of Family and Chil- In the United States, suicide accounts for ence in operating of the MHA of NYC. “Working with our dren’s Services of New York City, approximately 30,000 deaths annually. As 1-800-LIFENET, New York City’s pre- federal, State and local partners, we will LifeNet of New York City, Dutchess the lead agency tasked with advancing the mier multilingual mental health crisis, be able to capitalize on our strengths and County Department of Mental Hygiene- goals of the President’s New Freedom Com- information and referral hotline. LifeNet expand this national hotline to reach HELPLINE of Poughkeepsie and Life mission on Mental Health and the National is one of 113 crisis centers in 43 states suffering individuals in ways that each Line: A Program of DePaul, Rochester. Strategy for Suicide Prevention, SAMHSA is currently participating in the National of us could not do alone.” To ensure seamless support for the committed to working with state and local Suicide Prevention Lifeline network. National Suicide Prevention Lifeline and organizations, such as MHA of NYC, The daily operations of the network Suicide Prevention Lifeline Unifies to link mental health resources nation- NASMHPD, and community crisis centers, will be coordinated by Link2Health So- Local Services for New Yorkers ally, the MHA of NYC will work closely to expand the availability of suicide preven- lutions, an entity created by the MHA of with NASMHPD to create a centralized tion and intervention services. The National NYC for the primary purpose of over- Dr. John Draper, Director of the Life- database of treatment and support ser- Suicide Prevention Lifeline is funded by a 3- seeing this nationwide project. □ Mutant Gene Linked to Treatment Resistant Depression
By The National Institute In the current study, a similar variant culled from of Mental Health, (NIMH) human subjects produced 80 percent less serotonin in cell cultures than the common version of the enzyme. More than 10 percent of the 87 patients with mutant gene that starves the brain of sero- unipolar major depression carried the mutation, com- tonin, a mood-regulating chemical messen- pared to only one percent of the 219 controls. Among ger, has been discovered and found to be 10 the nine SSRI-resistant patient carriers, seven had a A times more prevalent in depressed patients family history of mental illness or substance abuse, six than in control subjects, report researchers funded by had been suicidal and four had generalized anxiety. the National Institutes of Health's National Institute of Although they fell short of meeting criteria for major Mental Health (NIMH) and National Heart Lung and depression, the three control group carriers also had Blood Institute (NHLBI). Patients with the mutation family histories of psychiatric problems and experi- failed to respond well to the most commonly prescribed enced mild depression and anxiety symptoms. This class of antidepressant medications, which work via points up the complexity of these disorders, say the serotonin, suggesting that the mutation may underlie a patients might respond best to serotonin-selective antide- researchers. For example, major depression is thought treatment-resistant subtype of the illness. pressants,” noted NIMH Director Thomas Insel, M.D. to be 40-70 percent heritable, but likely involves an The mutant gene codes for the brain enzyme, tryptophan The Duke researchers had previously reported in the interaction of several genes with environmental events. hydroxylase-2, that makes serotonin, and results in 80 percent July 9, 2004 “Science” that some mice have a tiny, one- Previous studies have linked depression with the same less of the neurotransmitter. It was carried by nine of 87 de- letter variation in the sequence of their tryptophan hy- region of chromosome 12, where the tryptophan hy- pressed patients, three of 219 healthy controls and droxylase gene (Tph2) that results in 50-70 percent less droxylase-2gene is located. Whether the absence of the none of 60 bipolar disorder patients. Drs. Marc Caron, serotonin. This suggested that such a variant gene might mutation among 60 patients with bipolar disorder Xiaodong Zhang and colleagues at Duke University an- also exist in humans and might be involved in mood proves to be evidence of a different underlying biology nounced their findings in the January 2005 “Neuron,” pub- and anxiety disorders, which often respond to serotonin remains to be investigated in future studies. lished online in mid-December. selective reuptake inhibitors (SSRIs) — antidepressants The researchers say their finding “provides a poten- “If confirmed, this discovery could lead to a genetic test that block the re- absorption of serotonin, enhancing its tial molecular mechanism for aberrant serotonin func- for vulnerability to depression and a way to predict which availability to neurons. tion in neuropsychiatric disorders.” □
PAGE 10 MENTAL HEALTH NEWS ~ SPRING 2005 POINTPOINT OFOF VIEWVIEW
Mental Health Is Key To Restructuring Long-Term Care
By Michael B. Friedman, LMSW bowel functions. We think of people work out the details of restructuring only next step. Housing alternatives with Alzheimer’s Disease who can no should include experts on geriatric including assisted living, community longer recognize their own children and mental health. residences, and other forms of congre- seem shells of their former selves. gate care should be available for older These images reflect only part of the • Home health and case management adults with co-occurring mental and reality of nursing homes residents. They services need to be reconceptualized physical problems. neglect the fact that mental and behav- as services to address mental health ioral disorders are among the major rea- and behavioral problems as well as • Widespread public education is sons that people go to, and remain in, health problems and the difficulties needed to help older adults, their nursing homes. of meeting life’s basic needs. families, their physicians, and others Yes, many people in nursing homes who care for them to understand have chronic physical illness or have • The health, mental health, and aging what mental illness is, that it is treat- failed to recover from injuries. But up- service systems need to be inte- able, and where to go for good treat- wards of 50% of this population have co- grated because health and mental ment. Public education also needs occurring mental illnesses –– especially health conditions, social isolation, to address stigma – the sense that depression and anxiety disorders. and difficulties meeting basic needs mental illness is shameful, and age- Yes, many people are in nursing homes co-occur and interact. They need be ism–the belief that mental illnesses because of dementia. But sometimes what addressed in a coordinated manner. (especially depression and cognitive is diagnosed as dementia is actually unrec- dysfunction) are the inevitable con- ognized – and untreated – depression. And • Mental health services need to be far sequences of old age. They aren’t. many people correctly diagnosed with more accessible than they are. dementia also have depression and anxiety There need to be more services. • Substantial efforts are needed to de- Michael B. Friedman disorders that, if treated, could result in They need to be affordable. They velop a workforce large enough and improved functioning. need to be mobile so as to reach competent enough to meet the mental In addition, 10% to15% of people are people in their homes and other health needs of older adults. This in nursing homes primarily because they community settings where older includes not just developing the work- consensus seems to be emerg- have mental illnesses with behavioral people go for help—such as senior force of geriatric mental health pro- ing in Albany that New York symptoms that make it difficult for them centers, social service programs in viders, but educating and training State should restructure its long- to be served in community settings or naturally occurring retirement com- primary care physicians, nurses, home term care system and reduce the cared for by their families. For the most munities, and houses of worship. A health workers, providers of services use of nursing homes by helping people to part, they are people who cannot care for And they need to be designed to to the aging, and others. live in community settings. This is a rea- themselves, at least at the time of admis- engage cultural minorities and oth-
sonable goal, but the effort to achieve it sion, and who do not have family or ers who tend not to seek mental • Finally, the delivery of mental health cannot be fully effective if the mental health friends who are able to take care of them health services. services that can help reduce the need needs of older adults are ignored. And at home. And let’s not forget that one of for people to go to nursing homes will sadly, none of the proposals now on the the ways New York State reduced the • The quality of mental health ser- table addresses mental health issues. census of state psychiatric centers was to vices needs to be improved. Cur- require a significant redesign of fi- For example, the governor has pro- discharge older adults to nursing homes. rently, primary care physicians pro- nancing models, ranging from the posed increasing home health and case Finally, it is critical to be clear that a vide most mental health services in very simple—such as higher fees for management services to help people great many people who are in nursing the community, and frequently they home visits-- to the very complex— avoid placement in nursing homes, or to homes putatively because of dementia or are unable to make accurate diagno- such as integrated funding for health help them return from nursing homes to physical illnesses or injuries are actually ses or provide the best treatment. In and mental health services. the community. Good concepts — but, there because of their behavior. Home addition, many mental health pro- unfortunately, mental illness is quite health workers, case managers and, most fessionals are not prepared to serve None of this will be easy, but these common among people who receive importantly, their families could manage older adults, whose mental health are the challenges that must be con- home health or case management ser- their physical problems in the commu- needs are often qualitatively differ- fronted in order to restructure long-term vices, and very few service providers are nity if it weren’t for such behavioral ent from those of younger adults. care in ways that help people live where prepared to deal with it. problems as wandering, non-adherence most prefer to live ––in their homes and It is not immediately apparent that to medical regimens, belligerence, and • Because families are the primary in their communities. It just can’t be mental health services should be a key actions that are dangerous to themselves caregivers for people with mental done without addressing mental health part of the effort to provide alternatives and to others —such as leaving stoves on and physical disabilities, significant needs, as well as health and concrete to nursing homes because the popular or smoking in bed. attention needs to be devoted to service needs. images of nursing home residents are of The fact that these mental and behav- providing support to help them to people who’ve become too decrepit or ioral disorders are among the major rea- continue their extraordinary efforts Michael B. Friedman is the Director demented to care for themselves any sons that people are put in nursing without burning out. of the Center for Policy and Advocacy of longer. We think of old people who homes has important implications for the The Mental Health Associations of New have broken their hips and never return effort to restructure New York State’s • Of course, it is not realistic to believe York City and Westchester. He can be to their previous level of functioning. long-term care system. that all older adults can continue to reached at [email protected]. The We think of people who have Parkin- live independently or solely with the opinions in this article are his own and son’s Disease who can no longer stand, • Every taskforce, planning group, support of their families or friends. do not necessarily reflect the positions of feed themselves, or control urinary or and advisory body convened to But nursing homes should not be the The Mental Health Associations. □ Send Someone a Gift Of Hope with a Subscription to Mental Health News See Page 43 for our Subscription mail-in Form
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 11
A Voice of Sanity
A Consumer Advocacy Column
Surviving A Deadly Game Of Ping Pong
By Joshua Koerner pack of cigarettes, which the staff found just to see if I could learn anything: a Executive Director, CHOICE immediately (another patient having bumper sticker, or maybe some CDs that ratted on me for the hash) and then might give me a clue as to who was tossed my room looking for more. That treating me. Substance abuse treatment hat’s wrong with this pic- was in 1979. In 1986, on what was by was a true peer service: most of the peo- ture: A blazingly hot Au- then maybe my fifth hospitalization, I ple working at the clinic I attended were gust day on the campus of went home on a pass and found a roach addicts themselves and didn’t care who W a big teaching hospital. I and smoked it, came back manic, and knew it. They also made no secret of am strolling past the tennis courts and admitted what had happened, and for the how tight-assed they thought some of the golf course, walking from the site of rest of that stay I was given a drug test those mental health people could be. the day hospital, where I am enrolled, to every time I came back from a pass. Sometimes a staff member would hug a the main building, where the cafeteria is You would think that somewhere patient. There is no hugging on inpatient located. My life is a shambles: in April I along the line someone would have units; that can get you thrown into seclu- had a spectacular meltdown, evidence of stamped my records POTHEAD and sion. These people weren’t about seclu- which can be seen on my left hand, which referred me for drug treatment. That’s sion. They were about fellowship. is still healing from the 3-inch gash that not the way it works. We have two dis- Wow. After years spent feeling like a required both micro-surgery and a skin tinct systems: one treats mental illness, bug, like something to be studied, this graft to close. I’m profoundly depressed, the other treats substance abuse. Even was astonishing. Still, it took me a long living at home with my mother for the first though having a mental illness raises the time to “get it.” Recovery is a complex, time in six years, unable to work, unable, chances that someone has a substance multi-dimensional process that involves really, to even think straight –– and I’m abuse disorder to roughly one in two, other people; I wasn’t much of a joiner, smoking a joint. Joshua Koerner substance abuse treatment within the and I didn’t trust other people. But being I see this all the time, or variations of mental health system is grotesquely un- part of what was to me a radically new I had a serious dalliance with Quaaludes, it: clients who are on disability, who der-funded. Even though addiction is treatment milieu helped me to achieve a but they were difficult to get and my cannot work, and yet they drink, or really just another mental illness, and level of self-acceptance that had always source, a script doctor in Watts, was smoke pot, or spend their entire precious many addicts have a number of co- eluded me in the mental health system. busted. And there was cocaine. benefit checks the first week of the occurring mental illnesses, mental health What if I had fallen into substance Which brings me to another conse- month on gambling, lottery tickets, or services within the substance abuse is abuse treatment first? Then my symp- quence –– poverty. Nothing was as im- hookers. Back when I was in the same just as inadequate. toms of depression and mania might portant as getting the drugs; certainly not situation, I wasn’t concerned with put- It was Abraham Maslow (the same easily have been labeled a consequence saving money. I went through thousands ting my life back together –– that Maslow who postulated the “hierarchy of the drug use and I could have suffered of dollars, fifty or a hundred dollars at a seemed impossible. I was horrifically of needs”) who said, “If the only tool for years trying to white knuckle my way time, sometimes little bags of coke, and depressed, and marijuana made me feel you have is a hammer, you tend to see through mood swings. mostly bigger bags of pot. I sold an en- better. It would continue to make me feel every problem as a nail.” Everyone in Neither system really wants the re- tire Honda Accord (granted it was better –– and continue to destroy my life the mental health system saw my drug sponsibility of dealing with the whole used, but still, I got five grand for it) –– for the better part the next ten years. use as self-medicating, thinking that if person. I have a friend who is diagnosed and basically smoked up the proceeds. That’s addiction. Addiction is one of my mental illness was under control I with schizophrenia and is a big-time I smoked and snorted the proceeds of a those words, like depression, that has wouldn’t need drugs. No one wanted to crack addict. Obtaining good treatment movie sale as well. entered common usage, but which most admit that the addiction was a distinct for the schizophrenia was hard enough; people really don’t understand com- Pot smoking influenced my educa- disease that needed to be treated. I have then he had a relapse and started using pletely. People call themselves worka- tion, my social life, and my career a friend who was in an IPRT (a type of crack again. He couldn’t find any sub- holics, chocoholics and shopaholics; but choices. It never occurred to me that my vocational program) for two years and stance abuse program that wasn’t scared addiction is more that just what, or how troubles –– the lack of a degree, the lack yet never got a job. He was smoking pot to death of schizophrenia. When he fi- much of, something you use. Addiction of a job, and a lengthening psychiatric every day, they all knew it, they would nally did, and successfully completed is a process: it’s the management of feel- history –– might be traceable to the say things like, “Gee, maybe you should nine months of drug treatment, the men- ings, using a substance (drugs) or activi- drugs I’d used, and was continuing to cut back on that,” but they never did tal health provider he had been seeing ties (gambling), in an obsessive fashion, use. I went from Mensa member to drop- anything about it. What is the point of made it clear they didn’t want him back: in spite of profoundly negative conse- out to mental patient to cab driver. I spending two years giving someone vo- they were afraid to deal with someone quences (loss of job, loss of spouse, ar- earned money, drove down to the Bronx, cational therapy if they’re smoking pot? who was addicted to cocaine. rest). So it isn’t the amount used: you copped, and smoked pot, all without I got lucky. Finally, someone did that It’s a disgrace that people in need are can have a drink after work every day leaving the cab. Sometimes I was even for me. I was showing up to therapy bouncing between two systems, perhaps and not be an alcoholic. On the other tipped –– not with cash, but with a joint. stoned. After having spent over a decade in making progress in one while losing hand, you can confine your drinking to Any connection between my deterio- the mental health system, someone finally ground in the other. It’s outrageous that the weekends, but if it leads to fights and rating socio-economic condition and my figured out that I had a drug problem and the mental health field isn’t paying more arrests for driving under the influence, near-constant use of drugs escaped me. sent me for drug treatment. They told me if attention to addiction, and that the addic- chances are you have a problem. For me, There’s nothing unusual about that; it’s I didn’t accept treatment for my addiction, tion field can’t also find a way to tolerate it wasn’t an occasional joint: I had a called denial. What’s more notable is I’d have to end my therapy, and by that the symptoms of mental illness. It’s been morning bong hit the way other people that a direct intervention to put a stop to point I was starting to figure out that I said for twenty years: we need better have a morning cigarette. the drug use didn’t occur to the people needed therapy if I was going to get a bet- integration of our mental health and sub- And then there were the conse- who were treating me, either. ter job than driving a cab. stance abuse services. When will this quences, one of which was insanity. It’s not like I ever made a secret of it. Drug treatment was a revelation. I message be heard? Drugs pushed me over the edge, from The very first time I was admitted to a was accustomed to the culture of mental the neurotic to the psychotic. Make no locked, inpatient psychiatric unit, I health professionals: this is about you, CHOICE of New Rochelle, New York, mistake: it wasn’t just marijuana. I smuggled in a chunk of hash that I not us, you are not us and we’re not tell- is a nonprofit consumer advocacy or- drank. I huffed nitrous oxide, mostly out smoked using an empty soda can as a ing you anything about us. I used to go ganization dedicated to helping people of balloons filled from Whip-it car- pipe. When I left the unit on a pass, I out to the parking lot of the outpatient with mental illness. You may reach Mr. tridges, but several times right off a tank. came back with four joints stashed in my clinic and try to find my therapist’s car, Koerner at (914) 576-0173. □
PAGE 12 MENTAL HEALTH NEWS ~ SPRING 2005
The NYSPA Report
Warning Labels and Psychiatric Medications: Clarifying the Debate
By Jack M. Gorman, MD even if the official FDA label does not However, it is important to remember Esther and Joseph Klingenstein mention them specifically. The physician that a number of medications prescribed Professor and Chair should weigh the scientific evidence by psychiatrists have black box warn- Department of Psychiatry and about the drug and its safety based on ings. These include the antipsychotic Professor of Neuroscience reports in the scientific literature –– they medication thioridizine (marketed in the Mount Sinai School of Medicine should not rely only by what is stated on U.S.before it became generic as Mella- the drug label. ril), sodium valproate (marketed as De- As all physicians know, the “label” pakote) for acute mania, and lamotrigine ecently, the United States for each medication is published in the (marketed in the U.S. as Lamictal) for Food and Drug Administra- Physicians’ Desk Reference (PDR), and bipolar disorder. tion (FDA) issued a “black includes a variety of information. Occa- In the examples mentioned above, black box warning” for all antide- sionally, the first section written about a box warnings have mainly served to alert pressantsR marketed in this country. The drug is a boxed “warning,” the so-called physicians to potential serious adverse warning cautions that children and adoles- “black box” warning. This is intended to reactions of drugs that are generally felt to cents treated with these medications may alert the physician to the particular drug be important in the treatment of mental experience an increase in self-destructive that has been found to have a particular illness. Like all physicians, psychiatrists thinking. The new warning has left parents serious and adverse effect, usually one recognize that medications can pose risks; and clinicians wondering whether it is safe that is uncommon but potentially life- that is one of the most important things we to prescribe antidepressants to children threatening (presumably, drugs with are trained to be alert for, and to know how with mood or anxiety disorders. common life-threatening adverse effects to evaluate and intervene. For doctors, they Ever since fluoxetine (marketed as are never approved by the FDA, and are are part of the risk to benefit assessment Prozac in the U.S. until it became a ge- withdrawn from the market once the we make every time we consider prescrib- neric drug) was first approved in 1987, Jack M. Gorman, MD problem is discovered). Pharmaceutical ing medication to a patient. Our work is there have been intermittent alarms that companies hate these warnings, because enhanced by having the risk part clearly Selective Serotonin Reuptake Inhibitor severe and potentially life-threatening it affects some of the marketing strate- and emphatically spelled out so that we (SSRI) antidepressants increase the risk adverse reactions, including profound gies they are able to undertake (for ex- cannot miss it. A black box warning for suicide. None of these claims has hypoglycemia and insulin shock. That ample, direct-to-consumer advertising is should never mean that a medication is ever been substantiated by scientific never dissuades pediatricians from pre- not permitted). Furthermore, physicians dismissed from consideration. Rather, it evidence when adult patients are con- scribing insulin; rather, it calls upon their become anxious when drugs get black means that physicians and their patients, cerned. Moreover, there is some evi- expertise to monitor their patients care- box warnings, and this can have a pro- including the parents of children who may dence that since the introduction of fully and intervene quickly in the case of found influence on whether or not they need to take antidepressants, are placed on SSRIs, the suicide rate in Western coun- impending complications. Every year, prescribe a particular medication. alert to watch for complications. □ tries has begun to decline, although far more children die from suicide than cause and effect is difficult to conclude. diabetes mellitus; hence, the treatment of In pediatric patients, however, the depression in children and adolescents is scientific evidence does appear to sug- important, and antidepressant drugs are gest that antidepressants may increase one of the tools we can use for that pur- New York State the risk for suicidal thoughts. Analyses pose. If a pediatrician feels comfortable conducted by several manufacturers (of monitoring a depressed child on antide- Psychiatric Association their own products), by the FDA, and by pressant medication for potential adverse a group of investigators at Columbia reactions, he or she should proceed, as University, found that about one in fifty would be the case in treating any medi- (2%) of children and adolescents treated cal condition. If not, then referral to a Area II of the American Psychiatric Association with antidepressants had increased child psychiatrist might be indicated. thoughts of suicide or self-destructive Physicians and the public often do not Representing 4500 Psychiatrists in New York behavior, a rate significantly higher than realize that the FDA has jurisdiction seen with placebo. Importantly, there only over drug companies; it has no au- have not been any actual suicides in any thority to regulate medical practice. In Advancing the Scientific of these studies, and the rate of suicide New York State, that responsibility rests attempts in this age group among de- with the Department of Health, and, in and Ethical Practice of Psychiatric Medicine pressed children who are not given treat- some instances, the Department of Edu- ment is higher than 2%. Still, there does cation –– the latter because it issues Advocating for Full Parity appear to be some risk of developing aber- medical licenses. Hence, the FDA only rant behavior in the pediatric age group determines which drugs may be mar- in the Treatment of Mental Illness when treated with antidepressant drugs. keted in the United States, and what the After two emotional public hearings companies may say about those drugs in Advancing the Principle that in which parents grieving the loss of advertisements and to physicians. their children who committed suicide Hence, if the FDA has approved a all Persons with Mental Illness Deserve an Evaluation testified, the FDA ordered that labels for drug for, say, the treatment of depression with a Psychiatric Physician all antidepressants begin with a “black in adults, the company may not advertise box” warning about the potential for the drug for any other purpose. The FDA to Determine Appropriate Care and Treatment suicide. Recently, I was asked at a con- has said publicly that it fully supports ference about depression and anxiety physicians who prescribe medications disorders for primary care physicians if “off label” when that practice is sup- Please Visit Our Website At: pediatricians should continue to pre- ported by the evidence. Parents of chil- scribe antidepressants. My answer was dren with depression and anxiety disor- as follows: every year we place children ders need to trust the judgment of physi- with diabetes mellitus on insulin. In a cians about whether a drug is effective www.nyspsych.org small number of cases, this results in for a particular problem or age group ––
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 13
THE MENTAL HEALTH LAWYER
What Are The Rights Of Parents hospital services for himself or herself, cial ability, to provide reasonable, safe meets the statutory criteria for involun- To Make Healthcare Decisions and the consent of no other person shall and –– if necessary –– life-sustaining tary hospitalization set forth by the Men- For Their Children? be necessary.” treatment for their children. tal Hygiene Law. More pointedly, a mi- Essentially, most minors are consid- Apart from general medical decision nor will be involuntarily hospitalized if
ered legally “incompetent” to make most making, parents are often faced with those statutory requirements are met, By Carolyn Reinach Wolf, Esq. health care decisions due to their age, situations relating to emergency medical regardless of whether or not the parent or and such decision-making authority treatment, psychiatric treatment, and guardian consents. vests in the parents. However, as pro- disclosure of medical information. vided in Section 2504 above, minors Outpatient and Inpatient Treatment who are married, or who have children Emergency Medical Treatment Within a Psychiatric Facility themselves, may make health care deci- Where the Child is Consenting sions for themselves. In some states, The provision of emergency medical children –– based upon their age, intel- services by a hospital does not require The Mental Hygiene Law states that, lect and level of maturity –– can be de- parental consent, or the consent of the in providing outpatient mental health clared “mature minors” and thereby child, where obtaining that consent services or anti-psychotic medications to “competent” to make decisions. This would imperil the child. Stated differ- a minor residing in a hospital, the impor- mature minor doctrine in New York law ently, when a hospital provides emer- tant role of the parents or guardians shall does not have a very clear (or useful) gency medical treatment to a minor, con- be recognized. As clinically appropriate, definition. sent to that treatment from the child’s steps must be taken to actively involve The New York State legislature gave parent is unnecessary. the parents or guardians, and the consent wide berth to parents to make health care of such persons shall be required for decisions on behalf of their children, but Psychiatric Treatment: such treatment in non-emergency situa- did not intend for Public Health Law Voluntary Hospitalization tions, except as otherwise provided. Section 2504 to be an absolute right, or However, a mental health practitioner all encompassing. For example, in 1981, A child under the age of sixteen may may provide outpatient mental health the New York Court of Appeals held that not voluntarily consent to inpatient psy- services or perform an initial interview a parent may not deprive their child of chiatric hospitalization. The child can with a minor voluntarily seeking such Carolyn Reinach Wolf, Esq. lifesaving treatment, even when the par- only be admitted upon application by a services without parental consent if the parent or guardian. mental health practitioner determines ent’s decision is based on constitutional If the child is between the ages of six- that: grounds, such as religious beliefs. The teen and eighteen, the director of the facil- he answer to this question may, parent’s right must yield to the state’s ity may accept the minor’s voluntary appli- (1) the minor is knowingly and voluntar- at first glance, appear to be a interest in protecting those who are cation, or that of a parent or guardian. ily seeking such services; and, simple one. Parents know their deemed incompetent. In ratifying cer-
children best, and children are tain provisions of the Family Court Act Involuntary Hospitalization (2) provision of such services is clini- oftenT too young and lack the maturity or and correlative laws, the state legislature cally indicated and necessary to the mi- intellectual capacity to make treatment set out guidelines as to when the state, There are no age restrictions on the nor's well-being; and, decisions on their own. But with recent through the Family Court or Supreme use of involuntary hospitalizations. The FDA warnings on antidepressants, new Court, may intervene against the wishes minor will be hospitalized if he or she see The Rights on page 20 confidentiality regulations, and a host of of a parent on behalf of a child, so that other concerns, parents often have more the child’s needs are properly met. This questions than answers relating to what provision for substituted judgment is authority they have to consent to –– or codified in the Family Court Act, Sec- refuse treatment –– for their minor chil- tion 233, which provides “that whenever The Law Offices of dren. The laws in New York, which out- a child within the jurisdiction of the line the rights of parents to make medi- court appears to the court to be in need Carolyn Reinach Wolf, P.C. cal and mental health care decisions for of medical, surgical, therapeutic, or hos- their children, are quite complicated. The pital care or treatment, a suitable order Devoted to the Practice of Mental Health Law following article is intended to provide may be made therefore.” an outline of the laws that govern paren- Such state intervention on behalf of a tal health care decision making for their minor is often referred to by the Latin The Law Offices of Carolyn Reinach Wolf, P.C. represents more than children. As always, one should consult phrase parens patriae. It is this parens twenty major medical centers, as well as community hospitals, nursing a professional before taking any action. patriae analysis that defines when paren- homes and outpatient clinics, in the New York metropolitan area in the tal decision making must yield to the field of mental health litigation, consultation, advocacy, and related disci- Medical Treatment Generally judgment of the state. A classic example is the case of a child who may bleed to plines. It is a well-established principle in death because of the parents’ refusal to our common law that a competent adult authorize a blood transfusion because of In addition, our team of attorneys, with more than forty years combined has a right to decline medical treatment, the religious beliefs of the parents. experience, offers legal representation to families and individuals affected despite the fact that the treatment may be Courts have held that the State’s interest by mental illness. We provide a broad range of legal services and counsel beneficial –– or even necessary –– to in protecting the minor’s health and wel- on such matters as: mental health case management and continuity of fare outweigh the parents legitimate reli- preserve the patient's life. The patient’s care; discharge planning; Assisted Outpatient Treatment (Kendra’s Law); right to determine the course of his or gious beliefs. By contrast, a New York her own medical treatment is paramount court has allowed, under very limited Mental Health Warrants; Hospital Treatment over Objection and Reten- to what might otherwise be the doctor's circumstances, a parent to terminate arti- tions; Patients’ Rights and Guardianships. obligation to provide needed medical ficial life support for a child living in a care. Accordingly, a violation of this persistent vegetative state. Our firm regularly contributes to a number of publications concerned with right may result in civil liability for those The courts have repeatedly high- Mental Health and related Health Care issues and participates in seminars who administer medical treatment with- lighted the importance of parental in- and presentations to professional organizations and community groups. out consent. In 1972, the New York volvement in making treatment choices State Legislature codified this common and, it should be noted, that parents are law principle as part of the Public Health not deprived of the right to choose 60 Cutter Mill Road - Suite 413 Law. Public Health Law Section 2504 amongst competing serious or life- states that, “any person who is eighteen saving treatments. Accordingly, parents Great Neck, New York 11021 years of age or older, or is the parent of a are legally empowered to make treat- child, or has married, may give effective ment determinations, in light of their (516) 829-3838 consent for medical, dental, health and families’ morals, social values and finan-
PAGE 14 MENTAL HEALTH NEWS ~ SPRING 2005 The NARSAD Report
The National Alliance for Research on Schizophrenia and Depression
Multiple Diagnoses in Children: Understanding and Tackling Co-morbidity
By Constance E. Lieber, President study (research which follows a group signs in pre-pubescent children that problem from a clinical perspective. NARSAD of subjects over an extended period of indicate a future susceptibility to devel- Young people with both ADHD and time –– often several years) to examine oping bipolar disorder. She is doing this depression may have more complicated the depression/substance abuse relation- by conducting a follow-up study of and protracted courses of illness than ship over time. Third, Dr. Wu aimed to adults who were diagnosed before pu- those with only one condition, with im- analyze gender differences as it relates berty with either depression alone, or pairment often persisting into adult- to depression and substance abuse. The with a co-morbid combination of de- hood. Furthermore, the course of each results of Dr. Wu’s study reinforced that pression and another disorder (either disorder is more severe –– and response rates of alcohol use and abuse are sig- attention hyperactivity disorder, con- to treatment reduced –– when this is the nificantly higher in depressed youth as duct disorder, or psychotic depression), case. Dr. Oandasan is examining two compared with their non-depressed or who have a family history of bipolar ways of treating children suffering from peers. His data further indicates that the disorder. It is Dr. Noaghuil’s hypothe- both of these conditions. Typically, co-morbidity between alcohol use and sis that the rates of bipolar disorder psychiatrists use either a combination depression can be partly explained by will be highest in the children who of drugs that include a stimulant and shared risk factors. Finally, Dr. Wu un- suffered from one of these co- an antidepressant (a two-drug ap- covered substantial gender differences occurring conditions, or who had a proach), or buproprion monotherapy in this area. His findings suggest a sig- family history of the illness. (a single-drug approach). In her ongo- nificant link between alcohol use and Attention deficit hyperactivity disor- ing study, Dr. Oandasan seeks to com- Constance E. Lieber depression among boys, while in girls der (ADHD) is a condition principally pare the two approaches and then de- there is a marked relationship between characterized by inattention, hyperactiv- termine which one is more effective in smoking and depression. Another re- ity, and impulsivity. The disorder be- treating these children. ncreasingly, it is recognized that searcher who studied co-morbidity in comes apparent in some children in the Mental illness in children and ado- many adults and children who young people is D. Tova M. Ferro, PhD, early years of schooling, and it is one lescents reduces young people’s ability suffer from a mental disorder also Columbia University (1998 Young In- that makes it hard for these children to to maintain healthy relationships with meet the criteria for an additional vestigator), in her work on understand- control their behavior and pay attention. family and friends, and to perform up to Ipsychiatric diagnosis. “Comorbidity” –– ing the co-occurrence of major depres- It is estimated that between 3 and 5 per- potential in school. When a psychiatric having two or more diagnosable condi- sion and conduct disorder in children. cent of children have ADHD –– or ap- disorder is compounded by a secondary tions at the same time –– compounds Conduct disorder is characterized by a proximately 2 million children in the condition –– very often depression –– it the torment of those with mental illness, pattern of behaviors that violate the United States. Additionally, by adoles- makes the formative and teenage years and presents treatment challenges for rights of others –– including behaviors cence, those with ADHD are 5.5 times that much more difficult. NARSAD is the health care providers who serve such as physical aggression, verbal likelier than the general population to committed to supporting scientists who them. The National Alliance for Re- abuse, and destruction of property. Ac- suffer from depression as well. W. are studying co-occurring disorders in search on Schizophrenia and Depres- cording to the National Institute of Burleson Daviss, MD, University of order to meaningfully aid the progress sion (NARSAD) researchers have been Mental Health (NIMH), this disorder is Pittsburgh (2002 Young Investigator), is towards alleviating –– and with hope, conducting investigations into various common among youths in juvenile de- involved in an ongoing study of poten- eventually curing –– the suffering of aspects of mental illness co-morbidity tention and those who end up in the tial risk factors for these conditions to these children. in children and adolescents. This work criminal justice system. co-occur. Dr. Daviss will also compare is expanding the knowledge base on the Bipolar disorder is a mental illness that the symptoms and general impairment NARSAD is the largest donor- subject within the scientific community, causes unusual shifts in a person’s of a depressed group of ADHD patients supported organization in the world and helping to pave the way for new mood, energy, and ability to function. with ADHD patients without depres- devoted exclusively to supporting scien- clinical treatment approaches. Different from the normal ups and sion. He theorizes that those adolescents tific research on brain and behavior With national studies showing a shift downs that everyone goes through, the suffering from both depression and disorders. Since 1987, NARSAD has to a younger age of onset for both de- symptoms of bipolar disorder are se- ADHD will be significantly more im- awarded $162.1 million in research pression and substance abuse among vere, and can result in damaged rela- paired than those with only ADHD. He grants to 1,902 scientists at 323 leading adolescents, D. Ping Wu, PhD, Colum- tionships, difficulty with day-to-day further suggests that the symptoms and universities, institutions, and teaching bia University (1998 Young Investiga- functioning, and poor job or school per- severity of the two conditions will vary hospitals in the United States, as well as tor), decided to try to better understand formance. Bipolar disorder occurs in over time, independently of each other. in 22 other countries. By raising and these changes by examining the rela- about one percent of the population Dr. Daviss’ work should shed additional distributing funds for research on psy- tionship between depression and sub- over 18. The condition typically devel- light on the course of illness for chil- stance use and abuse in this population. ops in late adolescence or early adult- dren with both conditions, and inform chiatric brain disorders, the pace has His study had three aims: First, he hood; however, some people have their future treatment approaches. accelerated –– resulting in greater wished to examine the relationship be- first symptoms during childhood, and Also studying co-morbid depression knowledge of brain functioning, neuro- tween various types of depression and some develop them late in life. Re- and ADHD in children is Aileen Oan- chemistry, new and improved treat- different substances (cigarettes, alcohol, searcher Filoteia Simona Noaghuil, dasan, MD, University of Texas Medi- ments, and genetic origins. marijuana and other drugs). Second, he MD, Columbia University (2002 Young cal Branch at Galveston (2003 Young Constance E. Lieber has served as also wanted to conduct a “longitudinal” Investigator), is attempting to determine Investigator), who is investigating the President of NARSAD since 1989. □
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 15
PAGE 16 MENTAL HEALTH NEWS ~ SPRING 2005 The NAMI-NYS 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: 800-950-3228 (NY Only) ● www.naminys.org ● Families Helping Families
By J. David Seay, JD violence, medication noncompliance, essary hospitalizations, and promotes tally ill children when they can no longer Executive Director, NAMI-NYS and failure to respond to treatment than recovery from mental illness in the com- care for them. Estimates show that do individuals with just one diagnosis. It munity. NAMI-NYS calls for Kendra’s 40,000 to 70,000 more housing units are also leads to overall poorer functioning Law to be renewed and made permanent. needed. NAMI-NYS calls for a commit- and a greater risk of relapse. There is Ask your legislators to preserve ment for 4,000 new units a year, and a also the social “downward drift,” Kendra’s Law. REACH FOR RE- long-term plan for housing and services. whereby they find themselves living in SULTS: RENEW KENDRA’S LAW! REACH FOR RESULTS: FUND bad neighborhoods, where substance MORE HOUSING! abuse is common, and where they are TIMOTHY’S LAW less able to establish good interpersonal COMMUNITY SERVICES relationships with others. Persons with Demand that comprehensive mental co-occurring disorders are also more health parity legislation be enacted in Under the Personalized Recovery- likely to be arrested and sent to prison, New York. Pass “Timothy’s Law,” the Oriented Services (PROS) program, or even to wind up homeless. Without bill named for 12-year-old Timothy community “safety net” programs –– the establishment of more integrated O’Clair from Schenectady, who tragi- such as small local clubhouses, drop-in treatment programs, these cycles will cally completed suicide after his family’s centers, vocational programs and other surely continue. mental health benefits ran out. His cou- “non-Medicaid” community mental In New York State, mental health and rageous parents have come forward to health services –– are in jeopardy. substance abuse services are handled by tell their devastating story, convinced NAMI-NYS urges the state to fund these two separate state agencies. This was not that Timothy would be alive today had services. Intensive Case Management always so. Some advocates have called New York’s laws prohibited insurance and Assertive Community Treatment for the Office of Mental Health (OMH) discrimination against persons with men- teams must also be fully funded. and the Office of Alcoholism and Sub- tal illness. Urge the senate and assembly REACH FOR RESULTS: FUND COM- J. David Seay, JD stance Abuse Services (OASAS) to be to settle their differences and reach an MUNITY SERVICES! re-merged back together in order to bet- agreement on Timothy’s Law now. ter address the problems of separate ser- REACH FOR RESULTS: PASS TIMO- RESEARCH ual-diagnosis, or “co- vices. Others feel that creating larger THY’S LAW! occurring” disorders –– men- bureaucracies is not the answer, and that Demand that New York State stop the tal illness co-diagnosed or there is no guarantee that a merger of “BOOT THE SHU” LAW efforts to slowly starve the research co-occurring with some other these agencies would actually result in budget through staff cuts and attrition. diagnosis,D such as addiction, mental re- more integrated services “on the NAMI-NYS calls for the passage of Keep the world-class Nathan Kline Insti- tardation, or developmental disability –– ground,” where people get services. Assemblyman Aubrey’s bill to ban the tute for Psychiatric Research and the are of special concern to NAMI New What is agreed upon is the need to take use of prison “special housing units” New York State Psychiatric Institute York State. The national NAMI organi- whatever actions are prudent to better (SHUs) –– the punitive 23-hour lock- intact and working toward cures for zation’s Web site (www.nami.org) has a integrate the mental health and addiction downs also known as “the box” –– for mental illness. Research is our hope for wealth of information on co-occurring services where they are provided, persons with mental illness. It is time to the future. REACH FOR RESULTS: disorders, and I will summarize some of whether or not the respective state of- end this barbaric practice. Ask your as- FUND RESEARCH! it in this column. fices are merged or remain separate. In semblyman to vote again to “boot the Research shows that in order to really either case, it presents a formidable chal- SHU” and ask your senator to sponsor FAMILY HEALTH PLUS, recover, a person with co-occurring dis- lenge for state policy makers to do the the bill in the senate. REACH FOR RE- MEDICAID SERVICES, orders must be treated for both problems right thing –– and do the right thing they SULTS: BOOT THE SHU! AND ACCESS TO MEDICATIONS at the same time. It does not work to just must; New Yorkers with co-occurring focus on one at a time. “We’ll fix the disorders deserve no less. HOUSING WAITING LIST LAW Mental health benefits must NOT be alcoholism, and then move on to the NAMI-New York State’s 2005 removed from the Family Health Plus clinical depression.” It just does not Agenda for Action is out, and our Gov- No one will ever know the full extent Program. work that way, and yet our system of ernment Affairs Committee, ably co- of the need for community mental health Efforts to restrict access to medications care often forces that approach. Dual chaired by Muriel Shepherd and Judith housing (with services) without a wait- by a Preferred Drug List (PDL) and to diagnosis services are designed to inte- Beyer, is off and running to advocate for ing list. Ask your elected officials to eliminate “optional services” such as den- grate help for each condition, allowing its key points The Agenda for Action for pass a bill that requires a waiting list for tal, nursing, podiatry, and psychological people to recover from both in the same 2005 is: “REACH FOR RESULTS.” community mental health housing. services must be stopped. For persons with setting and at the same time. REACH FOR RESULTS: PASS A serious mental illness, these are NOT op- Although better research is needed, LEGISLATIVE PRIORITIES HOUSING WAITING LIST LAW! tional. Restrictions to access for psychiatric the American Medical Association medications under Medicaid must NOT be (AMA) believes that about half of indi- KENDRA’S LAW BUDGET PRIORITIES allowed. PDLs and other schemes to save viduals with serious mental illness are money by blocking or slowing access are also affected by substance abuse or other Kendra’s Law (named after Kendra HOUSING unacceptable. NAMI-NYS opposes any addiction. Thirty-seven percent of alco- Webdale, a young woman who died in PDL. REACH FOR RESULTS: KEEP hol abusers and 53% of drug abusers January, 1999 after being pushed in front Increase the budget for housing –– MENTAL HEALTH BENEFITS IN also have at least one serious mental of a New York City subway train by a with services –– for New Yorkers living FAMILY HEALTH PLUS, PRESERVE illness. Of all people who are diagnosed person who failed to take the medication with mental illness. Thousands are inap- MEDICAID SERVICES AND OPPOSE as mentally ill, 29% abuse either alcohol prescribed for his mental illness) for propriately placed in adult homes, jails, A PDL! or drugs. assisted outpatient treatment for seri- prisons, homeless shelters and nursing I invite everyone who reads this col- The consequences are harsh for con- ously mentally ill New Yorkers must not homes, while countless others live at umn to join with us in urging our state sumers. Persons with a co-occurring be allowed to “sunset” on June 30th. home with aging parents who are terri- officials to “Reach for Results.” It is disorder have a greater propensity for Kendra’s Law saves lives, avoids unnec- fied of what will happen to their men- within our grasp. □
A Mental Health News Personal Message: You May Sometimes Feel Like Giving Up Because You Are Feeling Hopeless Right Now. This Is Common During A Mental Illness. It Is Not Your Fault - It Is Your “Illness Talking.” Call Your Treatment Professionals Today, And Tell Them You Need Extra Help. Don’t Ever Give Up - This Crisis Will Pass. You Are Needed In This World !
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 17
M The MHA-NYS Connection Can Your By Glenn Liebman Executive Director, Mental Health Association in New York State Community
ENTAL
ne of the rites of passage of mid- Afford January in Albany is the submis- sion of the Governor’s Executive O Budget Proposal to the legisla- To Not Have ture. After the governor introduces his budget proposal, everyone scrambles to in- terpret what the cuts or additions mean to their specific areas of interest, including An Assertive those of us in mental health. This year’s budget was a mixed bag for many of the mental health advocates. Rec- Mental Health ognizing the state’s multi-billion dollar budget deficit, our expectation was that there would be devastating cuts in mental Education health. Thankfully, this did not happen. There have been proposed cuts, but there have also been some additions as well. Glenn Liebman Program? The most notable addition is the increase to the rate for supported housing in the Many individuals living with mental downstate area –– a very positive step for health needs also have co-occurring recipients that will hopefully translate into physical health needs. For years, recipi-
rental subsidies, which will make sup- ents of mental health services, advo- H ported housing more affordable. One of cates, and clinicians have stressed that in Let Us the concerns we have about the budget, order to achieve recovery, we must rec- from our perspective, was the cut to local ognize the totality of the individual. It is assistance –– which will result in cuts to not fair to create separate silos for men- community mental health providers, in- tal health and for physical health. As Help You cluding some mental health associations former Surgeon General David Satcher
(MHA’s). Last year, $7.7 million of local stated, “there is no health without mental EALTH assistance funding was cut, leaving many health.” That is why a carve-out of these Reach Out community providers without the funding medications is only a partial solution. they needed to operate many critical pro- Side-effect medications for people with grams. This year, there are additional pro- psychiatric disabilities must also be To Those posed cuts of $3.9 million to local assis- carved out to insure greater access and tance. We have voiced our opposition and greater opportunity for recovery. will work hard to restore these cuts Another safeguard that many patient Who Are Another portion of the state budget advocacy organizations have pushed for is that has a major impact to our commu- a guarantee that physicians may override nity is the budget submitted by the De- the PDP to get the medications they need At Risk partment of Health. The Medicaid dol- for their patients. This would allow the lars that many recipients rely on comes doctor to have final say over what medica- through the Department of Health tion he or she is prescribing to their pa- budget. There have been major cuts pro- tient, based upon their best medical judg- posed for Medicaid, including elimina- ment. This judgment should not be made tion of coverage for mental health ser- by committees formed to develop the PDP (914) 948-6699 vices for individuals in Family Health formulary –– this decision should rest Plus. In addition, there are proposed cuts firmly in the hands of the individual’s doc- to psychological services, dental ser- tor, in consultation with the patient. vices and podiatry services in institu- There are other ways to reduce Medi- tional settings, such as hospitals and caid costs without the establishment of a nursing homes. PDP. There are individuals in Medicaid
One of the proposed remedies to the (just as in the private sector) that take a N spiraling cost of Medicaid is the pro- variety of medications, some of which posed establishment of a Preferred Drug may not be medically necessary for their Program (PDP). The PDP would imple- overall health care needs. By reviewing ment a series of mechanisms designed to Medicaid data and establishing a strong curtail the costs of prescription drugs by survey tool and assessment, the state can creating a list of preferred drugs that are better review individual data and work
only to be prescribed to Medicaid pa- with the advocates, clinicians, consum- EWS tients, unless the doctor obtains prior ers and other stakeholders in the health authorization to prescribe a medication care system to develop guidelines and not on the preferred list. protocols for medication management. In this year’s budget the governor, as With the inclusion of evidenced-based he did over the past several years, has practices, strong consumer feedback and carved out atypical antipsychotics and clinical judgment, this tool and assess- anti-depressants from the restrictions of ment will help identify the mechanisms the PDP. This means that those medica- necessary to insure the individualized tions would not be subject to the PDP, care needs of the patient without the and would remain openly accessible to arbitrary restriction imposed by a PDP. all Medicaid patients. This is a very To reach the Mental Health Associa-
positive step, which we support, but it tion of New York State call (518) 434-0439 does not go far enough to remove our and you are invited to visit their website at serious concerns about the PDP. www.mhanys.org. □
PAGE 18 MENTAL HEALTH NEWS ~ SPRING 2005 Finding Treatment For Co-Occurring Disorders
By Steven Bogen, MD A young professional woman was abuse and not his psychiatric illness. He Phelps Memorial Hospital Center seen for psychiatric consultation. The quickly became distraught and felt that psychiatrist evaluated her history of his situation was hopeless. He began to problems with her moods, irritability, save his pills with a plan to kill him- t should come as no surprise that and impulsive behavior. She was under self. He did not discuss this with the people can suffer from major psy- the influence of drugs at the time of the staff as he thought it would be of no chiatric conditions –– such as evaluation. She was diagnosed as having use, assuming they did not understand schizophrenia, bipolar disorder, a mood disorder. Her enduring history of his mental illness. Idepression, or panic disorder –– and at cocaine, pills and alcohol was not ad- Clearly, each condition has a direct the same time have addictions to drugs dressed in the assessment or the plan. effect on the other and its treatment. and alcohol. These conditions are rela- She was provided with prescriptions and Umbrellas are good when it’s raining but tively common, each affecting signifi- samples of several medications. She not when it’s also windy. If there’s also cant percentages of the population. Yet promptly took the entire supply of medi- lightning, an umbrella can lead to disas- finding treatment for these patients has cations with the hope of getting “high” trous results. Good treatment involves a generally not been easy. For the purpose on them. thorough view of the problems and a of this article, I will use the term A young man who had a history of thorough plan. “addiction” to refer to drug and/or alco- binge use with cocaine and ecstasy, plus hol addiction. I will use the term schizoaffective disorder, was referred by Dr. Steven Bogen is the Program “psychiatric disorder” to refer to severe his psychiatrist for residential treatment. Director of the Phelps Memorial Hospi- and long-lasting conditions, such as Steven Bogen, MD The patient overheard comments about tal Center Behavioral Rehabilitation mood disorders, schizophrenia, severe the program. and perceived that the treat- Unit, a 21-day rehabilitation program personality disorders, anxiety disorders, ment would focus only on his substance for dually-diagnosed patients. □ etc., and will refer to addiction sepa- The separation of treatments probably rately, although addiction is certainly a stems from the wish that addiction and real and very significant psychiatric con- psychiatric disorders be separate. Mak- dition. I will use the term “co-occurring ing a psychiatric diagnosis of a patient disorders” or “dual diagnosis” when with an addiction problem is, in fact, referring to people who have both types more difficult. Excessive and frequent of conditions, occurring either simulta- alcohol and drug use cause symptoms neously or in an overlapping fashion. that can mimic all major psychiatric syn- Addiction and psychiatric disorders dromes. Unfortunately, for dual diagno- are each common conditions, but how sis patients, ignoring or postponing treat- commonly do they occur in the same ment one of the two disorders is a recipe person? One of the most comprehensive for failure. studies to address the question was the If addictive disorders can cause the Epidemiological Catchment Area study same sort of psychiatric symptoms, how in1984, which was designed to deter- can co-occurring disorders be reliably mine the lifetime prevalence of many diagnosed? Good diagnosis begins with prominent psychiatric and addictive dis- a careful history. In addition to inquir- orders. The study found that the likeli- ing of the patient, external sources often hood of an alcoholic having a major de- can be crucial, albeit more time- pression is 1.7 times greater than for consuming, to elicit both the psychiatric non-alcoholics. For women there was an and addiction history. Of particular at- even greater co-occurrence: 19% of fe- tention is whether the psychiatric symp- male alcoholics had also been diagnosed toms preceded the substance use and with depression versus 7% of women in whether psychiatric symptoms have oc- the general population. Of course, these curred during periods of abstinence. If a findings do not address the question of person goes into depression only during whether depression led to alcoholism, if or immediately after bouts of drinking, alcoholism led to depression, or if inde- and feels okay when he sobers up, we pendent factors led to both. It is certain might classify this mainly as an addic- that many people will be dealing with tion problem. It would require addiction both problems at some point in their treatment, but not psychiatric treatment lives, if not simultaneously. such as antidepressants. Careful diagno- Obviously, these conditions cause a sis can spare the patient from unneces- great deal of distress, dysfunction, and sary medication. Other important fea- danger, and professional treatment for tures in making a proper diagnosis in- these disorders is extremely important. clude family psychiatric history, history Historically, treatment of addiction and of past psychiatric treatments, and direct psychiatric disorders were provided sepa- observation of the patient. For diagnostic rately. Treatments were developed in par- purposes, inpatient treatment provides allel to each other. Patients would be told the advantage of (hopefully) observing to come back for psychiatric treatment the patient while abstinent from sub- after being abstinent from alcohol or drugs stance use, while outpatient treatment for six months. People attending Alcohol- offers the advantage of (hopefully) ob- ics Anonymous meetings would be told serving the patient over a longer period that taking antidepressants or any of time. “psychotropic” medication was not “real” Many forces have put pressure on sobriety. Patients would enter psycho- mental health providers to treat more analysis for years and their drinking or patients more rapidly. Professionals You are Not Alone... drugging would be ignored, treated as a may have more expertise in psychiatric “symptom” that would go away after their disorders than addiction, or vice versa. The Mental Health Community inner conflicts were resolved. We still have With co-occurring disorders, a patient’s separate licensing of programs under the health is only as strong as the weakest Has Programs and Services To Help You New York State Office of Alcoholism and link. When the treatment focuses on Substance Abuse Services (OASAS) and only one of the two disorders, negative Through Difficult Times its Office of Mental Health (OMH). outcomes can occur:
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 19
PAGE 20 MENTAL HEALTH NEWS ~ SPRING 2005
The Rights from page 13 (ii) requiring consent of a parent or Treatment With Antipsychotic Medica- an individual, who is a minor and is a patient guardian would have a detrimental tions Where the Child is Not Consenting in a state-operated psychiatric center, (or a (3) (i) a parent or guardian is not rea- effect on the minor, provided the treat- facility licensed by the Office of Mental sonably available; or, (ii) requiring pa- ing physician and a second physician, A minor patient who objects to any Health) objects to psychotropic medication, rental or guardian consent or involve- who specializes in psychiatry and who invasive medical treatment or procedure to which his or her parent, legal guardian or ment would have a detrimental effect on is not an employee of the hospital, de- may not be treated over their objection other legally authorized representative has the course of outpatient treatment; or, termine that: (a) such detrimental except as defined below. It is worthwhile consented, such medication shall not be ad- (iii) a parent or guardian has refused to effect would occur; (b) the minor has for a parent to review the following rele- ministered, pending the completion of a hos- give such consent and a physician deter- capacity; and, (c) such medications vant portions of the New York Code, pital review process, which shall be fully mines that treatment is necessary and in are in the minor's best interests; or, Rules and Regulations: documented in the patient’s medical record. the best interests of the minor. (iii) the parent or guardian has refused (1) Emergency treatment. Facilities may give Medical Records - Consent for Release Once the three criteria set forth to give such consent, provided the treatment, except electroconvulsive therapy, above are met, a mental health physician treating physician and a second physi- to any inpatient (including minors), regard- Generally, a parent may consent to can provide outpatient services to a mi- cian, who specializes in psychiatry and less of admission status or objection, where the disclosure of protected health infor- nor, or can administer antipsychotic who is not an employee of the hospital, the patient is presently dangerous and the mation for a child if the child fits the medications to a minor who is an inpa- determine that: (a) the minor has ca- proposed treatment is the most appropriate definition of a minor as stated above. tient in a hospital, without the parent’s pacity; and, (b) such medications are reasonably available means of reducing that This disclosure may be made regardless consent. in the minor's best interests. Notice of dangerousness. Such treatment may continue of the consent of the minor. A minor child sixteen years of age or the decision to administer antipsy- only as long as necessary to prevent danger- older, who consents, may be adminis- chotic medication pursuant to this sub- ous behavior. Conclusion tered antipsychotic medications without paragraph shall be provided to the par- the consent of a parent or guardian, or ent or guardian. (2) Minors. (i) Except as provided in subpara- Medical decisions are often difficult the authorization of a court, where: graph (ii) of this paragraph, a patient who is to make, and in most circumstances, a Thus, a consenting minor over 16 a minor may be provided treatment over his parent is best-suited to determine what is (i) a parent or guardian is not reasona- years of age does not need parental or her objection if the patient’s parent, legal in their child’s best interests. Hopefully, bly available, provided the treating phy- consent or a court’s permission in or- guardian, or other legally authorized repre- this review of the applicable laws will sician determines that: (a) the minor has der to receive antipsychotic medication sentative has consented to the treatment, and help to clarify parental consent issues as capacity; and, (b) such medications are when the above-mentioned require- the treatment is not one for which the consent they apply to medical and/or psychiatric in the minor's best interests; or, ments are met. of a minor would be legally sufficient. (iii) If treatment of minors. □
Heroic Path from page 1 January 26, 2005, NAMI launched a new support group to address the needs of dually back, as well. I left school feeling like a fail- diagnosed consumers. This Co-occurring Advertise in Mental Health News ure, and the thought of drinking came back Illness Support Group is an integrative to me.” model for individuals diagnosed with both Experience, combined with her own in- psychiatric and addictive (drug and alcohol Reach Our 70,000 Readers nate strength, taught her that falling back on substance related) disorders. The two facilita- her addiction wasn’t the answer. “So I fought tors of the group, Shirlee Cohen, NP, and See Page 43 For More Details it, and I didn’t drink. I didn’t want to go Patricia Maher-Brisen, APRN, BC, strongly down that road again.” She realized that she believe from their experiences that both of needed to address both issues simultaneously these illnesses must be addressed equally if a if she really wanted to get well. “I sought person is to recover. Study from page 8 cantly impact a person’s belief hospitalization, received outpatient care for “On February 4th, 2005, I celebrated 25 system, self-perception and rela- my depression, and resumed AA meetings.” years of sobriety and two years of stability • Service providers must better rec- tionships with others. It was in a group setting where Lucee with my mental illness,” says Lucee. “Now I ognize the presence of trauma, learned that she was not alone in her battle know I can continue my life and accomplish past and present, as a central con- • Providers need to meet women against what members of the community call whatever I choose.” cern in a woman’s life. where they “are” mentally and co-occurring disorders –– or MICA. “The emotionally, with careful readi- groups that I attend give me a community of The NAMI-NYC Metro Co-occurring • Women should be encouraged to ness assessments, pacing and pa- people to turn to when I am feeling isolated Illness Support Group will continue to be play an active role in their healing tience. and want to drink. Even though my mental held on the fourth Wednesday of each month process, and provided with a bet- stability was off and on, I was able to con- from 6 PM to 7:30 PM at the NAMI-NYC ter understanding of how to do so The WDCVS, as well as TIP #25, tinue with meetings and my therapy as well. Metro Office. We are very excited about this from the onset. call on policymakers and service pro- Having resources for support in the commu- new group, and we welcome all interested viders to collaborate and coordinate nity is vital to recovery.” individuals. Please call the Helpline at 212- • There must be a more widespread services in order to improve care for NAMI-NYC Metro has long recognized 684-3264 to get on the participant list, and and comprehensive recognition women with co-occurring disorders the need for MICA groups. On Wednesday, for any additional information. □ that violence and trauma signifi- and trauma. □
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Hardwired To Connect: Nurturing “Authoritative Communities” And Lessening Anger In Our Youth
By Robert Brooks, PhD The commission lists the following raised in single-parent homes in which 10 main characteristics of an authorita- the parent receives little, if any, support, tive community: and is overwhelmed by a myriad of de- thought-provoking report mands that lessen her or his effective- was released several months 1. It is a social institution that includes ness as a parent. Of course, such stress is ago titled, “Hardwired to children and youth. not unique to the single parent. During A Connect: The New Scien- the past couple of decades, dual-parent tific Case for Authoritative Communi- 2. It treats children as ends in households have witnessed an increase ties.” The report, which was prepared themselves. in both parents working. Juggling work by the Commission on Children at schedules with parenting demands has Risk, a group comprised of 33 promi- 3. It is warm and nurturing. resulted in many stressed-out parents nent children’s doctors, researchers, who feel they are on a nonstop treadmill and mental health and youth service 4. It establishes clear limits and going around in circles. As one father providers, details the deteriorating expectations. said, “I want to spend time with my chil- mental and behavioral health of chil- dren. I know I should spend time with dren in the United States. 5. The core of its work is performed them, but with all of my responsibilities The commission contends, “In large largely by non-specialists. at work, I seem to be spending less and measure, what’s causing the crisis of less time with them.” A mother la- American childhood is a lack of connect- 6. It is multi-generational. mented, “I have some flexibility in my edness. We mean two kinds of connect- work schedule, but even with that flexi- edness — close connections to other peo- Robert Brooks, PhD bility I feel like I am constantly driving 7. It has a long-term focus. ple, and deep connections to moral and my kids from one activity to the next. I spiritual meaning.” The commission ob- on preventing problems from emerging. think I spend more time with my kids in 8. It reflects and transmits a shared serves that while research from the fields It makes more sense to adopt a crisis the car than anywhere else. That would of neuroscience and basic biology indi- understanding of what it means prevention rather than a crisis interven- be okay if I was relaxed in the car, but cate that children are “hardwired to con- to be a good person. tion approach in the upbringing of our I’m not, since I’m always rushing and nect” to other people and for moral youth, guided by the goal of creating worried that I won’t get my kids to meaning in their lives, “in recent decades, 9. It encourages spiritual and environments in which children feel where they should be on time.” the U.S. social institutions that foster religious development. secure and connected, and in which they As a parent and as a therapist, I cer- these two forms of connectedness for learn to be compassionate, caring indi- tainly recognize and appreciate the children have gotten significantly 10. It is philosophically oriented to the viduals. stresses of parenting in today’s world. I weaker.” equal dignity of all persons and to Each of us can contribute to the reali- can understand the parent who says, “I As an antidote to this lack of con- the principle of love of neighbor. zation of this goal. Each contribution, know I should limit the number of hours nectedness, the commission advocates regardless of how large or small, builds my children watch television or play the creation of “authoritative communi- This list requires more than just a upon the foundation and structure of an video games, but at least it keeps them ties.” They explain their use of the perfunctory reading. I believe we authoritative community. There are occupied while I’m catching up with word “authoritative” by noting, “First, should carefully consider each point and many ways in which parents and other other things.” However, while I can em- the word refers to a strong body of ask, “In what way do I foster the quali- adults can help to construct such a com- pathize with these sentiments, I believe scholarly evidence demonstrating the ties of an authoritative community munity. What follows are several sug- we must strive to build into our daily value of that particular combination of within my family, my neighborhood, my gestions, which I hope will prompt you routine opportunities to truly connect warmth and structure in which children place of work?” An awareness of the 10 to consider other possible avenues for with our children without the presence of in a democratic society appear most characteristics can guide our individual realizing an authoritative community. countless distractions. Not only will our likely to thrive. Second, the word behaviors as we assume responsibility I should first like to consider the role children benefit from our undivided at- comes from the Latin auctor, which can for ensuring that our children thrive of parents. Almost all parents recognize tention and love, but it has been my ex- mean ‘one who creates.’ We like that. emotionally, physically, and spiritually the value of developing warm, comfort- perience that our own emotional health Authoritative communities just don’t –– and that we lessen the alienation and able, and secure relationships with their will be enhanced as we engage in activi- happen. They are created and sustained violence that is prevalent in so many children, but various external pressures ties that bring meaning and purpose to by dedicated individuals with a shared youth. All too often as a society, we and challenges can serve as obstacles in our lives as parents. vision of building a good life for the have focused on dealing with children’s achieving this task. For example, there next generation.” problems once they appear, rather than are a large number of children being see Our Youth on page 24
Four Winds Hospital is the leading provider of Child and Adolescent Mental Health services in the Northeast. In addition to Child and Adolescent Services, Four Winds also provides comprehensive Inpatient and Outpatient mental health services for Adults, including psychiatric and dual diagnosis treatment.
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Our Youth from page 21 not, to support the existence of an authoritative community beyond the In “Raising Resilient Children,” boundaries of one’s family. To do the book I co-authored with my col- so, we must subscribe to the belief league, Dr. Sam Goldstein, we rec- that each child is our “own” child, ommend several steps for nurturing that each child is part of “our” com- connections with our children and munity. There is ample research to helping them to feel acceptance and demonstrate that the presence of unconditional love. For example, we even one caring adult in a child’s life advocate setting aside times each can foster hope and resilience in that day, week, or month that are desig- child and diminish the likelihood of nated as “special.” When we actually violent behavior, drug use, or drop- use the term “special,” we express to ping out of school. One must never our children that we value them and underestimate the power of one that we enjoy having uninterrupted adult to change the course of a time with them. Obviously, these child’s life forever. prearranged times should not pre- There is an urgent need for adults clude having other spontaneous mo- of all ages to serve as mentors for ments, in which they have our undi- children, especially those youngsters vided attention. However, time set who have limited experience with aside each week for all of our chil- caring adults who can help them to dren together, as well as each child develop compassion, responsibility, alone, emphasizes their significance self-esteem, and self-discipline. Nu- to us, and that we love them. merous organizations, such as Big When children are young, parents Brothers and Big Sisters, as well as can say to the child, “When I read to church-sponsored groups, are in ex- you, when I play with you, it is such istence to bring adults in contact an important, special time that even with children in need. Youth sports if the phone rings, I won’t answer is another avenue through which it.” One six-year old in my practice children can connect with adults, and reported with excitement and joy, “I in the process learn the importance know my parents love me.” When I of teamwork, fun, perseverance and, asked how he knew, he answered, very importantly, how to lose and “When they read to me and the win with grace and dignity. How- phone rings, they let the answering ever, without adults who are willing machine answer it.” As I have often to donate their time as coaches, noted, sometimes the simplest ges- youth sports cannot exist. Adults can tures bring far-reaching results. also tutor children and reinforce their These special individual times strengths or “islands of competence” should continue into the adolescent in areas such as music or art. years of our children. We must re- The specific activity with a child member that even as our teenagers is less important than the develop- appear to be pushing us away with ment of a child’s relationship with one arm, the other arm is often hold- an adult who appreciates the features ing us near. There are countless op- of a community in which children portunities to spend time with our are nurtured and valued. In this re- adolescent, whether going to a sport- gard, we should keep in mind a key ing event, going out for dinner, recommendation offered in cooking a meal together, playing a “Hardwired to Connect,” namely, video game (better to join certain “that all adults examine the degree to activities than to fight them), or be- which they are positively influencing ing involved with a cause that holds the lives of children through partici- special interest for our teenager. I pating in authoritative communities, recall one father’s relationship with and, where possible, to do a better his teenage daughter improving sig- job.” Many other recommendations nificantly when he collaborated with and suggestions may be found in her in her efforts to have a traffic this report. light placed at a dangerous intersec- As you consider the ways in tion in their town. which you can impact positively Connections with our children are on the lives of youth in your com- nurtured through family traditions munity, and help to lessen anger we create. Hectic schedules should and violence, you may wish to re- not deter parents from involving flect upon the words of Hillel, the their children in activities, such as Hebrew scholar who lived in the Tsunami Relief Fund holding a family meeting each week first century: to discuss “family matters” and to consider if any changes are neces- “If I am not for myself, then who The employees of Four Winds Hospitals, in Westchester and sary in family life, or volunteering as will be for me? Saratoga are committed to serving children in need, both locally, a family to work for a charity, or establishing a weekly meal during And if I am only for myself, then and globally. Saddened by the plight of the children left behind which family members voice posi- what am I? without families, shelter and food, Four Winds held a fundraiser tive comments about, and apprecia- tion for, each other. I worked with And if not now, when?” assisting the relief effort of the Save The Children Tsunami Relief several families who initially were Fund. Employees contributed $8,250 and the hospitals have skeptical about such an activity, be- Robert Brooks, PhD, is one of to- lieving it was very contrived; they day’s leading speakers on the themes matched the employee contributions. Together, the were pleasantly surprised to discover of resilience, self-esteem, motivation administration and staff of Four Winds were pleased to donate that even if contrived at first, they and family relationships. Visit his Web soon enjoyed hearing more positive site at: www.drrobertbrooks.com for $16,500 to assist in the Tsunami Relief effort in Southeast Asia. comments from each other. more information on his writings, pub- There are many opportunities for lished books, area speeches, and how adults, whether they are parents or to contact him. □
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 25
MHA Of Westchester’s Steps Westchester County DCMH Toward Integrated Substance Abuse Helps Individuals And Mental Health Treatment With Co-Occurring Disorders
Staff Writer ventions. The above initiative is in Staff Writer Mental Health News response to the growing number of Mental Health News Dually Diagnosed individuals re- questing treatment and the high cor- he Mental Health Associa- relation between substance use and n 2002 Westchester County’s tion of Westchester mental illness. Outcomes from this Department of Community Men- County, Inc. (MHA), in pilot project will be utilized to tal Health received a grant from the New York State Office of conjunction with the De- strengthen client service-planning IMental Health and the New York State Tpartment of Community Mental agency wide. Office of Alcoholism and Substance Health, other mental health programs As part of MHA’s community Abuse Services to develop a system of and the Office of Mental Health education program and dedication to care that would address the needs of (OMH), is piloting the use of the fostering professional development, adults with co-occurring mental health Dartmouth Assessment of Lifestyle we sponsored a community-based and substance abuse disorders. The Instrument (DALI), developed by conference in 2004 on integrated County hired Kathy Pokoik, who has a Rosenberg, et.al. (1998), a NYS treatment of the Dually Diagnosed. Masters degree in Public Health and is validated instrument that helps cli- MHA’s Co-Occurring Disorders a CASAC to be Westchester’s Dual nicians identify substance Track will provide integrated ser- Recovery Coordinator. Kathy came to use/abuse in individuals presenting vices and continue to foster height- the County with sixteen years of ex- perience in both systems to take on for mental health services. ened awareness, community educa- this important role. Research has demonstrated that tion, and increase the availability of Prior to the creation of this position integrated treatment approaches are quality services for individuals who it was difficult for an individual with a essential to the success of services are dually diagnosed. mental health problem and a substance provided to individuals with Co- abuse disorder to obtain proper treat- Kathy Pokoik Occurring Disorders. MHA is com- Additional information about MHA and ment According the latest research mitted to providing Evidence Based trainings/initiatives is available on our cited in Integrated Treatment for Dual barriers to care, as well as bringing in and Best Practice Treatment Inter- website (www.mhawestchester.org). □ Disorders, it is estimated that 40-60% experts in the field to provide excel- of individuals suffering from a mental lent training opportunities. She also health problems also have a simultane- provided 63 individuals with case ous addiction disorder, so the chal- coordination services through our lenge is considerable. department, bringing together many MHA In the past there had been attempts different service systems to provide to pull together the two treatment sys- individuals at high risk with a much A place to turn for help tems to develop a more cohesive ap- better outcome. proach. Some believed that abstinence During 2004, the emphasis was to was the only way to be enrolled in continue network development, to programs which included abstinence to create a more competent workforce Information and Referral psychotropic medication which did not through trainings and consultations, support persons in the mental health and to promote the use of screening Accurate, up-to-date information about mental health concerns system. Mental Health practitioners tools for mental illness and sub- and service choices is the first step to helping a child, a friend or supported the Harm Reduction Model, stance abuse. which Substance Abuse professionals As 2004 drew to an end, DCMH was family member resolve troubling problems. We can help with felt was not the answer. The differing already working with the Office of Mental treatment philosophies created further Health to field-test the DALI, a screening ▪ Mental health issues barriers and ultimately delayed an in- tool to be used in mental health programs dividual from getting help. Often to identify substance abuse disorders. Four ▪ Availability and locations of services nationwide individuals were referred back and agencies are in the process of piloting the ▪ Educational, financial, legal, social and other support services forth between the teo systems until DALI,: MHA/Westchester, St. Vincent’s they dropped out of treatment in Medical Center, the Yonkers and Peekskill Primary Locations frustration. Community Service Centers of DCMH Providers knew that problems ex- and Rockland Psychiatric Center/White isted, but did not have adequate time Plains The M.I.N.I., a screening tool a for 2269 Saw Mill River Road, Building 1A to look at creating a different system substance abuse programs to identify indi- Elmsford, NY 10523 of care, or possess adequate funding to viduals with mental illness, has already 914-345-5900 train their staff. The grant money pro- been piloted at St. John’s Riverside. vided all of these opportunities with DCMH received an award from the the creation of this new role. National Association of Counties 29 Sterling Avenue 344 Main Street Kathy’s initial task was to create (NACo) in 2004 for the Dual Recov- White Plains, NY 10606 Mount Kisco, NY 10549 networks in each of the geographic ery Initiative in recognition of innova- 914-949-1212 914-666-4646 regions, bringing together providers tive programming. from both the mental health and The Department under Commis- OASAS systems to discuss ways to sioner Jennifer Schaffer’s, Ph.D. lead- www. mhawestchester.org improve services. “No wrong door” ership looks forward to improving this was the new philosophy embraced by system further in 2005. both systems. Kathy also assembled an Advisory Board comprised of lead- If you or any member of your ers in the mental health and substance family need Kathy Pokoik’s help, or abuse fields to help inform the depart- you would like to attend network or ment as to what was needed to move training meetings, please don’t hesi- the process along. tate to call. She can be reached at In 2003, she was a successful in (914) 995-2703 or e-mail at helping the networks cut down many [email protected] □
PAGE 26 MENTAL HEALTH NEWS ~ SPRING 2005
Association Of You Recognize This Warning Sign, Behavioral Healthcare Management And You Take Action. New York Chapter One Day Conference Can You Recognize A Problem With Your Child’s Mental Health As Well? BEHAVIORAL HEALTH MANAGEMENT INSTITUTE
July 29, 2005 9:15 a.m. - 4:00 p.m. St. Vincent Catholic Medical Center To Help A Child New York, New York You Know, Keynote Presenter: Call Daniel Garza M.D. (914) 636-4440 Chair, Clinical Committee ext. 200 Disaster Psychiatry Outreach
For Information and Brochure Mark Gustin Conference Chair 718-245-5674
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 independently. 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 returning to a more satisfying and independent lifestyle.
• The Housing Services Program, available to low and moderate income individuals and families in Port Chester through the Neighborhood Preservation Company, includes tenant assistance, eviction prevention, home ownership counseling, 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 members from throughout the region.
• In the Case Management Program, HDSW staff provides rehabilitation and support services to persons recovering from psychiatric illness so that they may maintain their stability in the community.
HDSW HOPE HOUSE 930 Mamaroneck Avenue 100 Abendroth Avenue Mamaroneck, NY 10543 Port Chester, NY 10573 (914) 835 - 8906 (914) 939 - 2878
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 27
The Center for Career Freedom
On & Off Site Computer Applications Training for Persons with Disabilities
Microsoft® Certified Office Specialist Training Center When you need help, Westchester Jewish Community Services is here for you Licensed by NYS Department of Education
DCMH Drop-in Center WJCS offers comprehensive mental health services
Consumer Survey Research
Case Management Aids: Form-Link - 2004 Benefits Guide Out-patient Treatment for People of All Ages (914) 288-9763 Specialized services for individuals with developmental disabilities One East Post Road, White Plains, New York ● www.freecenter.org Intensive Community–based Services for Children and Their Families “Search for Change has been rebuilding lives for more than Learning Center for children and adults 25 years and continues to be a major force that provides a safe haven for individuals recovering from mental illness.” Geriatric Care Continuing Day Treatment
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Mental Health Association in Putnam County, Inc. 1620 Route 22 Brewster, NY 10509
Promoting a vision of recovery for individuals P.O. Box 635 and families coping with mental health issues Orangeburg, NY 10965 (845) 359-8787
● Peer-Run Information and Referral Warmline ● Consumer-Drop-In-Center ● Peer Bridging Program Mental Health Association ● Self-Help Groups of Rockland County ● Education and Support for Family Members ● Community Outreach and Education
all of our services are available free of charge.. “Working For The Community’s Mental Health” call us at 845-639-7400 20 Squadron Boulevard, New City, NY 10956 (845) 278-7600 visit us at: www.mharockland.org
PAGE 28 MENTAL HEALTH NEWS ~ SPRING 2005 In The News At The Office Of Mental Health News
Salud Mental Premier Inspires Latino Community
Staff Writer years ago with the creation of Mental health community the recognition it de- Advisory Council.” “We act as a team and Mental Health News Health News. Working without staff or serves for saving the lives of people with an extended family to create each exciting funds on the kitchen table of his one- mental illness each and every day,” issue of Mental Health News and now the bedroom ‘shelter-plus’ apartment, states Minot. The unassuming publisher new Salud Mental” states Minot. wo years in the making, the Minot’s Mental Health News quickly and founder who came from a back- Working with a “Field of Dreams” prin- premier issue of Salud Mental caught the attention of the mental health ground as a psychiatric social worker ciple of “build it and they will come,” has just been released. The community. Today, a nonprofit organi- and a fundraising director for nonprofits, Salud Mental is gaining momentum in new bilingual, bicultural men- zation, the publication reaches an esti- was struck down with severe depression attracting the funding required to expand talT health education quarterly comes to mated 70,000 readers made up of con- in his late 30’s. “Even with a graduate distribution beyond the metro-New York us from the publisher of our award- sumers and their families, clinicians, degree in mental health, I could not find region. Initial funders for the pilot project winning; Westchester, New York based mental health providers and decision my way out of an illness that strikes one- include: The New York Community Mental Health News. makers at the local, state and national in-five people in the United States.” Trust, The United Way of New York Reactions to the 48 page premier is- level. The organization’s Board and Ad- The new Salud Mental contains a City, Bristol-Myers Squibb, Forrest sue of Salud Mental and the story behind visory Council reads like a veritable wealth of articles in English and Spanish Pharmaceuticals and the New York State the project’s founder and publisher are ‘who’s who’ of notables from the most written by some of the northeast regions Office of Mental Health. inspiring many in the Latino community. prestigious mental health organizations, most influential leaders and provider Salud Mental is available in a full read- A survivor of a ten-year, life threaten- psychiatric hospitals, medical colleges organizations from the local and national able format on its new website which is ing battle with depression, which left and universities. Latino mental health community. funded by the Verizon Foundation at him homeless and destitute, Ira Minot, of “My goal was to provide a roadmap “I could not publish Mental Health News www.mhnews-latino.org. For further in- White Plains, New York wowed the to mental health education, information and Salud Mental without the help of our formation you may call Mr. Minot directly northeast’s mental health community six and resources and to give our mental dedicated readers, supporters, Board and at Salud Mental at (914) 948-6699. □
Mental Health News Announces Upcoming Issue Themes
Summer 2005 Issue: “Mental Health and Senior Adults” Fall 2005 Issue: “Understanding and Treating Schizophrenia”
See Page 43 For Deadline Dates: For Articles And Ads
Mental Health News Campaign 2004 Raises Vital Funds Thank You To All Of Our Generous Contributors
Individual Contributors Steven J. Friedman Dr. Eryn L. Oberlander Dr. Jonas Waizer Marsha Gordon Senator Suzi Oppenheimer Mindy Appel Many Anonymous Donors Steven Greenfield Sidney Paul Peter C. Ashenden Dr. Lee Gruber Gloria & Michael Pesce Paula Barbag Public and Corporate Contributors Mary Guardino Dr. Barry Perlman Kaye Barker Mary Hanrahan Isobel Perry Carolyn Beauchamp Bristol-Myers Squibb Penelope D. Johnston Debra Phillips Dr. Margo Benjamin Marge Klein Joyce M. Pilsner Forest Pharmaceuticals Robin Bikal, Esq. Andrea Kocsis Dr. Mark Russakoff Dr. David Brizer New York Community Trust Joshua Koerner Steven Rogowsky & Valerie Salwen Emory Brooks Mary Krout Dr. Newton M. Schiller John Butler New York State Dr. Pauline Kuyler Janet Z. Segal Office of Mental Health Dr. Peter & Patricia Campanelli Dr. Leo Leiderman Dr. Alan B. Siskind Dr. C. Deborah Cross Orange County Department Dr. Andrew Levin Steven H. Smith James Cunningham of Mental Health Constance Lieber Andrew Solomon Joseph D’Ambrosio Dr. Richard Liebman Arthur Soyk United Way of New York City Roni Dersovitz Ira H. Minot Gloria & Irwin Staple Rena Finkelstein Verizon Foundation Dr. Michael & Jan Minot Janet Susin Luisa Francoeur Peg Moran Zebulon Taintor Susan Frederick Westchester County Department Dr. Wali Mohammad Alan Trager of Community Mental Health Michael B. Friedman
Mental Health News - New York City Section: Spring 2005 Page 29 The Mental Health News New York City Section
Long-Term Planning and Funding: Turning The Patchwork Quilt Of Services For Individuals With Co-Occurring Disorders Into A Cohesive Whole
By Meggan Christman, mates suggest a 50% rate, or higher, of day. Integrated Dual Diagnosis Treat- Policy Advocate, Coalition of co-occurrence. ment (IDDT) as an evidence-based prac- Voluntary Mental Health Agencies In order to effectively plan how to get tice may be relatively new, but many of from point A to point B, you have to the basic underlying principles have We have come to accept that co- understand exactly where point A and been around for a long time, growing in occurrence is the rule, not the exception, point B are. Point B: The ultimate goal the laboratories of exceptional programs, and to believe that integrated treatment should be a seamless system of care, nurtured by insightful mental health for individuals with co-occurring psychi- where every door is the right door, and practitioners. There is also already an atric and addictive disorders is good services are provided in an integrated, Inter-agency Work Group, convened public policy. There is significant con- patient-centered way. To achieve this, jointly by the New York State Office of sensus that integrating treatment in- improvements must be made in 1) Mental Health (OMH) and the New creases the efficiency and success of the screening and assessment 2) staff train- York State Office of Alcoholism and treatment and is cost-effective in the ing, 3) program-level adaptations like Substance Abuse Services (OASAS), long-run. There is even consensus evidence-based practices, 4) system- with the purpose of providing coordina- around evidence-based and promising wide integration, and 5) fiscal support. tion and integration. practices –– with room for creative inno- Improvements at all levels must be ad- Initiatives on both sides of the aisle vation and regional adaptation. Training dressed simultaneously. Tackling the have sought to increase the frequency is becoming increasingly available; a improvements in a linear way, looking and quality of screening for individuals limited number of grants currently exist first and only at screening and assess- with substance abuse issues in mental to improve system integration and treat- ment creates the moral dilemma for health programs and mental health issues ment. some providers of screening for prob- in substance abuse programs. One such What is lacking is a comprehensive lems that they are not fully prepared to program is the New York City Depart- long-term, system-wide plan to link treat. Those who are already treating Meggan Christman ment of Health and Mental Hygiene’s appropriate existing services to individu- dually diagnosed individuals are not Quality IMPACT initiative, through als in need, to identify the gaps, and then being reimbursed at a rate that reflects resources into a coordinating body that which agencies implement the SAM- to fill them and fund them. To achieve a the cost of providing services –– result- aids in the implementation of integrated HSA-developed Simple Screen. The comprehensive gap-needs assessment ing in an inadequate capacity to treat service throughout the continuum of NYS OASAS has recently developed requires an accurate understanding of these individuals. providers. There is no need to re-invent supportive materials and guidelines what currently exists –– both in available Planning for a challenge that exists the wheel in order to accomplish this. around the Modified MINI, a screening services and needs. Neither is available pervasively in the here and now cannot Point A: I would be so bold as to instrument used to screen for mental right now with respect to co-occurring be linear. It must be tackled in a more propose that almost every mental health health problems. disorders. There are statistics that esti- aggressive way, more closely resembling program in New York City has some There is an assortment of trainings mate the co-morbidity of substance the branches of a tree with roots in every capability in co-occurring disorders, being offered. One concern is that train- abuse and mental health disorders fil- service sector: mental health, substance whether formal or informal. Many pro- ing staff in a piecemeal way –– without a tered through census data that give us a abuse, forensic, housing, children and viders are highly proficient, providing general, aggregate picture. Most esti- families, etc., feeding information and high-quality, innovative services every see The Patchwork on page 42
Treatment Services For Individuals With Co-Occurring Psychiatric And Substance Use Disorders: A Plan for Integrated Treatment
By Letitia Coburn, R-LCSW, • To reduce the incidence of relapse innovative mandate programs via drug uted to “acting-out,” or ascribed to psychi- DTR, CASAC-T, Program Director, for our consumers treatment courts; and evolving criteria atric symptoms unmanageable within a Chemical Dependence for continued treatment by managed care traditional treatment setting. Treatment St. John's Riverside Hospital • To reduce the need for lengthy and providers. These changes necessitate an programs have historically treated such costly inpatient psychiatric treat- intelligent and flexible response from individuals via either a parallel service ment today’s treatment providers. approach or a sequential approach. In the s treatment providers move • To return our consumers to their Kenneth Minkoff, MD, a leading ad- parallel treatment approach, an individual into 2005, we must recognize homes in the community vocate for people living with both disor- concurrently attends both a substance the increasing needs of indi- ders, supports this expectation of treat- abuse treatment program and a separate viduals with co-occurring • To implement less restrictive levels ment providers. He encourages programs outpatient psychiatric treatment facility. In A of care for our consumers. psychiatric and substance use disorders “to provide an empathic, hopeful, con- a sequential approach, an individual will (ICOPSD): those with both substance tinuous treatment relationship” (1998) traditionally attend a treatment program for abuse or dependence and mental health These improvements are constantly through necessary treatment episodes. one disorder (usually a substance abuse concerns. We need to respond to their in need of re-evaluation due to changes treatment program to secure sobriety), and complicated needs with vital, integrated in the sociological, psychosocial and Integrated Treatment then be referred to a program to address treatment provision designed to manage pharmacological world that our consum- the alternate disorder (Smyth, 1996). both their psychiatric symptoms and sub- ers inhabit. Recent environmental Treatment providers have frequently Minkoff (2001) recommends that each stance relapse potential, while lauding the changes include: the nature of entitle- mislabeled, misdiagnosed and/or not of the two disorders be considered pri- clients’ strengths and experiences of self- ment provision; availability of new and recognized individuals with co-occurring mary. Individuals with these disorders determination. A timely response to this increasingly dangerous opiates and other disorders. Traditionally, behaviors related need is crucial for multiple reasons: street drugs; declining family structures; to these two disorders are ignored, attrib- see Integrated Treatment on page 42
Page 30 Mental Health News - New York City Section: Spring 2005 INFO LINE PSYCH
A SERVICE OF THE PSYCHIATRIC SOCIETY OF WESTCHESTER
914-967-6810 This is an information and referral service sponsored by the Westchester District Branch of the American Psychiatric Association.
Psychiatrists of this organization are dedicated to providing treatment for mental disorders and advocating for equal health care for mental and physical conditions.
If you need information about psychiatry or assistance in finding a psychiatric physician - please call us.
THE PSYCHIATRIC SOCIETY OF WESTCHESTER 555 THEODORE FREMD AVENUE • SUITE B-100 • RYE • NEW YORK
Mental Health News Metro-New York Leadership Committee
Peter C. Campanelli, PsyD, President & CEO Peg E. Moran, CSW, VP Administrative Services Institute for Community Living Behavioral Health Svcs. - St. Vincent’s Catholic Medical Centers
Amy Chalfy, Mental Health Director - Bronx District Evelyn J. Nieves, PhD, Executive Director JASA Fordham-Tremont Community Mental Health Center
Marianne Coughlin, Vice President Program Development Evelyn Roberts, PhD, Executive Director The Mount Sinai Medical Center NAMI - New York City Metro
Kenneth J. Dudek, Executive Director Phillip Saperia, Executive Director Fountain House Coalition of Voluntary Mental Health Agencies
Mary Guardino, Founder & Executive Director Alan B. Siskind, PhD, Executive Vice President & CEO Freedom From Fear Jewish Board of Family & Children’s Services
Mark D. Gustin, MBA, Senior Associate Director Giselle Stolper, Executive Director Kings County Hospital Center Mental Health Association of New York City
Mary Hanrahan, Director, Treatment Services Jonas Waizer, PhD, Chief Operating Officer New York Presbyterian Hospital - Payne Whitney Division F.E.G.S.
Rhona Hetsrony, Executive Director Joyce Wale, Assistant Vice President - Behavioral Health North Shore LIJ Health System - Zucker Hillside Hospital New York City Health & Hospitals Corporation
Joseph Lazar, Director, New York City Field Office Peter Yee, Assistant Executive Director New York State Office of Mental Health Hamilton - Madison House committee in formation
Mental Health News - New York City Section: Spring 2005 Page 31 Best Practice In A Dual Recovery Program
By Joyce Kevelson, Assistant Vice Since relapse is part of recovery, a com- President, Queens Behavioral Health mitted community of staff and fellow Services, and Donna Ray, LCSW, “recoverers” was created who under- Program Manager, Project Cope stand and support each member’s wish F.E.G.S. to achieve abstinence and sobriety. Cli- ents are often surprised when they are not discharged from the program when fter decades of failed at- they slip and slide. They often say to us, tempts at recovery from sub- “You really understand our struggle.” stance abuse and mental ill- Others say, “I was ready to make A ness, Jean, a woman in her changes, but there weren’t any programs 50’s, enrolled at F.E.G.S. Project Cope. like this when I was younger.” Jean was the daughter of parents with Psychiatric rehabilitation is an action- serious drug problems. It was easy for oriented approach using direct-skills her to follow their path –– using alcohol, teaching techniques to help people with heroin, and crack cocaine. Trauma was disabilities achieve the goals needed to evident in her earliest years. She had improve their quality of life. It’s a been an abused child who did not gradu- strength-based approach with a strong ate from high school and was unable to belief that individuals can recover and hold down a job or sustain a healthy live productive lives. Combining the relationship. To pay for her drug addic- principles of psychiatric rehabilitation, tion, Jean turned to prostitution. together with the therapeutic commu- Her substance abuse and associated nity’s social learning philosophy, facili- lifestyle ultimately caused extensive medi- tates hope and assists individuals in re- cal problems, which she must still deal gaining functions in living, learning, with to this day. She hit bottom with the working, and socializing. loss of her soul mate, which was followed Individuals often take a circuitous by severe depression, several suicide at- path to recovery, ending up in prisons, tempts, and psychiatric hospitalization. hospitals, or on the streets. They are Finally Jean decided that, with the help of abandoned by family and friends and the counselors she met along this tragic feel like a runaway train, with no direc- journey, she would take another path –– tion and no control. F.E.G.S, in collabo- the path of recovery. ration with the State Office of Mental After nearly two years at Project Health and the University of Rochester, Cope, Jean is finally free of drugs, man- has initiated a family psycho-education aging her mental illness, reunited with program that reaches out to families and her family, and getting ready to move reunites them with clients. This effort into her own apartment. She feels that was developed in order to help the cli- the many groups, especially the individ- ent’s family members understand the ual counseling and the encouragement importance of their role in the recovery from peers, have helped her to recover. process. After nearly two years in the Project Modalities such as Dialectic Behav- Cope program, she finally feels ready to ior Therapy help clients develop impulse tackle her goal of becoming a home at- control, manage their anger, regulate tendant and to “give back” to those still their emotions, and employ alternatives suffering. to destructive behaviors. In addition, Dr. “Dual Diagnosis is an expectation, Alice Medalia, a well-known researcher not an exception,” says Dr. Ken Min- in Cognitive Remediation, trained the koff, noted psychiatrist in the field of staff to teach clients the skills that will dual recovery. A number of studies help them regain a sense of competence. clearly indicate that 55% of individuals Clients learn to negotiate interpersonal in treatment for psychiatric disorders relationships with each other through a have co-occurring substance abuse dis- variety of strategies: “push ups” orders. (positive feedback) and “pull ups” In some cases it is clear which came (negative feedback). Key concepts –– first, in others it is less evident. Yet for “You can’t keep it unless you give it decades, providers ineffectively contin- away,” “Live and let live” or “Easy does ued to treat individuals, either in a psy- it” –– are essential to letting go and chiatrically focused program or in a sub- moving on. stance abuse licensed program, with Project Cope has had great success in little appreciation of the interaction be- working with people to achieve recov- tween the two disorders. According to ery. Coordinating treatment with other many articles by Drs. Drake and Min- koff, treatment success involves the for- providers has been integral to ensuring mation of empathic, hopeful, integrated that we address all aspects of a person’s treatment relationships. The need for a life. Testimonies from clients tell us that dual recovery program prompted much of this is attributed to the struc- F.E.G.S., some four years ago, to de- ture; a smaller staff-to-client ratio and a velop Project Cope, a State Office of clean, intimate, and warm environment Mental Health-licensed rehabilitation that is safe and predictable. While we program for individuals with psychiatric have achieved much, we continue to and substance abuse disorders. explore research and listen very closely Understanding that recovery does not to our clients, who are the best source of follow a smooth path to success what works and what doesn’t. Flexibil- prompted F.E.G.S. to employ harm re- ity, and a willingness to learn, is the duction vs. abstinence on admission. name of the game. □
Page 32 Mental Health News - New York City Section: Spring 2005
Harm Reduction vs. Abstinence Approaches For Individuals With Co-Occurring Disorders: An Agency’s Evolution
By Michael Blady, LCSW lapses and continued use early in treat- grams that predominantly serve MICA chronically homeless consumers Associate Senior Vice President, ment are to be expected, they are explic- consumers are clustered under the direc- (two years of homelessness out of Adult Mental Health Services and itly defined as problematic behaviors, tion of a vice president who supervises the last four) and those who are Michael Skoraszewski, PsyD, even if there are no other consequences all the program directors in this cluster, being discharged from long-term Senior Vice President, associated with use, e.g., domestic con- and convenes monthly strategic planning state hospitalizations. Adult Mental Health Services flict, lost time at work. An important meetings. These strategic planning meet- It has been a challenge helping the Institute for Community Living, Inc. aspect of recovery in an abstinence ings have been occurring continuously MICA Cluster community (both staff model is that the individual has to admit since 1990, even before our first pro- and consumers) to consider and accept that he or she is powerless against his or gram opened. At these meetings, an alternate philosophy and associated n 1991, when the Institute for her addiction, and that the only way to every aspect of the MICA service- interventions into the system. One exam- Community Living (ICL) began recover is to not use. delivery system is reviewed on a ple of the flexibility that has been providing residential services spe- The other school proposes a much regular basis, and changes in pro- achieved is that we now have residential cifically designed to address the more ‘palliative’ approach, emphasizing gramming are carefully planned from programs that accommodate the needs of Iunique needs of individuals with co- choice and control of behaviors. This concept to implementation. consumers on methadone maintenance. occurring serious mental illness and sub- ‘harm reduction’ model starts from a Our four congregate residential In abstinence-oriented programs, it is stance abuse disorders (who were, in premise that not all conditions are cur- MICA treatment programs continue to very problematic introducing someone addition, homeless), the concepts ‘best able, and that control of the negative offer abstinence-oriented modified thera- who is using a substance –– which can practices’ and ‘evidence-based treat- behaviors and problems resulting from peutic community programming for be abused and has street value as a drug ment’ were not yet part of the lexicon of use is an acceptable outcome. Tempo- those who both want and need that level –– into the community. By broadening mental health services. All we knew was rary cessation or reduction of use, along of support. While reduction of harm is the philosophical basis of our system that our residential programs for people with reduction in symptoms of addiction continually celebrated through level to include other approaches, we have with serious and persistent mental illness and the severity of co-existing problems, changes that acknowledge the achieve- been able to serve a population that were ill-prepared, as were those of our are all improvements, short of cure, that ment of intermediate goals, the tacit ac- has, in the past, languished in shelters colleagues, to address the growing sector are worthy of pursuit. ceptance of usage in these programs is because of the mental health commu- of the population that was also present- In reviewing the current literature, it perceived as undermining the fabric of a nity’s (including our own) reluctance ing with substance abuse issues. We also is clear that there is no single approach recovery community that relies on the to serve them. learned that residential programs for or model that is universally regarded as establishment of a shared commitment to Services to consumers with co- substance abusers were not prepared or ‘the best practice.’ Motivational inter- the goal of abstinence. occurring disorders within ICL are not willing to admit individuals with psychi- ventions, cognitive-behavioral ap- Many of the therapeutic-community limited to the MICA Cluster. All of our atric disorders. proaches and therapeutic communi- graduates move into specialized and residential services programs –– congre- Working with researchers who had ties have all produced positive out- supported housing programs, in which gate treatment, CR/SRO’s treatment, and experience with therapeutic communi- comes with certain segments of the they complete the final phase of their apartment and supported housing –– ties, we developed an integrated ap- target population. treatment. Many of these apartments are work with people who are dually- proach that viewed mental illness, com- What researchers and practitioners do clustered in single sites, which permit disordered. The approach in all of plicated by substance abuse, as a unique agree on is that treatment must be inte- the development of an ongoing sober these programs, as well as among our disorder that demanded a unified ap- grated. As defined by the federal Center support system. The apartments are re- ACT, Blended-Case Management, proach instead of sequential treatment. for Substance Abuse Treatment (CSAT), garded as permanent housing, though and clinic programs is based more on Essentially, what ICL did was to take the “Integrated treatment is broadly defined some of the residents opt to move to harm reduction and cognitive- self-help, community-as-healing-agent as any mechanism by which treatment scatter-site supportive housing when behavioral approaches. components that had proven effective in interventions for co-occurring disorders they are ready. While this range of programs and residential substance abuse programs are combined within the context of a Residential case managers and approaches enables ICL to provide a full and replaced the confrontational aspects primary treatment relationship or service counselors are cross-trained in both array of interventions to meet the with an ego-supportive approach. We system.” For services to be fully effec- mental health and substance abuse in- agency’s goal of an integrated service then added modalities from the field of tive, integrated treatment should be pro- terventions, and are supported by sub- system for MICA consumers, there re- psychiatric rehabilitation –– e.g., psy- vided within the context of an integrated stance abuse specialists, many of main formidable challenges. Primary cho-education, and psychiatric symp- program that provides an organizational whom are in recovery themselves. In- among them is improving our ability to tom management (including medica- structure, and which supports the provi- service training on the concepts and match intervention to individual needs, tion) –– to create an integrated treat- sion of comprehensive interventions. In practice of therapeutic community in- wants, and aspirations. Performing accu- ment model that simultaneously ad- turn, an integrated program should func- terventions are regularly provided by a rate clinical assessments; understanding dressed both disorders. tion within an integrated system, which senior coordinator of MICA service, how such factors as trauma, incarcera- In the 13 years since Halsey House will provide an organizational struc- who works to ensure that there is clini- tion, culture, and gender can impact the (our first program) opened, there has ture to support an array of treatments cal consistency across the programs. effectiveness of treatment; and, training been considerable program development that can be matched to the individual Treatment is further integrated our staff to reliably provide services that and study in the field of co-occurring needs, wants, and aspirations of indi- through participation in a specialized incorporate practices grounded in the disorders. It is now the rule rather than vidual consumers. MICA Continuing Day Treatment Pro- best outcome data available, are all parts the exception that mental health and sub- Over the past 14 years, ICL has con- gram, which employs cross-trained Mas- of the challenge. As an organization stance abuse agencies offer integrated tinuously reviewed it’s approach to pro- ters-level therapists and persons in re- and in collaboration with other service services to serve this population, which viding integrated MICA services within covery. The clinicians in this pro- providers and research centers, we are is sometimes described as comprising up the context of changing populations, gram, including the psychiatrist and actively working to identify ‘evidence- to 70% of the seriously mentally ill. changing needs, assessment of outcomes the nurse, address the complex inter- based practices’ and advocate for In recent years, there has been a good and published research. Our system of action of behavior, attitudes, values maintaining a statewide system of deal of debate among practitioners of the treatment for MICA consumers now and brain chemistry that marks co- treatment alternatives that best serve two main philosophies in substance- encompasses both harm reduction and occurring disorders with a consistent, the needs of all consumers with co- abuse treatment –– abstinence and harm abstinence philosophies. The organiza- whole-person approach. occurring disorders. reduction. One school of thought main- tional structure that supports this system In the past 18 months, two new pro- If you would like more information tains that any use of substances is prob- starts at the top with a CEO, who has grams, both CR/SRO’s operating on about ICL’s range of MICA housing and lematic and it presents only one goal as been committed to integrated program- harm- reduction principles, have been treatment alternatives, contact our Cen- an acceptable outcome –– abstinence ming from the very beginning (‘buy-in’ added to ICL’s MICA Cluster of pro- tral Access Department at 1-866-ICL- from all drugs and alcohol. While re- from leadership is crucial). The pro- grams. These programs primarily serve ACCESS (1-866-425-2223). □
Mental Health News - New York City Section: Spring 2005 Page 33
OUR MENTAL HEALTH SERVICES CAN HELP YOU AND YOUR FAMILY THROUGH DIFFICULT TIMES
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Page 34 Mental Health News - New York City Section: Spring 2005
Everyone Deserves Treatment For Co-occurring Disorders
By Harris B. Stratyner, PhD Associate Professor of Psychiatry, Clinical Division Director of Addiction Recovery Services Mount Sinai Medical Center
ver my 25 year career, I have been known for what was originally referred to as O MICA treatment (utilizing my model of “care-frontation”). In its original form, what has now come to be referred to as treatment for individuals with co-occurring disorders, was gener- ally considered to be indicated for peo- ple with seriously persistent mental ill- ness (SPMI) and addiction. This placed them in a “chronic” category and gener- ally translated to a lower socioeconomic level because the illnesses were seen as Harris B. Stratyner, PhD eventually preventing these individuals from earning a living, continuing in school, or interrupting their professions. things), we must realize that they are However, some 20 years later, we now accustomed to a certain amount of being know, at least some of us, that co- “catered to.” I am not here to say this is occurring or dual diagnosis treatment right or wrong –– it simply “is.” This is can help those individuals lead produc- a controversial topic, but I would be tive lives, and furthermore, is needed remiss if I did not bring it up here –– it for all socioeconomic groups, even is what I believe Robert Millman, MD, including those who are very finan- meant by the term “acquired situational cially successful. narcissism.” There are many specific What’s different about treating the factors that treating this population CEO of a corporation, a successful attor- raises, like exposure to the press, fear of ney, or perhaps a celebrity? As some- financial ruin, or perhaps even addi- one who has specialized in this type tional stigma, if you will. of patient for over 15 years, allow Let’s face it, when you have a lot of me to elaborate. money, power, or are a well-known pub- Basically, people are people, but the lic figure, people do cater to you, and if approach that a clinician takes with a you are, for example, a bipolar individ- certain individual, based upon his or her ual with alcoholism, you still need socioeconomic status in the community, someone to talk realistically to you has to be designed to engage that person about these two diseases that feed off of in treatment, rather than deter them from each other –– just like the individual seeking help. Many people who have who is not in the limelight. achieved a lifestyle that is considered to So we begin to see that amenities be associated with success and wealth programs are simply a way of removing have certain psychosocial and environ- another rationalization for not engaging mental stressors (AXIS IV issues) that in treatment. A concierge, gourmet are, in some ways, unique to their life- meals, a private bath, and other accou- style. For example, if someone is a fa- trements that these individuals pay a mous writer, can we really expect a re- premium for are simply a way to engage habilitation program to forbid that indi- them in treatment. Don’t these people vidual from bringing his or her laptop to deserve recovery as well? the unit? Isn’t it more logical that clini- I grew up around many famous and cians should consider our hypothetical powerful individuals simply because of writer’s profession to be a potential re- my late father’s profession; however, lapse trigger, and therefore help that both my father and my mother always individual to learn how to be productive made it quite clear to me that all people without the use of drugs and alcohol? are created equal. Therefore, I believe This is not enabling –– it’s teaching cop- even the “rich and famous” deserve ing skills. However, if the laptop does treatment. I would hope someday that all become a distraction, it can always be programs had these amenities without discussed in treatment. extra fees that only a few can afford, but When we talk about counseling peo- we are not there yet –– I am grateful, ple who have acquired a certain amount though, that the programs I have been of success, and/or money, or celebrity associated with at least keep the atten- (or however our society defines these tion to treatment on an equal plane. □
Mental Health News - New York City Section: Spring 2005 Page 35
Page 36 Mental Health News - Connecticut Section: Spring2005
TAKE CONTROL OF YOUR LIFE COME TO SILVER HILL HOSPITAL
Mental Health News - Connecticut Section: Spring 2005 Page 37 Mental Health News The Connecticut Section Greenwich Hartford BRIDGEPORT Stamford Kent New London
Many Patients Have Co-occurring Mental Health and Substance Abuse Disorders: Both Must Be Addressed for Successful Treatment
By SAMHSA, Substance Abuse and tings and models for treating patients Along with the TIP, SAMHSA has disorders; increased collaboration be- Mental Health Services Administration wherever they show for treatment, created a State Incentive Grant for Co- tween SAMHSA and the Centers for whether it be in substance abuse treat- Occurring Disorders to help states en- Medicare and Medicaid to explore ways ment facilities, mental health facilities hance their infrastructure and treatment to use existing reimbursement mecha- or medical offices or clinics. TIP 42, systems; established a national co- nisms for services to people with co- created by a panel of experts and re- occurring disorders prevention and occurring disorders; and convened two viewed in the field, also emphasizes that treatment technical assistance and cross- National Policy Academies on Co- outcomes for patients are enhanced training center, the Co-Occurring Cen- Occurring Disorders to help states and when both illnesses are addressed using ter for Excellence, to provide a broad communities enhance service capacity. an integrated approach. array of information on co-occurring The TIP panel was chaired by “All too often individuals are treated disorders to states and community pro- Stanley Sacks, Ph.D., of the National only for one of the two disorders – if viders in the substance abuse, mental Development and Research Institutes, they receive treatment at all,” SAM- health and related public health fields; Inc., New York and co-chaired by Rich- HSA Administrator Charles Curie said. and increased federal agency collabora- ard Ries, M.D., Professor of Psychiatry, “If one of the co-occurring disorders tion within HHS to enhance research University of Washington. remains untreated, both usually get attention to co-occurring disorders. TIP 42, inventory number BKD515, worse. Additional complications often SAMHSA has also broadened the can be ordered through SAMHSA's arise, including the risk for other medi- agency’s efforts to identify and dissemi- National Clearinghouse for Alcohol and cal problems, suicide, unemployment, nate known effective programs for pre- Drug Information (NCADI), P.O. Box homelessness, incarceration, and sepa- vention and treatment of co-occurring 2345, Rockville, MD 20847-2345, by ration from families and friends.” disorders, including the development of calling 1-800-729-6686, or via the web- “Since people with co-occurring a new tool kit on treating co-occurring site http://ncadi.samhsa.gov. □ disorders cannot separate their addiction from their mental disorder, they should not have to negotiate separate service delivery systems,” Curie said. “We know that with appropriate treatment and supportive services people with co- Mental Health News Connecticut Leadership Committee
o-occurring substance abuse occurring disorders can and do recover. and mental disorders are This is the premise of TIP 42. ” Thomas E. Smith, MD, Medical Director Hall-Brooke Hospital more common than most pro- SAMHSA’s 2003 National Survey Chairman fessional counselors, medical on Drug Use and Health shows that C personnel or the general public realize. 27.3 percent of persons 18 and older in Committee Members A new Treatment Improvement Proto- the past year with serious mental illness col released today by the Substance used an illicit drug. In 2003, the survey Abuse and Mental Health Services Ad- also found that 5.7 million persons ages Sigurd Ackerman, MD, President & Medical Director William J. Hass PhD, Executive Vice President ministration (SAMHSA) estimates that Silver Hill Hospital Family Services Woodfield 18 and over with serious mental illness 50-75 percent of patients in substance engaged in binge alcohol use and 1.9 Alan D. Barry PhD, Administrative Director Kristin A. Lue King, LCSW, Executive Director abuse treatment programs have co- million were heavy drinkers. Overall, Norwalk Hospital Department of Psychiatry Southwest Regional Mental Health Board
occurring mental illness while 20-50 the survey showed that about 4.2 mil- Alexander J. Berardi, LCSW, Executive Director Florence R. Kraut, LCSW, President & CEO percent of those treated in mental health lion adults aged 18 and older met the KEYSTONE Family & Children's Agency
settings have co-occurring substance medical criteria for both substance Richard Maiberger, MD, Chairman Remi G. Kyek, Director Residential Services abuse. Most people with co-occurring abuse and mental illness. Norwalk Hospital Department of Psychiatry Mental Health Association of Connecticut
disorders do not receive treatment for The consensus panel that created the Selma Buchsbaum, Member Charles Morgan, MD, Chairman both mental disorders and substance document is encouraging development Southwest Regional Mental Health Board Bridgeport Hospital Department of Psychiatry
abuse. Many receive no treatment of of a unified substance abuse and mental Douglas Bunnell, PhD, Director James M. Pisciotta, ACSW, CEO any kind. health approach. Emphasis is placed on The Renfrew Center of Connecticut Southwest Connecticut Mental Health System The new Treatment Improvement assisting substance abuse treatment sys- Joseph A. Deltito MD, Clinical Prof. Psychiatry Selby P. Ruggiero, LCSW, Associate Director Protocol is designed for substance abuse tems to develop the capacity to treat & Behavioral Science, NY Medical College Clinical Services, New Learning Therapy Center treatment counselors and mental health individuals with co-occurring disorders Steve Dougherty, Executive Director Marcie Schneider, MD, Director providers who usually treat one or the while mental health systems develop Laurel House Greenwich Hospital Adolescent Medicine other of the two ailments, but it will similar capacities. Stephen P. Fahey, President & CEO Janet Z. Segal, CSW, Chief Operating Officer also be useful for administrators, pri- This Treatment Improvement Protocol Hall-Brooke Behavioral Health Services Four Winds Hospital mary care providers, criminal justice is part of SAMHSA’s promise to Con- Susan Fredrick Edward Spauster, PhD. President & CEO staff and other health care and social gress following the November 2002 Re- Family Advocate LMG Programs service personnel who work with people port to Congress on the Prevention and with co-occurring disorders. Carla Gisolfi, Director Wilfredo Torres, MSW, Site Director Treatment of Co-Occurring Substance Dr. R. E. Appleby School Based Health Centers F.S. DuBois Center Substance Abuse Treatment for Per- Abuse Disorders and Mental Disorders to
sons with Co-Occurring Disorders, TIP document state-of-the-art treatment for Margot O’Hara Hampson, APRN, Manager Greenwich Hospital Outpatient Center committee in formation 42, provides counselors with principles, individuals with co-occurring mental and assessment instruments, strategies, set- substance abuse disorders.
Page 38 Mental Health News - Connecticut Section: Spring2005 Understanding from page 1 and the National Association of State Alcohol and Drug Abuse Directors experts now agree that co-occurring (NASADAD) entered into a partnership disorders should be seen as the expecta- that resulted in the development of a tion among persons with serious mental new conceptual framework that presents illness, not the exception. Therefore, our co-occurring disorders in terms of multi- treatment systems must be designed with ple symptoms and severity instead of their needs in mind. diagnosis. The framework provides a Unfortunately for people with co- visual way of thinking about both the occurring disorders, the decision to seek systems of care and the level of service professional help can be frustrating and coordination needed to improve con- confusing –– should they enter the men- sumer outcomes –– especially the inte- tal health or the substance-abuse treat- grated care necessary for individuals ment system? Traditionally, the mental with the most severe mental illnesses health system has had a tendency to ex- and substance use. This conceptual clude persons who also abuse sub- framework combines observations about stances, maintaining that the primary the current service delivery systems with work of providers is with mental illness a vision for the future delivery of inte- and not with substance abuse. Likewise, grated services. many substance-abuse treatment pro- Typically, if they are treated at all, grams have often excluded people who individuals with less severe mental dis- were taking prescribed medications cor- orders and less severe substance abuse rectly, by requiring that all individuals enter the service system through a pri- entering treatment demonstrate their mary-care setting (Quadrant I). These motivation by being “clean” of all drugs individuals may present to a primary- –– including prescribed medications. care doctor, a school-based health clinic Many substance-abuse treatment pro- or other primary-care setting. For per- grams have relied heavily on confront- sons with mild mental disorders or sub- ing the individual’s denial of a problem stance-abuse problems, it may be appro- at all. To the contrary, mental health priate to manage their psychiatric medi- treatment often focuses on shoring the cations and other treatments in less in- individual’s fragile defenses, taking a tensive or specialized settings, such as supportive rather than confrontational primary care. When necessary, individu- approach. Historical differences in culture, als may be referred to specialized ser- philosophy, structure, and funding have con- vice agencies or providers. tributed to a lack of coordination that has Those individuals with increasingly made it difficult for either consumers or pro- severe mental disorders accompanied by viders to move easily across service settings. a lower level of substance abuse are These and other differences have more likely to be seen in a community contributed to inadequate and costly mental health setting, which provides care, and therefore, the failure of either treatment for the primary mental disor- system to address the comprehensive der and also may address the substance needs of consumers. Many of these indi- abuse problems (Quadrant II). Individu- viduals have long histories of engaging als with a high degree of substance in self-destructive behaviors to cope abuse and lower level of mental disorder with the pain of their illnesses. These typically are seen primarily in substance behaviors often worsen symptoms, caus- abuse service settings (Quadrant III). ing the individual to lose hope of recov- While the mental disorders of these indi- ery. People with co-occurring disorders viduals may be addressed, the agency’s may then become stuck in a cycle of primary expertise remains substance pain, alienation, and self-destructiveness abuse. Referrals to other specialized that isolates them from their personal service settings are common in both support systems and from treatment sys- Quadrants II and III. These referrals tems. Providers themselves may become place the burden of connecting the sepa- frustrated, not understanding how to rate treatment systems squarely on the help individuals move away from self- individual and family. destructive patterns of behavior. Inade- Both the mental health and sub- quate and costly care has been the result. stance-abuse fields generally agree that Individuals and providers both remain the most effective treatment for persons stuck in a cycle of hopelessness, with with substance abuse and severe mental the person with co-occurring disorders illnesses – those found in Quadrants II feeling like a misfit –– “unwelcomed, and IV – is integrated treatment, in unwanted, and blamed for the complex- which services are offered through a ity of their difficulties.” single, unified, comprehensive service Fortunately, in recent years, a grow- system. Integrated treatment matches the ing consensus has emerged asserting the intensity of the disorders with a com- need to do more for this population. mensurate intensity of treatment inter- Both mental health and substance-abuse ventions. With increasing evidence that service providers have a responsibility to any substance abuse by persons with understand the disease processes and to serious mental illness is potentially de- help clients recover. Research is avail- stabilizing, some treatment professionals able that points the way. and researchers, therefore, are calling for integrated treatment to be available to Integrated Treatment persons in Quadrant III as well. An integrated, community-based Beginning in 1998, with the support treatment setting is consumer-centered of the Substance Abuse and Mental and provides services through a “no Health Services Administration wrong door” philosophy; that is, no mat- (SAMHSA), the U.S. Department of ter how the individual enters care, the Health and Human Services, the Na- services needed to respond effectively to tional Association of State Mental Health Program Directors (NASMHPD) see Understanding on page 42
Mental Health News - Connecticut Section: Spring 2005 Page 39
Page 40 Mental Health News - Connecticut Section: Spring2005
Tragic Tsunamis from page 6 their concepts of themselves and attach- people enhances coping with the vicissi- adults. There is a paucity of information ment capacities are not as mature as tudes of new life roles, such as being the about the risk for developing psychiatric population and to administer interven- those of adults. Adolescents experience head of the house, the sole parent, and disorders after traumatic events associ- tions, these individuals may be at a sig- hopelessness, and they worry about their the financial provider. Expressive psy- ated with the death of loved ones. Cur- nificantly higher risk for psychological futures. They often avoid speaking with chotherapy fosters discussion of the trau- rently, there exists an insufficient problems. These issues highlight the surviving caretakers about the loss and matic events to enable the bereaved to amount of research for understanding very complicated events leading to men- prefer communicating with peers. There- extinguish recurrent intrusive images of what effective psychotherapeutic and tal health recovery. fore, interventions should have a devel- the event. For children, art therapy is an psychopharmacologic interventions are Bereavement is a process that is a opmental specificity for children, adoles- important intervention method to de- available for traumatized populations. normal reaction to a significant loss. cents, and adults. crease frightening images associated This is particularly relevant for bereaved Children and adults experience grief, but Deaths caused by natural disasters, with the traumatic event. Cognitive psy- children. Research, further investigation, in different ways. Young children do not similar to those by suicide, terrorist attacks, chotherapeutic methods help the survi- and clinical care of traumatized individu- have cognitive development sufficient to homicides, and accidents, are usually asso- vors’ to restructure the way they think als should become an integrated effort in understand the permanence of death. ciated with traumatic reactions. Such trau- about the traumatic event, and it also relieving bereaved people of their pain, Children are less able to tolerate the in- matic bereavement involves disturbing helps to reduce the despair associated suffering, and despair. Increased finan- tense and painful emotions of sadness, recurrent images and intrusive thoughts of with loss. Cognitive therapy aims to cial support and higher enthusiasm for guilt, anger, and anxiety, which are the how the loss occurred, hyperarousal to decrease depression and anxiety. these intertwined research and clinical fundamental aspects of grieving. Chil- sudden sounds, problems sleeping, night- Medications, such as selective sero- endeavors will ensure that the most sig- dren display various coping characteris- mares, intense longing for the deceased, tonin re-uptake inhibitors, can be help- nificant needs of bereaved individuals tics, such as increased activity and with- and intense shock at the loss. ful in reducing some of the symptoms are addressed, and that the potential for drawal, in order to decrease experiencing Interventions for those who suffer of traumatic reactions already dis- healthy outcomes are strengthened. these painful emotions. Children may traumatic bereavement involve consis- cussed (such as hyper-arousal), as well Bereavement is a human condition appear not to be impacted by a signifi- tent external support from others, discus- as intense anxieties about the event, that is gripping, intense, and painful. cant loss. However, physical symptoms, sion of feelings and reactions, methods and worries about coping with new life Grieving reorganizes ones’ emotions and such as sleeplessness, bedwetting, and to decrease hyperarousal, and techniques circumstances. Selection of other perceptions. For many, this condition is strong emotional reactions (including to maintain a focus on other activities medications is based on an individual’s long-lasting and debilitating, but for clinging onto the surviving caretakers), that enable the bereaved to have relief symptom profile. most it leads to new personal strengths worries about the safety of surviving from recurrent and intrusive images and Genuine expressions of kindness of- and goals. It is imperative for all of us relatives, and the inability to be away thoughts. Techniques to assist in relaxa- fered to bereaved individuals are one of the to understand more about the physical from surviving loved ones, are manifes- tion are often helpful. Guided expressive most effective approaches to reduce feel- and psychological manifestations of tations of children’s responses to the psychotherapy enables the bereaved to ings of loneliness, anxiety, and sadness. It this universal process; we must de- death of a loved one. Adolescents re- talk about their painful feelings; longing empowers the bereaved to conceive of velop more effective socio-culturally spond to the death of a loved one in for the deceased and anxiety about their hope in order to confront life’s course. pertinent interventions to help reduce similar ways as adults because they have life circumstances is an important aide to More research is needed to under- bereavement complications that are abstract cognitive abilities and greater the bereavement process. The support of stand the long-term outcomes of trauma- suffered by those whose loss occurs tolerance for painful feelings. However, group discussions with other bereaved tized bereaved children, adolescents, and under traumatic circumstances. □
MENTAL HEALTH NEWS ~ SPRING 2005 PAGE 41
CALL US TO PUT IT ALL TOGETHER.
Anxiety · Stress · Mood Swings Changes in Relationships · Lack of Energy Eating Disorders · Hopelessness · Irritability Substance Abuse · Sleeplessness · Problems at Work
If you’re suffering from emotional stress or have any of the above symptoms prompted by a medical problem, we can help. From toddlers to seniors, the Behavioral Health Center at Westchester is uniquely qualified with a comprehensive range of behavioral health services. If you need
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To put it all together, simply call 914-493-7088
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PAGE 42 MENTAL HEALTH NEWS ~ SPRING 2005
The Patchwork from page 29 ders is improving. Training is available. services to an individual with a singular Individuals who are dually diagnosed and Interagency task forces convene to aid in mental health disorder. Child psychia- do not receive integrated treatment will con- context of expectations around compe- coordination. However, there are still trists charge higher rates because of the tinue to have high rates of negative outcomes, tency, or standards for credentialing –– many blanks to fill in. A comprehensive required additional specialization and including hospitalization, overdose, violence, can waste resources. In order for training plan for integrating these efforts is nec- training. Dual recovery providers also legal problems, homelessness, victimization, to be truly effective, mental health pro- essary, and we cannot fill gaps in need need additional specialization, education, HIV-infection, and other co-occurring health fessionals should be involved in all when we do not have a complete picture training, and experience with multiple concerns. The Presidents’ New Freedom stages of planning and evaluation. On- of where we are and where we’re going. disorders across many delivery systems Commission on Mental Health, Report of the site technical assistance with application A comprehensive planning effort is nec- in order to provide effective treatment. It Subcommittee on Co-occurring Substance of learned skills into daily treatment essary for assessing needs, assessing is logical that these professionals be Abuse and Mental Health Disorders states, practices is one way to increase the ef- existing services, credentialing programs compensated for their additional spe- “Individuals in integrated programs spent fectiveness of training and impact and individuals who achieve a standard cialization and expertise. With current significantly less time in institutions, hospi- agency culture. Creating a feedback of core competency, training those who reimbursement rates, agencies are unable tals, emergency rooms, jails, or living on the mechanism that assesses the impact that do not, providing incentives for agencies to offer salaries that reflect these higher streets homeless.” The high cost in human the trainings have on improved outcomes to provide services, and adequately reim- competencies, and therefore have diffi- potential, as well as the high cost to tax- for patients, and program performance bursing those agencies who are provid- culty hiring and maintaining staff that payers for these expensive alternatives, measurement, will help to improve fu- ing integrated treatment already. are able to effectively treat the individu- can be minimized. A larger investment ture trainings. Funding is drastically lagging behind als who walk through their doors. now will mean significant savings down Measures are being taken at all levels the motivation and inclination of both Unless funding is adapted to accurately the road. Looking at the big picture over of government –– federal, state and local policymakers and service providers to reflect the true cost of providing effec- the long term, both in funding and in –– to improve services for dually diag- implement them. The cost of providing tive evidence-based services, agencies planning, is necessary in order to im- nosed individuals. Prevalence and qual- services to individuals with dual diagno- will continue to be limited in their prove the quality of life and to reduce ity of screening for co-occurring disor- ses is higher than the cost of providing ability to do so. costs to our society. □
Integrated Treatment from page 29 in a dialectical framework that would support as a team that collaborates on all initial tation. One patient with frequent rape- varying stages of change within each individ- assessments and treatment planning. Pro- related flashbacks may need to have in- function best when their symptoms are ual. Finally, they are compatible with a treat- gram planners and staff members should creased staff monitoring or a peer “buddy” managed within an integrated treatment ment philosophy that relapse within each of anticipate a wide range of behaviors and to minimize dissociation. Consumers with setting. Challenges associated with an the disorders is expected. Staff members must symptoms that affect our consumers dur- borderline personality disorder may need to integrated approach include: ensuring that be prepared to work with collateral treatment ing their stays in co-occurring disorders have increased structure and written assign- staff are trained comparably in treating providers, e.g., Dual Diagnosis Intensive Out- treatment. These symptoms and behaviors ments with concrete and definable goals. both substance abuse disorders and psy- patient Programs, that maintain a “Harm Re- can be managed through the use of phar- Group work is the modality of choice for chiatric illness; providing adequate time duction” model of treatment. The treatment macological, behavioral, psychodynamic treatment with this population. They should to assess both illnesses separately and as task is to join with the client’s goals for and educational interventions. Staff mem- include: psycho-educational groups with an co-factors of each other; individualizing growth and to help the client integrate how bers must collectively gain an under- emphasis on building coping skills, learning treatment plans so as to address the di- “small” changes improve his or her chances of standing of the probable cause for any about psychiatric symptoms, and managing verse levels of individual functioning; reaching those goals. maladaptive behaviors. They must re- medication; short Support Groups to gener-
and ensuring that individuals are often Training and Supervision for Staff spond to those behaviors in a way that ate connection among peers and to normal- functioning at different stages of change provides a sense of safety for all consum- ize living with co-occurring disorders; 12- (Prochaska & DiClemente, 1984) in re- Program planners must incorporate appro- ers, contains the anxiety that may have Step groups that normalize the use of psy- gards to the two disorders. Stages of priate staffing and training plans to meet the given rise to the behavior, and provides a chotropic medication, as in “Double Trou- change assessments must be made for needs of our consumers. All staff should be therapeutic milieu for the patient to gain ble” groups; and Relapse Prevention both of the disorders. trained in the theoretical underpinnings of the an understanding and experience of men- Groups that integrate a disease and re- The last challenge necessitates an ex- program, treatment models, chemical depend- tal health and sobriety. At St. John’s Riv- covery model for both disorders, mini- ample to illuminate its complexity. An ency and the psychiatric disorders. Ongoing erside Hospital Behavioral Health Ser- mizing shame regarding the relapse individual may recognize that he needs in-services should introduce new areas of vices in Yonkers, New York, our staff process. This model also increases treatment for his cocaine addiction and expertise to staff on a monthly basis, so as to utilizes the Crisis Intervention Services’ hopefulness: recovery can be framed to therefore may be assessed to be in the increase staff effectiveness and familiarity Model of Non-Violent Crisis Intervention applaud decreased use, decreased time preparation stage for substance abuse. with the evolving health care system. as a means of formulating interventions to between treatment episodes, and in- However, he may concurrently be in the The population of individuals with co- help a client manage anxiety. Minkoff creased length of sober time. pre-contemplation stage of change in re- occurring disorders can be a demanding (1998) further recommends that clients Treatment providers have an opportu- gards to his PTSD symptoms. group with which to work. Clinicians and who are discharged for non-compliance nity at this juncture to spearhead an im- In order to optimize treatment outcomes, nursing staff need to have ongoing, regu- or substance use be encouraged to return. portant treatment approach for our indi- program planners must address each of the lar supervision to ensure excellent treat- Consumers with co-occurring disorders viduals with co-occurring disorders. We above concerns in a comprehensive way. The ment provision, to minimize ineffective need specialized program content and struc- must initiate this venture with a keen at- program could utilize Prochaska & Di- counter-transference, and to maintain ture. Many consumers may be operating at tention to the multiple needs of our con- Clemente’s model of change and Motivational staff member wellness. their baselines, and yet may still be experi- sumers, the development of excellent care Interviewing as joint methodologies for the encing internal stimulation and negative for our consumers, and providing essen- program. These approaches would serve to Guidelines for Treatment symptoms, such as poor social skills and tial support of our staff members. Such provide the flexible and compassionate stance Expectations for Consumers isolative behavior. These consumers will an approach will result in continuing im- necessary for our consumers. They would also need a flexible structure that adapts to the provement in the service provision for all ground clinical assessment and interventions Staff members must definitively work changing nature of their symptom manifes- of our consumers. □
see Understanding from page 38 being conducted by the State Mental language, race, religion, age, disability, homeless, incarcerated, or institutional- Health and Substance Abuse Directors. In gender, sexual orientation, or socioeco- ized), with higher rates of mental disor- an individual with both severe mental 1999, SAMHSA issued a policy state- nomic standing. Because the nation’s popu- ders and more barriers to care. These and illness and severe substance abuse are ment that enthusiastically supported the lation is shifting rapidly, this challenge is other findings suggest it is more impor- available and accessible. Integrated ser- conceptual framework for its ability to becoming more complicated. tant than ever that persons with co- vices are often offered through a single- capture all levels of functional impair- Today, for example, one in three occuring mental and substance-abuse service agency, whose staff have been ment related to mental illness and sub- Americans are non-white. By 2050, pro- disorders be offered services that are cul- cross-trained and are competent to re- stance abuse, and indicates a need to pro- jections place the population of non-white turally sensitive and tailored to their spond to the unique challenges of co- vide such services on a broader, more and/or Latino individuals at 47 percent. unique needs. occurring disorders. systematic basis. According to Mental Health: Culture, Credits: This article was excerpted Unfortunately, integrated services are not Race and Ethnicity; A Supplement to from “Co-occurring Mental and Sub- currently available in most communities. Cultural Competency Mental Health – a Report of the Surgeon stance-Abuse Disorders: A Guide for Consequently, many individuals who would General (DHHS, 2001), minorities are Mental Health Planning and Advisory benefit from integrated treatment find them- A key responsibility of behavioral less likely than whites to receive needed Councils,” 2003. U.S. Department of selves in hospital emergency rooms, jails, health care systems is to deliver effective mental health services and more likely to Health and Human Services, Substance prisons, and other non–health-oriented set- services in an environment that is both wel- receive poor quality care. Minorities are Abuse and Mental Health Services Ad- tings that may not meet their needs. coming and responsive to individual needs, over-represented among the nation’s most ministration, Center for Mental Health There is growing support for the work irrespective of ethnicity, national origin, vulnerable populations (people who are Services: www.samhsa.gov □
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