MENTAL HEALTH NEWSTM YOUR TRUSTED SOURCE OF INFORMATION, EDUCATION, ADVOCACY AND RESOURCES

FALL 2005 FROM THE LOCAL, STATE, AND NATIONAL NEWS SCENE VOL. 7 NO. 4 Understanding and Treating Schizophrenia

National Institute of tion hold the promise of new insights Mental Health, NIMH into the disorder.

Schizophrenia as an Illness chizophrenia is a chronic, se- vere, and disabling brain dis- Schizophrenia is found all over the ease. Approximately 1 percent world. The severity of the symptoms and S of the population develops long-lasting, chronic pattern of schizo- schizophrenia during their lifetime— phrenia often cause a high degree of more than 2 million Americans suffer disability. Medications and other treat- from the illness in a given year. Al- ments for schizophrenia, when used though schizophrenia affects men and regularly and as prescribed, can help women with equal frequency, the disor- reduce and control the distressing symp- der often appears earlier in men, usually toms of the illness. However, some peo- in the late teens or early twenties, than in ple are not greatly helped by available women, who are generally affected in treatments or may prematurely discon- the twenties to early thirties. People with tinue treatment because of unpleasant schizophrenia often suffer terrifying side effects or other reasons. Even when symptoms such as hearing internal treatment is effective, persisting conse- voices not heard by others, or believing quences of the illness—lost opportunities, that other people are reading their minds, stigma, residual symptoms, and medication controlling their thoughts, or plotting to side effects—may be very troubling. harm them. These symptoms may leave to suffer some symptoms throughout and safer medications and unraveling The first signs of schizophrenia often them fearful and withdrawn. Their their lives; it has been estimated that no the complex causes of the disease. appear as confusing, or even shocking, speech and behavior can be so disorgan- more than one in five individuals recov- Scientists are using many approaches changes in behavior. Coping with the ized that they may be incomprehensible ers completely. from the study of molecular genetics symptoms of schizophrenia can be espe- or frightening to others. Available treat- This is a time of hope for people to the study of populations to learn cially difficult for family members who ments can relieve many symptoms, but with schizophrenia and their families. about schizophrenia. Methods of im- most people with schizophrenia continue Research is gradually leading to new aging the brain’s structure and func- see Schizophrenia on page 22 A New Context for the Treatment of Schizophrenia

By Stuart Forman, MD In the traditional view of chronic illness, other less costly interventions. If prop- our control. (This is not to disparage, of Medical Director schizophrenia is understood to be a brain erly understood as organ malfunctions, course, the critical “lifestyle” changes Capitol Region Mental Health Center disorder in the same sense that diabetes psychiatric illnesses might attract less that can make an enormous difference in Hartford, Connecticut is considered a disorder of the pancreas. stigma. Maybe insurance companies diabetes; it is merely to suggest that the Patients diagnosed with diabetes are told would then cover psychiatric illnesses as processes of thinking and producing that they will need to measure their fully as they do medical problems. insulin are probably more different than have spent the last 23 years mainly blood sugars, watch their diets, and Perhaps, on the other hand, brains are they are similar.) working with people who carry the probably take some sort of medication different enough from pancreases that The Recovery Model reminds us that diagnosis of Schizophrenia. Only for the rest of their lives. Similarly, peo- the analogy doesn’t really work too well. psychiatric illnesses have a way of de- during the past year have I heard ple with schizophrenia have often been At this moment in time, a person whose priving people of their hopes and Ithe term “recovery” routinely mentioned. told that they “have a chronic illness” pancreas has stopped making insulin is dreams. In the broadest sense, our goals These days, however, one is hearing it and will always need to take medication. likely to need insulin injections on a as mental health providers should be to more often. It appeared repeatedly in the The idea regarding both schizophrenia and permanent basis. Let’s now contrast this help people recapture these treasured report of the New Freedom Task Force diabetes is that one can treat the symptoms with a person experiencing some sort of aspects of their lives. We professionals appointed by President Bush to redefine (i.e., high blood sugar for diabetes and psychotic symptom. Someone experi- need to remember, of course, that we are mental health services in our country. psychosis for schizophrenia), but that in encing auditory hallucinations, for ex- technical consultants with relatively Implementation of the Recovery Model some sense, the disease persists even in the ample, might be able to learn to ignore modest contributions to make to the re- is a major strategic goal of Connecticut’s absence of symptoms. the hallucinations, or at least to distin- covery efforts of the people with whom Department of Mental Health and Addic- For years, the idea of making mental guish them from other stimuli. Might we work. What we have to offer is tion Services. Is something new really health more “medical” has been appeal- this have the effect of reducing (or even “treatment.” We are, after all, experts in going on here, or are we simply playing ing to many. Perhaps, if we could some- eliminating) the need for medication? using medications to reduce certain with semantics? how become more “scientific,” we The fact that psychiatric symptoms over- “symptoms.” We know how to teach One way to understand the recovery would discover more effective and effi- lap with conscious thinking renders them certain skills, and how to help people paradigm is to contrast it with more tra- cient treatments. Some of our notori- quite different from bodily functions understand psychological patterns in ditional “medical model” views of se- ously labor-intensive treatments might (e.g., insulin production) that tend to vere and prolonged psychiatric illnesses. be dropped in favor of medications and operate apart from things that are under see New Context on page 39

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PAGE 2 MENTAL HEALTH NEWS ~ FALL 2005 Mental Health News Advisory Council

Sigurd H. Ackerman, MD, President & Medical Director Donald M. Fitch, MS., Executive Director Rabbi Simon Lauber, Executive Director Thomas E. Sanders, CSW, President & CEO Silver Hill Hospital The Center For Career Freedom Bikur Cholim of Rockland County Family Service of Westchester

Nadia Allen, Executive Director Pam Forde, Director Joseph Lazar, Director, New York City Field Office Phillip Saperia, Executive Director Mental Health Association in Orange County Putnam Family Support and Advocacy New York State Office of Mental Health Coalition of Voluntary Mental Health Agencies

Richard Altesman, MD, Representative Michael B. Friedman, LMSW Leo Leiderman, PsyD, ABPP, Director Jennifer Schaffer, PhD, Commissioner American Psychiatric Association National Assembly Public Policy Consultant Saint Vincent Hospital - Latino Treatment Services Westchester County Department of Community Mental Health

Gene Aronowitz, PhD, Director of Operations Maureen Friar, Executive Director Dominick Lepore, MS, CTRS, Vice President Judy L. Scheel, PhD, Director Fordham-Tremont Community Mental Health Center Supportive Housing Network of New York Westchester Medical Center - Behavioral Health Center Center for Eating Disorder Recovery

Peter C. Ashenden, Executive Director Steven J. Friedman Andrew P. Levin, MD, Medical Director Edythe S. Schwartz, ACSW, Executive Director Mental Health Empowerment Project Mental Health & Public Policy Analyst Westchester Jewish Community Services Putnam Family & Community Services

Chris Ashman, MS, Commissioner Kenneth M. Glatt, PhD, ABPP, Commissioner Robert M. Lichtman, PhD, DAPA J. David Seay JD, Executive Director Orange County Department of Community Mental Health Dutchess County Department of Mental Hygiene Rockland Psychiatric Center NAMI - New York State

Jeannine Baart, MS Arnold Gould, Co-President Constance Lieber, President, Board of Directors Janet Z. Segal, CSW, Chief Operating Officer Mental Health Education Consultant NAMI Queens/Nassau NARSAD Four Winds Hospital

Alan D. Barry, PhD, Administrative Director, Flemming Graae, MD, Chief, Child & Adolescent Glenn Liebman, President & CEO Kren K. Shriver, MPH, MD, Clinical Director Department of Psychiatry, Norwalk Hospital Psychiatry, Westchester Medical Center Mental Health Association In New York State Hudson River Psychiatric Center

Alexander J. Berardi, LCSW, Executive Director Steven Greenfield, Executive Director Robert Litwak, CSW, Assistant Executive Director Michael Silverberg, President KEYSTONE Mental Health Association of Nassau County Mental Health Association of Westchester NAMI - New York State

Al Bergman, Chief Executive Officer Ralph A. Gregory, President & CPO Hon. Nita M. Lowey Alan B. Siskind, PhD, Executive Vice President & CEO SLS Health United Way Of Westchester & Putnam U.S. Congress - 18th District Jewish Board of Family and Children’s Services

Sheldon Blitstein, CSW Mary Guardino, Founder & Executive Director Paige Macdonald, Executive Director Jeffery Smith, MD NY United Hospital - Behavioral Health Services Freedom From Fear Families Together in New York State Private Practitioner

James Bopp, Executive Director Mark D. Gustin, MBA, MPS, Senior Associate Director Lawrence Mandell, President & CEO Steven H. Smith, PsyD, Consulting Psychologist Rockland and Middletown Psychiatric Centers Kings County Hospital Center United Way of New York City Grace Church Community Center

Linda Breton, CSW, Assistant Executive Director Abraham Halpern, MD, FACP, Professor Emeritus Randall Marshall, MD, Associate Professor of Clinical Thomas E. Smith MD, Medical Director Westchester Jewish Community Services of Psychiatry - New York Medical College Psychiatry, New York State Psychiatric Institute Hall-Brooke Behavioral Health Services

David S. Brownell, ACSW, Commissioner Mary Hanrahan, Government Relations Specialist Richard H. McCarthy, PhD, MD, CM, Associate Professor Andrew Solomon, Contributing Writer, Magazine Onondaga County Department of Mental Health New York Presbyterian Hospital of Psychiatry, Albert Einstein College of Medicine The New York Times

Jacqueline Brownstein, Executive Director Dean B. Harlam, MD, Associate Medical Director Steven Miccio, Executive Director Hon. Andrew J. Spano Mental Health Association in Dutchess County Saint Vincent’s Behavioral Health Center - Westchester PEOPLe Westchester County Executive

John F. Butler, Director of Community Affairs Carolyn S. Hedlund, PhD, Executive Director David H. Minot, Ithaca College, Chairman Hon. Nicholas A. Spano Verizon - New York Mental Health Association of Westchester Mental Health News - University Advocacy Division New York State Senate - 35th District

Peter C. Campanelli, PsyD, President & CEO Rhona Hetsrony, Executive Director Grant E. Mitchell, MD, Director, Mental Health Services Giselle Stolper, Executive Director Institute for Community Living North Shore LIJ Health System - Zucker Hillside Hospital The Mount Vernon Hospital Mental Health Association of New York City

Sharon E. Carpinello, RN, PhD, Commissioner Richard S. Hobish, Esq., Executive Director Peg E. Moran, CSW, VP, Administrative Services Harris B. Stratyner, PhD, CASAC, Director New York State Office of Mental Health Pro Bono Partnership Behavioral Health Services - St. Vincent’s Catholic Medical Centers Mount Sinai Hospital Chemical Dependency Program

Alison Carroll, CSW, Director of Day Treatment Doug Hovey, Executive Director Charles Morgan, MD, Chairman Jeannie Straussman, Director, Central NY Field Office Putnam Family & Community Services Independent Living Center of Orange County Bridgeport Hospital - Department of Psychiatry New York State Office of Mental Health

Megan Castellano, Director Marsha Hurst, PhD, Director, Health Advocacy Program Meryl Nadel, DSW, Chairwoman Timothy B. Sullivan, MD, Clinical Director Mental Health Association of Putnam County Sarah Lawrence College Iona College - School of Social Work Saint Vincent’s Behavioral Health Center - Westchester

Amy Chalfy, CSW, Bronx District Director Beth Jenkins, Executive Director Sarah Newitter, President Janet Susin, Co-President JASA Mental Health Association in Tompkins County NAMI of Westchester NAMI Queens/Nassau

Steven K. Coe, Executive Director Tom Jewell, PhD Evelyn J. Nieves, PhD, Executive Director Richard P. Swierat, Executive Director Community Access Family Institute for Education Practice and Research Fordham-Tremont Community Mental Health Center Westchester ARC

George M. Colabella, President Sabrina L. Johnson, BA, Recipient Affairs Liaison Karen A. Oates, DSW, President & CEO Alan Trager, Executive Director & CEO Colabella & Associates Westchester County Department of Community Mental Health Mental Health Association of Rockland County Westchester Jewish Community Services

Marianne Coughlin, Vice President Program Development Rami P. Kaminski, MD, Medical Director of Operations Senator Suzi Oppenheimer Anthony F. Villamena, MD, Chief of Psychiatry The Mount Sinai Medical Center New York State Office of Mental Health New York State Senate - 36th District Lawrence Hospital Center

Hugh Cummings, MD, President John M. Kane, MD, Chief of Psychiatry Matthew O’Shaughnessy, Senior Vice President Jonas Waizer, PhD, Chief Operating Officer Psychiatric Society of Westchester Hillside Hospital WVOX & WRTN Radio F.E.G.S. Health and Human Services System

Anthony A. Cupaiuolo, Director Anne Katz, Vice President Ellen L. Pendegar, MS, RN, CS, CEO Joyce Wale, Assistant Vice President - Behavioral Health Michaelian Institute - PACE University North Fork Bank Mental Health Association In Ulster County New York City Health & Hospitals Corporation

Joseph Deltito, MD, Clinical Professor of Psychiatry and Ron Kavanaugh, Executive Director Barry B. Perlman, MD, Chief of Psychiatry Mary Ann Walsh-Tozer, Commissioner Behavioral Science, New York Medical College Search For Change St. Joseph’s Hospital - Yonkers Rockland County Department of Mental Health

Anthony B. DeLuca, ACSW, Commissioner James J. Killoran, Executive Director Premkumar Peter, MD, Medical Director Michael Wein, CSW, CASAC, Administrator Tompkins County Mental Health Services Habitat For Humanity - Westchester Putnam Hospital Center - Mental Health Services NY United Hospital - Behavioral Health Services

Steve Dougherty, Executive Director Thomas A. Kirk, Jr., PhD, Commissioner Cynthia R. Pfeffer, MD, Professor of Psychiatry Peter Yee, Assistant Executive Director Laurel House Connecticut Dept. of Mental Health & Addiction Services Weill Cornell Medical College of Cornell University Hamilton-Madison House

Toni Downs, Executive Director Samuel C. Klagsbrun, MD, Executive Medical Director Michael J. Piazza, Jr., Commissioner Neil Zolkind, MD, Clinical Director Westchester Residential Opportunities Four Winds Hospitals Putnam County Department of Mental Health Westchester Medical Center - Behavioral Health Center

Douglas Drew, Consumer Link Advocate Easy Klein, Media Coordinator Starr R. Rexdale, MD, Medical Director committee in formation Mental Health Association of Nassau County NAMI - New York Metro Division The Guidance Center

Kenneth J. Dudek, Executive Director Andrea Kocsis, CSW, Executive Director Evelyn Roberts, Executive Director Mental Health News Fountain House Human Development Services of Westchester NAMI - New York City Metro wishes to expresses its deep appreciation to the members of our Advisory Council Stephen P. Fahey, President & CEO Joshua Koerner, Executive Director Harvey Rosenthal, Executive Director for their inspiration, guidance and support. Hall-Brooke Behavioral Health Services Choice NYAPRS Many thanks to our readers, contributing writers Rena Finkelstein, President Lois Kroplick, MD, Founder & Chairwoman L. Mark Russakoff, MD, Director of Psychiatry and to our many advertisers for their support NAMI-FAMILYA of Rockland County Mental Health Coalition of Rockland County Phelps Memorial Hospital Center without which this publication would not be possible.

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 3 Table of Contents From The Publisher This Issue: Continued

4 The Hope for People With Serious Mental Illness 39 Stopping the Stigma of Schizophrenia

Mental Health NewsDesk Columns

8 Nathan Kline Receives $9.1M for Alzheimer’s Research 13 Point Of View: Baby Boomers Should Prepare Now 8 Med Students Push AMA for Mental Health Education 14 NARSAD Report: Supporting Schizophrenia Research 9 NYS-OMH Implements Med Management Initiatives 16 A Voice Of Sanity: Back to Being Disabled 9 NYS Passes Mental Health Legislation for the Elderly 17 NYSPA Report: Medicare “Part D” an Emerging Reality 18 NAMI-NYS Corner: Research - Our Hope for the Future This Issue: Understanding Schizophrenia 19 Mental Health Lawyer: A Forum for Discussion 1 NIMH Comprehensive Overview of Schizophrenia 1 Connecticut’s New Context for Treating Schizophrenia Additional Articles of Interest

5 Reflections Before the Onset of Schizophrenia 11 Mental Health News Founder Receives Media Award 6 A Second Chance for People With Schizophrenia 11 NYS Attorney General Spitzer Receives APA Award 10 A Day Treatment Perspective on Schizophrenia 11 Hall-Brooke Names New Head of Residential Services 12 Trapped in A Fugue: Jimmy’s Story 27 Medicare “Part D” Could Have Profound Effect 21 Family Involvement Improves Schizophrenia Outcomes 34 Westchester County DCMH is Here To Help You 27 Regaining A Life: Orlando’s Story Four Winds Hospital Advertising Supplement 28 Schizophrenia Treatment: One Size Does Not Fit All 31 Delivering Science-Based Information on Schizophrenia 23 Fawns in Gorilla Suits: Working with Aggressive Children 33 Self-Help Model Serves The Dually Diagnosed 24 Four Winds Hospital Fall Calendar of Events 35 We Are Not Our Illnesses - We Are Not Our Diagnoses Mental Health News Wishes to Thank 36 The Story of L.A. a Client at Connecticut Valley Hospital All of Our Volunteer Contributing Writers Who Made This Issue Possible

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a tax-exempt, not-for-profit organization located at Alan B. Siskind, PhD, Executive Vice President & CEO Janet Z. Segal, CSW, Chief Operating Officer 65 Waller Avenue, White Plains, New York 10605. Jewish Board of Family and Children’s Services Four Winds Hospital

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Note: all articles and letters to the publisher must be e-mailed. Anne Katz, Vice President All group photo credits always view from left to right. North Fork Bank

Members of the Board of Directors Our office hours are from 9-5 (M-F) at (914) 948-6699 Our e-mail address is [email protected]. Please visit our website Peter C. Campanelli, PsyD, President & CEO Leo Leiderman, PsyD, Director, Latino Treatment Services Institute for Community Living Saint Vincent Catholic Medical Center

Donald M. Fitch, MS., Executive Director Peg E. Moran, CSW, VP, Administrative Services The Center For Career Freedom Behavioral Health - St. Vincent Catholic Medical Centers www.mhnews.org Michael B. Friedman, LMSW Barry B. Perlman, MD, Director of Psychiatry Public Policy Consultant St. Joseph’s Hospital – Yonkers Mental Health News does not endorse the views, products, Mary Hanrahan, Government Relations Specialist Alan Trager, Executive Director & CEO or services contained herein. No part of this publication New York Presbyterian Hospital Westchester Jewish Community Services may be reproduced in any form without written permission. Carolyn S. Hedlund, PhD, Executive Director Jonas Waizer, PhD, Chief Operating Officer Mental Health News is not responsible for omissions or errors. Mental Health Association of Westchester F.E.G.S. Health and Human Services System

Andrea Kocsis, CSW, Executive Director Ira H. Minot, CSW, Executive Director Copyright © 2005 Mental Health News. All rights reserved. Human Development Services of Westchester Mental Health News Education, Inc.

PAGE 4 MENTAL HEALTH NEWS ~ FALL 2005 From The Publisher

The Hope For People You want to be alert, vibrant and as far an opportunity to call on their own inner away from an altered state as possible. strengths when they find themselves With Serious Mental Illness Most importantly, knowing that there's seeing the light at the end of the tunnel. hope - that I could get better - kept me During my own battle with serious By Ira H. Minot, CSW, Founder striving.” depression, I reached a pivotal time and Publisher, Mental Health News In his own words, L.A., a young man when I knew I was ready to leap ahead who sustained Traumatic Brain Injury toward recovery. For me, it came several (TBI) and has the additional burden of a months after a specialized course of am truly proud of everyone who mental illness, gives us his feelings treatment had finally succeeded in lifting helped us put together this issue of about his recovery process in: The Story the dark curtain of my depression. I will Mental Health News which is dedi- of L.A., A Client at Connecticut Valley never forget my frustration and chagrin cated to the understanding and Hospital (page 36). With TBI, L.A. has with the program director of the outpa- Itreatment of schizophrenia. Thanks to difficulty doing simple tasks, He credits tient program I had been attending, who our volunteer network of clinicians, pro- his own determination, his spiritual be- would not take my enthusiasm for recov- vider organizations, consumers, advo- liefs and the caring staff at his facility ery seriously. When I insisted I be put on cates and public policy analysts, we are for keeping him going towards success. a faster track to recovery she said, “why fortunate to provide you with many in- He says: “I’ve learned to love myself don’t we talk about this in Group.” I will spiring and informative articles. They more and hate myself less. I’ve been also never forget a staff member at the run the gamut from life-saving treatment doing really well now. I stay real busy same program who understood my frus- programs, individual triumphs over ad- by working at separate things. I like feel- tration at being turned a deaf ear. She versity, calls for action on the legislative ing like this inside—happy and content! took me aside behind closed doors that front, and the hope that research gains Plus I don’t feel so stupid anymore. I very day and told me, “there is a peer- will improve the lives of people with Ira H. Minot, CSW take that bad attention off myself and put run drop in center in the community that serious mental illness. it on things I know I can do and I do I think can help you.” I went, it helped, Our cover story by the National Insti- mation from darkness into a brighter them...I have a lot more friends now and the rest is history. tute of Mental Health (NIMH) gives us a light as the spirit within all living things: including staff who will take some time If I had more room I would tell you comprehensive look at the many clinical “to move beyond our limitations—to to talk to me when I need it. They tell about all the other wonderful articles in and treatment aspects of schizophrenia. I build a fire underneath ourselves and to me “good job L.A., Keep it up!” I plan this issue, but will leave that to you. am eternally grateful to the NIMH, finally acknowledge and give honor to not to let them down or myself.” As the fall season comes our way and whose website always helps us provide the individual unique strength in each of I wanted to single out these personal beckons forth another new year, it is my our readers with concise and up-to-date us to survive, endure and excel.” accounts for their courage, hope and hope that we continue to fight for more reviews of the full range of mental ill- Mindy Appel, ACSW, LCSW, tells inspiration. However not all stories have adequate funding for mental health ser- nesses. I encourage you to visit their the story of a young man’s decent into happy endings—reminding us of the vices, increased funding for ground- website, www.nimh.nih.gov. schizophrenia in: Trapped in A Fugue: importance of providing mental health breaking research which is unlocking the Our second cover page article is by Jimmy’s Story (page 12). Her compel- education to you and to communities mysteries of brain disorders, and for all Stuart Foreman, MD. Dr. Foreman pro- ling description of Jimmy, his parents near and far. It reminds us that proper of us to become more vigilant stewards vides us with a fresh and inspiring look and younger sister, details the pain, de- treatment, family involvement, and re- for the elimination of stigma towards at how mental health providers in the spair and feelings of guilt, that many covery options must be provided to help people with mental illness. State of Connecticut are establishing and families endure when a loved one is people with mental illness. We must also implementing ‘recovery’ principles as a gripped by a serious mental illness. Ms. remember that people need respect and Have a wonderful fall season !! major strategy. Their hope is to be able Appel offers a hopeful message amidst to demonstrate that by listening to and the tragic story of Jimmy in saying: “It is involving the client in providing treat- essential that there be more parent and ment services, they will increase their family education concerning treatment effectiveness in helping people with and medications available in such cases. Mental Health News mental illness regain valued aspects of Only in destigmatizing those with mental their lives. I was inspired and filled with illness can we hope to get them the treat- Upcoming Themes & Deadlines feelings of hope for the clients who will ment they need and cut down on the de- be impacted by Connecticut’s initiative, nial and ignorance of the true nature of because of memories of my own recov- mental illness. Jimmy’s life was a testa- your participation is welcomed ery from a ten-year battle with severe ment to the need for that process – may depression. After years of repetitive out- his legacy be in increasing the awareness patient attempts to get well, it was at- of others in similar situations before it is tending a neighborhood (peer-run too late.” Winter 2006 Issue ‘recovery’ oriented) drop-in center that Denise Kreitzman, of The Mental helped me reclaim the lost elements of Health Association of Nassau County “The Many Faces of Anxiety Disorders” my own inner strengths as a person—not tells the story of Orlando and his battle just as a patient. This, put me on the road with schizophrenia in: Reclaiming a Deadline: November 1, 2005 to recovery and led me to create the pub- Life: Orlando’s Story (page 27). In it, lication you are now reading. she describes Orlando’s ordeal, the help Isn’t it amazing what people with and support he received from the MHA mental illness can achieve, if given the and his inspiring path to recovery. In his Spring 2006 Issue right care, respect and opportunity? own words, Orlando shares his personal Providing hope for people with men- feelings in saying: “Recovery is a com- “Managing Mental Health Crises” tal illness is one of the cornerstones of bination of things. Getting better hap- Mental Health News. This theme contin- pens when you utilize the system to your Deadline: February 1, 2006 ues to weave a heartfelt and compelling advantage…to the best of your capabili- fabric in this issues four personal ac- ties. That means compliance with meds, count stories. therapy and the internal drive to want to Susan Weinreich, an award-winning recover. I had to hit rock bottom before artist, gives us a close-up look into her I came around and saw things realisti- Summer 2006 Issue childhood and her oncoming decent into cally again. When that happened I schizophrenia in: Reflections on a Child- wanted the stability, I wanted to be at my “Understanding Autism Spectrum Disorders” hood Before the Onset of Schizophrenia best. Once you start to get your old feel- (page 5). Susan, who today has re- ings back…feelings of wellness, you Deadline: May 1, 2006 claimed her life, explains her transfor- don't want any other conscious state.

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 5

Reflections on a Childhood Before the Onset of Schizophrenia

By Susan Weinreich to my nostrils. I managed to open a tube old, including my own, during my journey and with the smear of an index finger I through illness and recovery. For all of the placed a dab of oil and pigment behind years of suffering and torment, I could not ith the delighted mind of each ear. I failed every subject in school help but ask why? an inquisitive child grow- except art and English. I even failed Janice was a brilliant young poet ing up amongst the dense gym. Biology fascinated me, especially whom I had met during my hospitaliza- W embrace of an enigmatic dissection, reproduction and osmosis. tions. She fought her demons as I had nature, I began my life. I studied the In the fall of 1973 I entered my fresh- and struggled incessantly. I wanted so earth’s floor, overturning rocks and ex- man year at The Rhode Island School of much to make sense of what was lost amining birds with their locked wings as Design. Unprepared emotionally, my and I wondered what had become of her. they lay in silence in the steamy decay of isolation continued and I succumbed I had hoped that despite her illness, her leaves that padded the woods outside my rather steadily into a deep descent with soul had continued to flourish. I also had home. Having flown unaware into the extreme psychological deterioration. The hoped that some of her poetry, which she large plate glass windows of our contem- intensity and confusion of my sexual read to me night after night from my porary house, the birds struck with a drive served to exacerbate an already hospital bedside, was contained in the force and fell stunned, to the ground. accelerating disease process. With the suitcase that she left with me for safe Some recovered and in time, flew off. analytic spin of the Freudian psychiatrist keeping. Her suitcase had been locked Others did not. Numerous streams and treating me, I continued to unravel with for twenty years and had rested un- marshy terrain surrounded the neighbor- great force. My mind eventually shat- touched in the basement of my child- hood in which I lived. Crouching for tered and disseminated into a thousand hood home in Connecticut. As the years hours, my knees damp and stained, I isolated multiple fragments, a splintering passed, I grew impatient. My need for relished the deep draw and ornery scent of substance into ether. Mirrors, when answers swelled within my now fully of skunk cabbage nearby. Those were the placed facing each other, receded into an functioning heart and mind, until one times I would lose myself in the endless endless reverberation of boundary-less day, hammer in hand, I made the famil- flow of water, navigating pebbles, leaves sensory and psychological reality. iar descent down the green linoleum and twigs to redirect the rush of foam and Susan Weinreich Many years have passed in what has stairs. That afternoon, in the summer of frogs. Creation lived in the woods. In its felt like a lifetime. In me, a new soul was 1999, I broke into Janice’s suitcase. I simple sophistication and in it’s rigorous my internal world. I contemplated death born and a new breath was given. From was looking for her poetry, her life, her brutality. Both held equal fascination. and identified strongly with significant the dryness and desolation, I evolved, art, for meaning. What I found that day Following these explorations of na- figures from Shakespearean tragedies. and built a new life. A gift so profound, shocked me. I found a suitcase filled ture were the quiet, concentrated and Anything I learned about life, I there are no words. Yet I found myself with empty aluminum pie tins and a solitary years I spent in the damp, unfin- learned, not from parents, family, searching for the meaning in all of the lives ished basement of my family home friends, teachers, but from the execution of all of the people I had met, young and see Reflections on page 38 working with clay. There I abandoned of my work. From the design of the natu- myself to making art under the earth, in ral world. I learned about risk-taking, the dark place, while the other children chance, problem solving and the things

played outdoors, smoked cigarettes and that brought breath to a painting as well drank in the light of the sun. They prac- as the things that destroyed it. My si- ticed their sexual innuendoes, grew tall lence and detachment with others led to SUSAN WEINREICH and went to the prom. countless fantasy and isolation. Yet, my Everyday after school and on week- tendency towards introspection gave me ends, I went down to my basement stu- the ability in later years, to develop tre- dio. My drive to create engulfed me, mendous insight. I had difficulty form- intrigued by the seductivity and sensuos- ing and maintaining friendships. The two ity of this fundamental earthy substance. adults in the house, my mother and my “As clay is to the hand of the potter, father drew consistently and emotionally thus, is man to the hand of God”. I dis- absent, though I had a profound feeling covered this passage in the high holiday of closeness and attachment towards my prayer book during Rosh Hashanah, the father, an architect by profession, who Jewish New Year. Keeping a time sheet supported and nurtured my interest in on the basement wall, I logged in daily art. One brother retreated into his intellect, and recorded the hours I spent at work. the other, perhaps the strongest, ventured Eventually I would surface, leaving a out of the family domain. All of us in our trail of muddy wet clothes and dusty own illusive cocoons, spinning independ- footprints on the polished black slate ently, without any real communication floor, above. with each other of any kind. At times I would fixate on the kilns The basement was a virtual landscape and large walk-in gas furnaces that of skirting field mice, spiders, bugs and would bring my clay vessels to a place musty dark corners. I had a great fear of of stability, inevitably, my mind would the basement. Whether my fear stemmed shift to the gas chambers of World War from a common apprehension or a ques- II. I imagined the fingernail scratches on tionable crime scene of childhood the firebrick from inside the kiln as I trauma, I will never know. Nonetheless, loaded my earthenware for transforma- I forced myself daily down the green “The Kiss” tion to its hardened state. linoleum steps that served as a mote be- Retreating deeper and deeper into my tween the world above and my world New Drawings ~ Oct 7 - 30 work with a mind that had not been chal- below. Each time I went down to release lenged by any external discipline, I man- the intense passion that I felt through my Opening Reception ~ Open to the Public aged to avoid communicating my trou- art, I had to battle the dragon waiting. blesome thoughts. I avoided any form of One afternoon when I ventured into a Friday, October 7, 2005 ~ 6 - 9 PM social development. Whatever the degree section of the basement I clearly kept my of instruction I received from my par- distance from, I found my father’s paint The Northern Westchester Center for the Arts ents, was negligible. Despite my exces- box. It was sitting on a work bench in 272 North Bedford Road, Mount Kisco, New York sive desire and driven instinct to be crea- the far corner of the cellar. Most of the tive from a young age, I was haunted by tubes were old and dry but the strong 914 - 241– 6922 a dark cloud which cast a shadow over infusion of oil remained and I drew them

PAGE 6 MENTAL HEALTH NEWS ~ FALL 2005 Providing a Second Chance For People with Schizophrenia

By Andrew Bloch, MSW, Program nity supports. To date, almost all of the Coordinator and Adam Savitz, MD, 30 dedicated beds have been filled with Unit Chief, Second Chance Program individuals who have graduated from NewYork-Presbyterian Hospital Second Chance. The housing providers Westchester Division have done an excellent job supporting the patients in the community and con- tinuing to teach the community living espite advances in psy- skill in vivo that were reinforced in the chopharmacology, many in- inpatient setting. We are currently dis- dividuals with schizophrenia charging the patients through the SPOA remain too impaired to be system, mostly in New York City, com- dischargedD from the state hospitals. One peting with other hospitals for limited response to this problem in New York openings in the community residences. State was the establishment of a unique Initially there were regularly sched- partnership among a private hospital, the uled meetings with OMH, NYPH-WD New York Presbyterian Hospital- and the housing providers to discuss the Westchester Division (NYPH-WD), the newly developing working relationships New York State Office of Mental Health and to facilitate a better understanding of (OMH), and four community residence the special needs and perspectives of the providers in New York City. The goal of partners. There was genuine excitement this partnership was to develop an alter- and enthusiasm amongst the partners native treatment model for those embarking on this new relationship, and “untreatable” patients who had been in a trust that developed as we worked to- state hospitals for more than three years, gether in the service of providing the or who had otherwise been unable to Andrew Bloch, MSW and Adam Savitz, MD best transition for the patients whom had establish any substantial tenure in the been institutionalized for many years. community. Such patients would be we knew that the community residences transition 80% into the community, and Andrew Bloch has been the liaison be- placed in what was called the Second placed a high premium on these skills, as 80% of these individuals are out in the tween Second Chance, OMH and the Chance Program, a specialized 30-bed well as that consumers with these skills community at any given time. Increas- housing providers since the program inpatient unit at NYPH-WD. The pro- have longer community tenures than ingly over the past 1-2 years, we have opened its doors, and having one contact gram was initially conceived and devel- those without them. been working with individuals who as the “point person” has facilitated the oped by Rami Kaminski, MD who is the The program also uses a token econ- would otherwise have been transferred to smooth transition of patients from one Director of the Family Liaison Bureau at omy, which can be thought of as a pros- a state facility for intermediate level of level of care to another. Housing provid- OMH, Ken Terkelsen, MD who was the thetic environment for people with se- care, and the social learning and token ers find working with Second Chance director of the day treatment program at vere cognitive deficits. Patients earn economy has been effective in prevent- advantageous from several perspectives. the time at NYPH-WD, and Michael tokens for meeting specific behavioral ing state hospital transfer for many of They know that the patients being re- Friedman, MSW who was doing pro- targets: such targets may be for the be- these individuals. We have demonstrated ferred have been through a comprehen- gram development at NYPH-WD. haviors noted above or for aspects of that when intensive behavioral treatment sive rehabilitation program that maxi- The program opened its doors in the group therapy, including arriving on is combined with appropriate pharmacol- mizes the acquisition of community liv- winter of 1998. Patients are identified by time, participating and staying for the ogy, the number of patients deemed to ing skills. They also know that the pa- the staff at the state hospitals as potential entire session. These are skills that are have treatment refractory psychosis is far tients have been stabilized on a medica- candidates for Second Chance. All pro- important for the patients to have as they lower than when medication alone or tion regimen that best addresses their spective patients are then interviewed for re-enter the community and participate medication plus traditional milieu ap- psychotic and affective symptoms while clinical appropriateness, to make sure in day treatment or pre-vocational pro- proaches are used. minimizing troubling side effects. The they understand the nature of the pro- grams. Tokens provide immediate rein- At the program’s inception, fore- housing agency gets “credit” toward gram, that they and their families have forcement for positive, prosocial behav- thought was given to the need for avail- their requirement for taking state hospi- had all of their questions answered, and iors and provide a daily sense of success able community residence beds where tal patients when they take a Second that they are willing to participate volun- and mastery for even the most impaired the patients could be placed once they Chance patient. The agencies work tarily in the program. individuals. As a patient’s behavior be- were ready for re-integration into the closely with Second Chance to have In the Fall of 1999 Steve Silverstein, gins to approach community standards community. OMH used reinvestment someone readmitted to the hospital for PhD came to NYPH-WD from the Uni- the external reinforcers (tokens) are used monies at the time to provide the pro- stabilization if that should be required. versity of Rochester to become the Pro- less, and social and internal controls are gram with 30 supported housing beds This provides a supportive safety net for gram Director of Second Chance. His relied on more. dedicated to Second Chance patients the housing agencies when working indi- primary mission at the time was to intro- Adam Savitz, MD, has been the Unit being discharged who needed the sup- viduals with such challenging difficulties. duce a comprehensive behavioral treat- Chief since July 2001 and has been dedi- port and structure provided by a commu- Establishing these partnerships be- ment program that has long been known cated to the social learning program as nity residence. This was a vital compo- tween the inpatient setting and the hous- to be effective in treating the severe and well as to overseeing the psychopharma- nent of the program as many of our pa- ing providers has clearly been beneficial persistently mentally ill (SPMI) popula- cology for the patients. The general phi- tients have comorbid medical problems to the consumers of these services. On tion. Recognizing that behavioral prob- losophy is to not over-sedate the patients such as diabetes and high blood pressure, occasion a clinician from Second Chance lems as well as symptoms can be major with medication, for two very important serious substance abuse histories, as well has been asked to consult with a particu- impediments to many patients’ ability to reasons. First, over-sedation simply as histories of involvement with the lar residence to strategize together on live successfully in the community, be- masks problem behaviors and symptoms criminal justice system that make them how to use some of the behavioral inter- havioral interventions to address behav- which need to be addressed more ac- very difficult to place in the community. ventions at the residence as they attempt ior excesses (e.g., aggression) and defi- tively in treatment; and second, the em- We obtained a commitment from four to address troublesome behaviors effec- cits (e.g., social isolation) were imple- phasis of Second Chance is to help the well-established housing providers in tively. Unfortunately, limited resources mented at the milieu, group, and individ- patients learn essential skills needed to New York City to prioritize the Second of time and personnel do not allow for ual treatment levels. A point system live in the community, and it is very Chance Program patients. It was decided this potentially very useful service to based on comprehensive observational difficult to learn when over-sedated on at the time to concentrate the 30 beds occur often. It would greatly benefit the ratings of both socially inappropriate and medication. among fewer housing providers to pro- consumers if there could be even greater appropriate behavior is used for deter- The Second Chance Program model mote closer and more intensive working coordination of the treatments being mining on-ward and off-ward privileges. has proven to be quite effective for treat- relationships between the inpatient set- used across treatment settings, from in- Patients receive daily ratings, and feed- ing patients who were considered ting and housing providers taking the patient, to residential and day treatment back, for appearance and grooming, unlikely to be discharged from state hos- patients, and this proved to be a good programs. It remains a curious phe- room cleanliness, behaviors during meal- pitals. We have discharged over 250 decision. We also wanted to use housing nomenon that while some of the best times, and preparation for sleep. These individuals since the program’s incep- providers that were close to where the specific behaviors were targeted because tion and have been able to successfully patients had family and/or other commu- see Second Chance on page 16

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 7

PAGE 8 MENTAL HEALTH NEWS ~ FALL 2005

MENTAL HEALTH NEWSDESK

NKI Center for Dementia Research Awarded $9.1 Million To Examine The Root Causes of Alzheimer's Disease

Staff Writer support broad-based, multidisciplinary, heimer's disease and to improved thera- Mental Health News long-term research. The program involves pies to prevent and forestall the devastat- a large team of investigators at NKI (Efrat ing deterioration associated with the Levy, PhD, Stephen D. Ginsberg, PhD, disorder,” says Jerome Levine, M.D., he National Institute on Aging Paul M. Mathews, MD, PhD) and collabo- interim director of NKI. (NIA) of the National Institutes rators at McLean Hospital (Ann M. “The team led by Dr. Nixon has already of Health (NIH) recently an- Cataldo, PhD) in Boston and Albert Ein- made substantial progress toward a better nounced the award of a $9.1 stein College of Medicine (Ana Maria understanding of Alzheimer's disease millionT program project grant to Ralph Cuervo, MD, PhD) in the Bronx. pathobiology, and we look forward to even Nixon, PhD, MD, director of the Center With the new award, Dr. Nixon and further progress with this next cycle of for Dementia Research at the Nathan his team will develop and characterize grants,” says Dr. Stephen Snyder, program Kline Institute for Psychiatric Research new laboratory models to complement director in the NIA Dementias of Aging (NKI) in Orangeburg, New York. human tissue studies on Alzheimer's Branch. “Beyond Alzheimer's disease, the The grant will allow Dr. Nixon and his disease. Using sophisticated genomic group's work may also yield new insights team to continue their pioneering work and proteomic analytical techniques, into similar neurodegenerative diseases, analyzing brain cells of individuals at the they will be able to simultaneously ex- especially the so-called proteinopathies, earliest stages of Alzheimer's disease--- amine thousands of genes and proteins at work that we hope will help to identify even before memory problems surface---to the level of even a single brain cell or a novel therapeutic targets.” identify the biological factors that trigger fraction of isolated brain endosomes to Dr. Nixon is also a professor and plaque-like aggregates of a peptide called understand how they function or mal- vice-chair of the Department of Psychia- amyloid-beta (Aβ) and other pathology function. They will also investigate how try and professor of cell biology at New associated with memory impairment. genetic, dietary and pharmacological York University School of Medicine. He Many scientists believe that Alz- Ralph Nixon, PhD, MD factors affect the functions of the en- has published nearly 200 scientific pa- heimer's disease may be caused by over- dosome system in brain cells and influ- pers and is a member of the editorial accumulation of Aβ, a toxic form of pro- which become overactivated in Alz- ence the development of the disease. board of numerous scientific journals. tein that is normally present in healthy heimer's disease. In addition, endosomes An estimated 4.5 million Americans He is the recipient of numerous awards, cells. Unfortunately, the factors underly- perform many roles that are crucial for suffer from Alzheimer's disease, accord- including the MERIT Award and the ing the abnormal rises in brain Aβ levels brain cell survival and for communica- ing to the Alzheimer's Association. In- Leadership and Excellence in Alzheimer have long remained a mystery. Prior tion between brain cells during memory creasing age is the greatest risk factor for Research (LEAD) Award from NIH, the work by Dr. Nixon’s laboratory identi- formation. Impairment of these en- the disease, which is estimated to affect Academic Career Leadership Award from fied abnormalities of small vesicular dosomes in Alzheimer’s, therefore, has one out of 10 individuals over the age of the NIA, the Temple Foundation Discov- components of the cell, called en- further consequences in promoting 65 and half of those over 85 years of age. ery Award and the Zenith Award from the dosomes, which are one of the first tell- symptoms of the disease that are cur- “This new avenue of research prom- Alzheimer's Association, and the Focused tale signs of the disease. They found that rently being explored. ises to increase our understanding of the Giving Research Award from Johnson and these endosomes are potent Aβ factories, The NIA grant program is designed to root causes and risk factors for Alz- Johnson Corporation. □

American Medical Association Students See Need for Mental Health Education Albert Einstein Medical School Students Gather Support at National AMA Conference

By NAMI work with mental health organizations to across a NAMI program called Queens/Nassau, New York encourage patients to discuss mental health “Breaking the Silence” (BTS). BTS are concerns with their physicians; and be it user-friendly teaching modules for further Resolved, that our AMA work with grades 4-12 designed to separate fact rin Callahan, a second year the Department of Education and state from fiction; combat the stigma of men- medical student at Albert Ein- education boards and encourage them to tal illness and promote early treatment. stein Medical College, in adopt basic mental health education de- “We feel it is imperative that mental Bronx, N.Y., a NAMI Queens/ signed specifically for elementary through illness be taught alongside other important NassauE (National Alliance for the Men- high school students.” health topics. Just as students learn about tally Ill) volunteer, presented a resolu- The resolution will be forwarded to cancer, diabetes and AIDS they need to tion titled, “An Initiative to Encourage the AMA at its 2006 annual meeting and know about diseases of the brain. The fact Mental Health Education in Public presented to the House of Delegates of that these medical students took on the task Schools” to the medical student’s section the Physicians Section. If adopted as of approaching the AMA to back mental of the national American Medical Asso- policy, specific funding and lobbyist illness education speaks volumes for the ciation (AMA) conference which was resources may be designated to promote need for mental illness awareness among held this past June. Initially written by the adoption of mental health education our young people,” states Janet Susin, BTS medical students Erin Callahan, Robyn programs in public schools nationwide. Co-Author, Project Director & NAMI Gartner and Katherine Scott, it was ap- “Growing up, one of my best friends Queens/Nassau Co-President. proved by the Albert Einstein Medical suffered from bipolar disorder. I watched NAMI is a nationwide, grassroots, self College division of the AMA student as her illness caused her to live in shame help, support and advocacy organiza- section last fall. The resolution was and secrecy. Knowing she was not her tion of people with mental illness and amended to include SUNY Buffalo illness and feeling frustrated by my in- their families and friends. For further medical student, Lauren Scott’s resolu- ability to really help her, I vowed to play Janet Susin information on this resolution, BTS tion titled, “Reducing Stigma and In- a part in combating the stigma associated and NAMI contact NAMI Queens/ creasing Detection of Mental Illness.” with mental illness and finding a way to “Breaking The Silence” Nassau at 516 -326-0797, E-mail The amended resolution that passed as help others. This prompted my decision NAMI [email protected] or visit policy reads, ”Resolved, that our AMA to become a psychiatrist where I came Queens/Nassau, New York www.btslessonplans.org. □

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 9

MENTAL HEALTH NEWSDESK

New York State Office of Mental Health Implementing Medication Management Initiatives

By Sharon E. Carpinello, RN, PhD cacy of medication trials. It also in- clinical practice guidelines, we can in- Commissioner, New York State cludes access to clinical guideline-based crease quality of care, improve patient Office of Mental Health quality indicators, and fiscal indicators. outcomes, and can better enable recov- The program was initially developed ery from schizophrenia and other psychi- as a way to improve clinician access to atric disabilities. PSYCKES builds on he New York State Office of patient medical information and relevant previous clinical algorithms by provid- Mental Health (OMH) is con- clinical practice guidelines, but its use ing clinicians with an individual’s treat- tinuing to advance its transfor- has improved care in other ways as well. ment history, dosing and outcomes in mation to a system of recov- PSYCKES has proven itself to be an one integrated decision support tool. To ery-basedT care through a multi-year, effective clinical tool that supports re- the best of our knowledge, it is the first multi-layered approach that improves covery by helping individuals obtain and example of an integrated, guideline- outcomes for adults and children with maintain functional levels that enable driven, clinical and fiscal decision sup- psychiatric disabilities through the use of them to live successfully in community port system for psychiatry. proven, effective treatments. OMH has settings. For example, by displaying an been making marked progress in the area individual’s treatment history, PSY- Reducing the Use of Polypharmacy of medication management: the Phar- CKES allows for past use of medications macy Service and Clinical Knowledge to be examined, and provides informa- Another new initiative will simplify Enhancement System, or PSYCKES, is tion about medications that were effec- dosing requirements, and go far to im- having a positive impact at State- tive in helping an individual, as well as prove outcomes and quality of life for operated psychiatric centers and on the about medications that were not helpful. individuals with serious mental illness. individuals served by them; and building Sharon E. Carpinello, RN, PhD PSYCKES was developed by an in- It is part of a national trend to support on the success of PSYCKES, OMH has novative team of critical thinkers from medication compliance by making it also recently started to implement other into day to day practice. Implementation Creedmoor Psychiatric Center and easier for people to adhere to and main- new pharmacotherapy initiatives de- was completed within the past year and OMH’s Central Office. The PSYCKES tain their medication regimen. signed to improve outcomes for New PSYCKES is now being used in all State- team received the 2004 Workforce The new initiative, “Rational Phar- Yorkers with mental illness. operated psychiatric facilities. Champions Award from the Governor’s macotherapy Quality Improvement” PSYCKES pulls together information Office of Employee Relations, and (RPQI), is examining current practice PSYCKES from multiple sources, and gives clini- PSYCKES was recently selected as a concerning use of multiple antipsy- cians real-time access to previously un- recipient of the Council of State Govern- chotic medications. There is insuffi- PSYCKES is a state of the art, web- available information about an individ- ments’ prestigious 2005 Innovations cient evidence in the medical literature based tool designed to support the deci- ual’s treatment history. It displays data Award, being cited as one of the best of any potential benefits of concurrent sion making and information needs of on admissions and locations of service, new and creative approaches to address administration of three or more antip- physicians. It improves the quality and length of service, diagnoses, types of an issue facing the State. sychotic medications, to justify the safety of medication prescribing practices medications received, adequacy of the By improving clinician access to pa- by incorporating evidence-based medicine doses prescribed, and duration and effi- tient medical information and relevant see Initiatives on page 16

New York State Passes Landmark Legislation Designed To Address The Mental Health Needs Of The Elderly

By Jane Linker With the population of older adults “It will stimulate needed innovation with mental disorders in the United and establish a planning process that States expected to jump from 7 million will bring together key state agencies ith the passage of The to 14 million over the next twenty-five to develop integrated approaches of Geriatric Mental Health years, mental health advocates have responding to the health and mental Act (A.4742/S.7672), been warning that existing services are health needs of aging New Yorkers.” W New York State has woefully inadequate to meet the antici- “It has long been said that those that taken a leadership position in address- pated demand as the Baby Boom be- fail to plan are planning to fail. The ing the need mental health needs of its comes the Elder Boom. Already, ex- Geriatric Mental Health Act engages elderly citizens. The Act, which perts say, the elderly with mental ill- New York in a planning process that will passed both houses of the legislature ness are a severely underserved popu- help us begin to better prepare to address last summer, is expected to be signed lation. They point to statistics that the growing mental health needs of our by Governor Pataki in the fall. It is the estimate that of the 2-3 million Ameri- munity as they receive treatment and ever-growing elder population,” said first legislation of its kind, according can seniors with depression, only 20% ongoing services. The Act also creates Assemblyman Peter M. Rivera, the to mental health advocates. are receiving treatment from mental an inter-agency planning council that Bill’s lead sponsor in the Assembly. The Act had strong bi-partisan sup- health professionals. will ensure cohesive action among “We know that untreated mental port in both houses of the New York The Geriatric Mental Health Act, state agencies that work with seniors. conditions can lead to disability, ex- State Legislature. In the Senate, lead- which had the strong support of over “The Act lays the groundwork for acerbate symptoms of other illnesses, ership was provided by Nicholas 110 nonprofit advocacy and service future programs and improvements for lead to premature death, and may Spano, Senior Assistant Majority organizations, outlines what New York a segment of the population that has all result in suicide. In fact, the rate of Leader, Thomas Morahan, Chair of the State must begin to do in order to be too often been ignored and under- suicide among elderly men is the Mental Health Committee and Martin ready to provide adequate mental served,” said Michael Friedman, chair- highest of all age groups. This is Golden, Chair of the Aging Committee. health care for its growing elderly man of the Geriatric Mental Health vital legislation, and its passage In the Assembly, Peter Rivera, Chair of population. It provides for the devel- Alliance of New York, an advocacy means that we will be able to begin the Mental Health Committee and Ste- opment of innovative, model mental group with over 750 individual and to meet the mental health challenges ven Engelbright, Chair of he Aging health programs for older adults that organizational members that was in- Committee took the leadership role will enable them to remain in the com- strumental in initiating the legislation. see Legislation on page 16

PAGE 10 MENTAL HEALTH NEWS ~ FALL 2005 Schizophrenia: A Day Treatment Perspective

By Matthew Romanelli, MD involved. She was started on medication illness.) Such attitudes may prevent earlier Phelps Memorial Hospital Center while in the hospital, her symptoms im- recognition and appropriate treatment, dis- Behavioral Health Department proved, and she was discharged to outpa- courage continuation of successful treat- Continuing Day Treatment Program tient mental health care. Over the next sev- ment, and limit valuable social support. eral years, J. was hospitalized on three other Schizophrenia for most individuals is a occasions, usually for hearing voices chronic illness: about two thirds with a young woman named J.* was an (auditory hallucinations) and becoming good medication response for three to five outgoing teenager, an honors agitated. Often, symptoms returned because years relapse off medication within a year student in junior high school she tried to stop her medication. Ultimately, and a half. Medication is only part of the A with a circle of good friends. she was diagnosed with schizophrenia. She treatment picture. Individuals benefit from She lived at home with her parents and sis- remained on medication, which was moni- understanding their illness and the risks and ter, and her hobbies included sports and tored in regularly scheduled outpatient vis- benefits of medication, finding support from reading. Her family began to notice that J. its. Although she did not complete high others with similar symptoms, learning to was becoming more and more isolated, school due to her illness, J. was able to ob- recognize skill deficits, and working in a avoided spending time with her friends, and tain her GED. She participated in a day structured way to improve their overall stopped participating in school activities treatment program, which she attended sev- functioning. Psychosocial treatments, there- like her soccer team, which she had once eral days a week, and where she received fore, have a proven role along with effective enjoyed. She was less attentive to her ap- education about her illness, attended ther- medication in managing the symptoms of pearance, and her mother had to remind her apy groups with people who had similar schizophrenia. repeatedly to shower and comb her hair. J’s illnesses, and worked with a psychiatrist to Matthew Romanelli, MD Day treatment is an intermediate level of grades deteriorated and she was in danger adjust her medication. Having found an care that lies between more intensive inpa- of failing at least two of her classes. Her effective medication that she was able to thought disorganization, changes in muscle tient (overnight hospitalized) care level, parents were concerned about possible drug tolerate, she attended a job training pro- tone or movement (catatonia) or loss of which tends to be short term (weeks); and use, but J. didn’t appear to have access to gram, worked with an employment coun- normal nonverbal behaviors (such as loss of less intensive outpatient clinic care, which illicit substances. She hardly left the house selor, and began her first part-time job, facial expressiveness or tone of voice.) Of- may be weekly or monthly for clients who and didn’t even receive phone calls at using her day program to assist her in ad- ten, there is a decline or change in behavior are able to effectively manage symptoms home. She appeared increasingly preoccu- justing to the stresses and challenges of prior to the onset of clear symptoms, called with less oversight. In day treatment, clients pied, anxious and disorganized. One night, employment. a prodromal phase, which may include typically attend a structured program sev- she became very agitated and struck a fam- Schizophrenia likely represents a group withdrawal from social, personal or occupa- eral days a week but continue to live in their ily member. She accused the family of try- of brain disorders that may leave varying tional functioning; anxiety; physical com- homes. (Many clients with chronic ill- ing to hurt her, her thoughts seemed discon- amounts of residual impairment. Symptoms plaints; and unusual behavior, speech or nesses such as schizophrenia benefit from nected from each other, and she reported typically begin before age 25, and occur in ideas. Persons with schizophrenia fre- the additional structure of a group home, hearing voices. Her family called 911. about 1% of the population. (This appears quently have difficulty attaining their poten- adult home, or community residence.) The J. was brought to a local emergency to be true across cultures.) Symptoms in- tial in interpersonal relationships, occupa- treatment in day treatment includes group room where she was evaluated. Her blood clude disorders of thinking, such as false tion and other areas of achievement due to therapy, education groups (such as coping tests were unremarkable, and a urine toxi- beliefs (delusions), hearing voices or seeing their illness. skills, physical health management, asser- cology test indicated that drugs were not things (auditory or visual hallucinations), Although the exact cause of schizophre- tiveness and self-esteem), individual coun- nia is unknown, there is evidence for both seling, and medication management. genetic and environmental risk factors. Indi- Clients benefit from spending time with viduals with relatives who have schizophre- others with the same illness, and build com- nia are more likely to have the disease petence and self-esteem by learning from themselves. The closer an affected relative good examples as well as serving as role is, the higher the risk. The identical twin of models for others. The sense of community a person with schizophrenia carries the that is built among clients reduces stigmati- highest risk (even if the twins are raised zation and can assist in building a more separately by adoptive parents), but that risk positive personal and social identity. Pa- is still well under 100%. (An identical twin tients often arrive at a very different under- of a person with schizophrenia is more than standing of their symptoms when they ob- five times as likely to have the disease as a serve others struggling with similar difficul- non-identical twin.) Environmental factors ties. Some individual need assistance in also may increase the risk of developing learning basic social and interpersonal hab- schizophrenia. More people with schizo- its (such as appropriate eye contact, speech phrenia are born in winter months. Minor and body language), and day treatment pro- neurological deficits may include alterations vides a safe environment to practice and of some reflexes, changes in rapid eye perfect these communication skills. The day movements and blinking, impaired percep- treatment environment can act as a micro- tion of emotion (such as interpreting facial cosm for the larger world outside of treat- expression and tone of voice), impaired left- ment, as clients address issues including right discrimination, and inability to carry stigmatization, anger, and jealousy, as well out certain tasks (apraxias). as positive experiences such as developing Schizophrenia takes an enormous toll on friendships, working as a team, and contrib- individuals and their families. The onset of uting as a recognized member of a commu- illness, commonly in early adulthood, can nity. (Community meetings are a standard effectively delay or block important devel- feature of day treatment as well as other opmental milestones. Individuals may have outpatient and inpatient settings.) Clients difficulty building adult relationships or utilize the support offered within the pro- meeting academic or occupational goals. gram to develop and meet their potential. Patients of all ages may experience a pro- Many clients in day treatment participate found sense of loss with the realization that additionally in outside services including peers have progressed while their own case management, self-help groups, voca- achievement is slowed or stalled. Depres- tional counseling and volunteer jobs. Cli- sion is a common co-occurring disorder and ents who successfully move toward their also requires treatment. Families experience goals inspire staff and other clients alike. emotional (and often financial) stress in attempting to assist an affected family It’s been my privilege to work in the member, and all are impacted by the social Continuing Day Treatment Program for the stigmatization that frequently accompanies last two and a half years, part of the Phelps mental illness. Individuals or families may Memorial Hospital Center’s continuum of themselves hold stigmatizing attitudes (e.g., care. For further information about our that mental illness is a character defect or program, please contact Toby Greene, personal weakness rather than a medical ACSW, at 914-923-5700. □

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 11 Mental Health News Founder Receives Media Award

Staff Writer passed through the difficulty and pain Mental Health News of mental illness and not only recov- ered your own life, but you have real- his June, Mental Health News ized a vision that would help others Founder and Publisher, Ira H. learn from your experiences and help Minot, was presented with The them focus on the silver linings in their 2005 Media Award given by own dark clouds. TheT Coalition of Voluntary Mental You were an early mental health Health Agencies, Inc. The Coalition worker, directing your energies to which was founded in 1972 is the um- fundraising and public relations for brella advocacy organization of New health and human service organiza- York’s mental health community, rep- tions. You were always involved in a resenting over 100 non-profit commu- career of helping others. But debilitat- nity based mental health agencies that ing depression that did not respond to serve more than 300,000 clients in the medication stopped you in your career five boroughs of New York City and and family tracks. its environs. But persistence and strength on your Presenting the award to Mr. Minot part and the diligence of your caregivers were Phillip A. Saperia, Executive Di- helped to lift the dark cloud that had rector of The Coalition, Dr. Peter C. settled on you. Today you are energeti- Campanelli, President and CEO of The Mental Health News Founder and Publisher Ira H. Minot cally publishing Mental Health News, Institute for Community Living and cur- looking for new entrepreneurial horizons rent President of The Coalition Board of Receives The Coalition of Voluntary Mental Health Agencies and raising money to take your message Directors, and Dr. Alan B. Siskind, Ex- 2005 Media Award to as wide an audience as possible. ecutive Vice President and CEO of The As you have said so simply, yet elo- Jewish Board of Family and Children’s The following, are Dr. Siskind’s re- According to James McGregor Burns, quently; “When I was out there strug- Services, Past President of The Coalition marks in making the presentation which “great leadership arises out of great con- gling to overcome my illness, I had three Board of Directors and current Chairman tell of Mr. Minot’s heroic struggle that flict”. Surely, Ira, you embody the resil- of the Board of Mental Health News . led him to start Mental Health News: ience of the human spirit. You have see Media Award on page 18 Spitzer Receives APA Award Platz New Residential Head

Staff Writer Staff Writer Mental Health News Mental Health News

n June 15, 2005, Dr. Barry B. oyce A. Platz, a member for 17 Perlman, Director of Psychia- years of Senior Management at try at Saint Joseph’s Medical Hall-Brooke Behavioral Health O Center and President of the Services, has been named to the New York State Psychiatric Association, J organization’s new position of Execu- presented the Jacob K. Javits Public tive Director, Community Residential Service Award to New York State Attor- Services Division. Hall-Brooke is lo- ney General Eliot Spitzer. Dr. Perlman cated at 47 Long Lots Road, Westport. cited Attorney General Spitzer’s action The Division includes the highly against GlaxoSmithKline and others for lauded Homestead Residential Program concealing data relevant to prescribing which provides permanent housing and antidepressants for children. This action supportive services to adults and single will help ensure that pharmaceutical com- parent families with behavioral health panies are more open with their clinical disorders in 16 locations throughout findings. “Once fully realized, this move- Bridgeport, Norwalk, Fairfield and West- ment towards transparency, we believe, port. The US Department of Housing and will greatly improve the care provided by Attorney General Spitzer and Urban Development (HUD) and the Con- psychiatrists and other physicians for their necticut Department of Mental Health and Joyce A. Platz patients,” said Dr. Perlman. Barry B. Perlman, MD Addiction Services funds the program. The Jacob K. Javits Public Service Ms. Platz played a key role in the “I am excited about the opportunity to Award was established by the Ameri- As Director of the Department of development, implementation and ad- develop and expand our services to pro- can Psychiatric Association (“APA”) Psychiatry at Saint Joseph’s Medical ministration of Hall-Brooke’s award vide additional residential opportunities in 1986 to honor the legacy of a U.S. Center since 1981, Dr. Perlman oversees winning residential programs for almost for adults, as well as for children and ado- Senator from New York, Jacob K. a comprehensive program of mental two decades. In her new role as Execu- lescents, and possibly to include commu- Javits. Senator Javits served as Sena- health services, including inpatient and tive Director, Ms. Platz will oversee, nity services ,such as educational and vo- tor for 24 years and spearheaded many outpatient care, continuing day treat- develop and expand these programs, and cational programs,” says Ms. Platz. reforms that advanced the care of the ment, community support and substance will implement a recent $750,000 award “Hall-Brooke’s successful residential mentally ill and those who battle sub- abuse treatment. from the Department of Housing and programs demonstrate that persons with stance abuse issues. These issues have The New York State Psychiatric As- Urban Development (HUD) to develop behavioral health disorders can live in- been advanced by numerous other sociation is an organization representing 12 units of supportive housing. The dependently in the community provided Public Service Award recipients in- 4,500 psychiatrists in New York State grant also calls for development of col- they have the necessary support. Our cluding U.S. Senator Pete Domenici, on professional issues, as well as advo- laborative relationships with other agen- goal is to continue meeting the needs of Senator Paul Wellstone, State Senator cacy on behalf of persons with mental cies for expansion of supportive housing communities we serve and to further our Nicholas Spano, Senator Harry Reid, illness. The NYSPA is the state affiliate opportunities in Fairfield County, and mission by expanding housing opportu- and Connecticut Attorney General of the American Psychiatric Association. for expansion of Hall-Brooke’s commu- nities and supportive services for per- Richard Blumenthal. It is the Commit- Saint Joseph’s Medical Center, a full- nity residential programs through devel- sons with behavioral health disorders, tee on Government Relations of the service, 194-bed hospital, is located at opment of additional housing and sup- APA that bestows the award. 127 South Broadway in Yonkers. □ portive services for all age groups. see Platz on page 38

PAGE 12 MENTAL HEALTH NEWS ~ FALL 2005 Trapped in A Fugue: Jimmy’s Story

By Mindy Appel, ACSW, LCSW tional well-being as much as she could. again and again that everything was fine, As the years passed, Jimmy never He, in turn, became her defender and and that he was happy making grades at held a meaningful job commensurate protector from what he perceived to be the top of his class. Part of Jimmy’s ill- with his intelligence and became more e was the first-born male in a dangerous and over-bearing parents. ness during college was an extreme level and more a social anomaly. His beloved loving Jewish family. He Seeing her brother (whom she truly of narcissism and grandiosity which led to sister followed in his footsteps to another came into the world destined adored), go through the torment he fre- cocky and arrogant behavior. The incon- college in upstate New York, from for greatness and surrounded quently experienced, and shared only gruence of his life versus his perception of which she graduated about the time he withH love. He fulfilled every family with her, she determined (while still in that life was drawing him further and fur- was returning home from Iowa. She prophecy and expectation throughout grade school) that she would devote her ther away from reality. continued her education in graduate school, and became class valedictorian. life to helping people who were strug- When the truth finally surfaced and he school in New Orleans, and established He graduated with honors, scored a gling emotionally. was about to flunk out of college, he was residency there, earning a masters degree nearly perfect score on the SAT test, and Jimmy’s family, throughout these sent to the local Mental Heath Center and in social work and becoming a board was accepted by every college to which years of inner struggle, was in complete it was suggested that he take some time off certified social worker. She worked in he applied, except Princeton. He never denial as to the reality of the situation from school and graduate a semester late. both private practice and at a series of got over the fact that Princeton had and the depth of Jimmy’s needs. They Entering into psychiatric care at that time hospitals, and was on the job on July 24, turned him down. This first major rejec- felt responsible for his psychosis, and as resulted in the first confirmation by Jimmy 1992, when the call came in from home tion (as he saw it) started him on a down- they were unable to accept that responsi- and by his family that perhaps his prob- that Jimmy was dead. ward spiral which would end, ultimately, bility, it became easier and easier to lems were more serious than time, love She rushed home to New York to with his death at age 40, alone, in a hotel deny its existence or to accept that a son and support could correct. His first treat- comfort her grieving parents, and tried to room, absent friends, absent family, and of theirs could be mentally ill. Living ment with anti-psychotic medications make some sense of what had happened. beset with the psychiatric demons that had day to day consumed them, and dwelling (Haldol, Prolixin, and Cogentin) began at The coroner’s report indicated that threatened him for years. on things they could not “fix” was coun- that time. Jimmy was inconsistent in the Jimmy had died of asphyxiation. There Jimmy was not accepting of failure or terproductive and even destructive to administration of these medications be- was no indication of foul play. A bright falling short. From an early age, his their son’s emerging psyche. So life cause he disliked the detached emotional light was extinguished on that summer desire to be perfect led him to obsessive went on, with each day resulting in more feelings and felt that he was not living life day almost 15 years ago, and all of those compulsive behaviors ranging from un- being swept under the family rug. to its fullest in the zombie-like, drug- left behind are filled with questions and compromising perfectionism to obses- Meanwhile, Jimmy was exhibiting more induced calm. His conscious decision to no answers. A man of infinite promise sion with washing his hands in a deliber- and more symptoms: disorganized eschew medical advice and deal with his became trapped in a disturbed state of ate manner throughout the day. Always speech and behavior, decompensation, psychosis head on would eventually schizophrenia. suspicious of family and friends, the regression, and psychosis. His lack of spell disaster. The story of Jimmy’s journey is told predromal signs before psychotic epi- trust made friendships difficult due to his Upon graduating from college, in order to help someone else who might sodes began to appear early in life. He inability to attach to others. Jimmy applied to a number of law recognize themselves or a family mem- was socially awkward from an early age, Jimmy left for college, and once he schools, and was accepted at only one ber in this description. In this way, and exhibited unusual behaviors which arrived there, he found himself among which was located in the mid-west. He Jimmy will always live on to help others further isolated him from his peers. But 2500 other valedictorians from across moved out to Iowa, and although he even though he could not help himself. nothing in his upbringing could account the country. He discovered, to his cha- made frequent phone calls and sent His mother felt a tremendous sense of for his descent into the abyss of schizo- grin, that his innate intelligence was not many letters back home as to his out- guilt because she thought she had done phrenia. His sister was born when he adequate for the cut-throat academic standing progress there (he reported all something wrong and was not a good was five, and they forged a partnership competition at that level. He was a loner, A’s, and an invitation to the Dean’s enough parent. It is essential that there together as best friends and mutual pro- and preferred his own company to social house to be honored, etc.,) his ruse was be more parent and family education tectors, which nothing could sway. But gatherings in which he never partici- uncovered when the school sent his concerning treatment and medications in the final analysis, all of the love and pated. Lonely and alone, and experienc- grades home and he had all D’s and F’s. available in such cases. Only in destig- encouragement of his mother, father, ing less than A’s for the first time, he Shortly thereafter, his mental state dete- matizing those with mental illness can sister, and extended family could not plodded through college doggedly, riorated and he arrived home one day we hope to get them the treatment they compensate for the inner turmoil he barely keeping his head above water. He with only the clothes on his back, no need and cut down on the denial and faced daily. was consistent in denying that his in- food, no money, and in a disoriented ignorance of the true nature of mental As a young man, his bar mitzvah at creasingly isolative and antisocial behav- state of mind. Realizing that the situation illness. Jimmy’s life was a testament age 13 placed him again in the family ior and periods of losing contact with was critical, he was hospitalized (one of to the need for that process – may his spotlight. Even at the tender age of 8, reality were symptomatic of deeper many times) and released shortly after with legacy be in increasing the awareness his sister saw his desperate need for ap- problems. His trips home reflected his the recommendation for medication man- of others in similar situations before it proval and tried to take care of his emo- altered state of reality and he affirmed agement and follow-up therapy. is too late. □

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MENTAL HEALTH NEWS ~ FALL 2005 PAGE 13 POINTPOINT OFOF VIEVIEWW

Baby Boomers With Schizophrenia And Other Long-term Psychiatric Disbilities: Prepare Now

By Michael B. Friedman, LMSW people with severe psychiatric disabili- chiatric disabilities die with dignity, nesses. Improvements in institutional ties as they age. close to those they care about. care are critical. As part of this undertaking, the mental health system—working col- 3. Expand and redesign housing ser- 7. Enhance family support: For those laboratively with the health and aging vices: A large percentage of adults with families who survive and remain healthy systems—must confront several key serious mental illnesses live with their long enough to continue to care for fam- challenges. families. When their families can no ily members with long-term psychiatric longer provide care, they will need alter- disabilities, family support will become > Loss of family caregivers: Over time, native housing, preferably in the com- increasingly important. As well as res- more and more parents of adults with munity. pite and access to support in times of serious mental illness will become dis- And housing for older adults with crisis, this undoubtedly should include abled and die. The mental health system psychiatric disabilities needs to be con- the adaptation of psycho-educational is not adequately prepared to take over structed with an eye to the physical prob- approaches that currently are designed the care giving roles that parents have lems that are increasingly common with for families with young and middle-aged played. age. For example, housing will need to adults so that they can be used with be accessible to people with physical families with older adults with psychiat- > Problems with Physical Health: As disabilities and designed to prevent inju- ric disabilities. people with long-term psychiatric dis- ries from household accidents— It is particularly important to reach abilities age, new needs emerge— particularly falls. In addition housing- out to families who have cared for fam- especially needs that have to do with related support staff will need to be bet- ily members with psychiatric disabilities physical health problems. They are ter prepared to handle co-occurring men- virtually without help from the mental prone to obesity, hypertension, diabetes, tal and physical disorders and to manage health system. These families tend to be heart disease, and pulmonary disorders. multiple medications. poorly informed about mental illness, Michael B. Friedman And people with long-term psychiatric treatment and rehabilitation, and where disabilities are no less likely than other 4. Adapt the Community Support Pro- to go for services. Outreach to senior older adults to develop dementia. This gram: Since the early failures of deinsti- centers, settlement houses, and social limits their ability to manage activities of tutionalization, the mental health system service programs in naturally occurring illiam, who just turned 75, daily living. has been devising supports to help peo- retirement communities (NORCs) should has suffered from schizo- ple to remain in the community includ- be organized so as to engage this hidden phrenia since his early > Low Life Expectancy: People with ing case management, rehabilitation, population. W 20s. He was a patient in a long-term psychiatric disabilities live assertive community treatment, family We should also develop appropriate state hospital for many years. During approximately 10 years less than the support, peer advocacy, etc. All of these supports for people with psychiatric dis- deinstitutionalization, he moved to a general population. This appears to be services have been designed with mid- abilities who try to take care of their single room occupancy hotel (SRO) and the result of poor health exacerbated by dle-aged adults in mind. They will need parents when they become disabled. would have become homeless when inadequate health care as well as high some modification to meet the unique With support and education, some of SROs were converted to luxury housing suicide and accident rates. needs of older adults. For example, them can probably play this role effec- if his parents had not been able to take much of psychiatric rehabilitation fo- tively. him in. When they died ten years ago, > Developmental Changes: People with cuses on employment; many older adults he was fortunate enough to get a sup- long-term psychiatric disabilities experi- will prefer “retirement.” And rehabilita- 8. Provide public education: Older ported housing unit with a visiting case ence important developmental changes. tion’s emphasis on access to the main- adults with psychiatric disabilities are manager. As he has aged, he has be- Like all older people, their expectations stream should probably be broadened to affected by two stigmas—the negative come increasingly obese. Now he has of themselves change, they experience include linkages to senior centers and perception of people with mental ill- diabetes, arthritis, and the beginnings of saddening losses of friends and family, other services for older adults. nesses and ageism, the perception that dementia. Living independently and and they must come to terms with their aging results in a hopeless decline that participating in a day program have both own mortality. 5. Provide more mobile treatment: Cur- makes recovery meaningless. Public become difficult for him. His case man- rently the mental health system is largely education is needed to counter these in- ager has been unable to arrange good To meet these challenges, New designed on the assumption that people accurate stereotypes. medical care or to find housing with York State needs an innovative system with mental illnesses can go to clinics, more supports in the community. He has of care to: day treatment programs, or private prac- 9. Develop an adequate workforce: begun to consider referring him to an titioners’ offices for treatment. But as There is a vast shortage of people with adult home or a nursing home. 1. Focus on life expectancy: Helping people age, going to treatment settings the clinical and cultural competence to As the population of the United States people with long-term psychiatric dis- becomes increasingly difficult. Provid- serve older adults with long-term psychi- ages over the next 25 years, so will the abilities to live long enough to become ers often need to go to consumers in the atric disabilities. This includes psychia- population of people with schizophrenia elderly and to remain healthy as they age home, rather than waiting for them to trists and other mental health profession- and other serious, long-term psychiatric should become a key goal of the mental come to the office. als. It also includes physicians, nurses, disabilities. Unfortunately, the mental health system. and home health workers. To address health system is not adequately prepared 6. Improve care in institutional settings: this shortage we need more training, to serve these older adults; and, as a re- 2. Integrate health and mental health: With higher quality, more mobile, and better education in professional schools, sult, many will end up losing their inde- People with long-term psychiatric dis- more integrated mental health and health and incentives to entice people to enter pendence and being shifted from mental abilities would have improved access to services, it should be possible to help professions serving older adults with health services in the community to adult quality health care and enjoy improved more and more older adults with serious mental illnesses. homes and nursing homes that will not health, if health and mental health care mental illnesses to live in the commu- It is also important to develop new provide adequate care for them. were integrated. This includes linking nity. But there will undoubtedly con- roles using paraprofessionals and volun- The recent passage of the Geriatric primary health care and mental health tinue to be a need for congregate care teers—especially peers. Peer advocates, Mental Health Act provides a great op- services, developing home health ser- facilities. We know, however, that the bridgers, etc. play important roles in the portunity for New York State to develop vices designed for people who have both quality of care in adult homes and community mental health system. With interagency plans and innovative pro- physical and mental health problems, nursing homes is generally inadequate gram models that will meet the needs of and helping people with long-term psy- for people with serious mental ill- see Prepare Now on page 43

PAGE 14 MENTAL HEALTH NEWS ~ FALL 2005 The NARSAD Report

The National Alliance for Research on Schizophrenia and Depression

Schizophrenia Research: NARSAD Supports the Search for Risk Factors & New Treatments

By Constance E. Lieber, President schizophrenia by virtue of a family his- Recognizing new susceptibility genes for brain, and maladjustment of this receptor NARSAD tory of the disorder. Previous research psychosis may help to more rapidly ad- system may be linked to schizophrenia’s suggests that many children who go on vance the understanding and treatment of disordered thought patterns. Dr. John- to develop schizophrenia are anxious and psychotic disorders. son’s research is examining whether – socially withdrawn, and may also show for schizophrenia patients – symptoms, evidence of cognitive impairments, de- Prenatal Risk Factors learning, memory, inhibition and distrac- velopmental delays, and abnormalities in tibility are improved or made worse by motor and language function. Other A research team led by Alan S. heavy marijuana use. children who later develop schizophrenia Brown, M.D., New York State Psychiat- Another NARSAD researcher investi- have conduct and behavioral problems ric Institute (NARSAD 2004 Independ- gating substance use is D. Darlene H. that persist into adulthood. ent Investigator) is studying prenatal risk Brunzell, Ph.D., Connecticut Mental Dr. Laurens’ team will use magnetic factors for schizophrenia. Other re- Health Center (NARSAD 2005 Young resonance imaging (MRI) techniques to search suggests that schizophrenia may Investigator). Schizophrenia patients are study both the structure of the children’s be partly caused by a disturbance of up to three times as likely as the general brains and their brain function – how the brain development, and that environ- population to smoke cigarettes. As with children use their brains while perform- mental factors may foster this abnormal- marijuana, many scientists believe the ing tasks involving memory and motor ity. Specifically, Dr. Brown’s team is cigarette smoking is an attempt to “self- control. The study will compare the studying the schizophrenia risks that medicate,” using nicotine to help relieve brain structure and function of those prenatal stress and vitamin A deficiency schizophrenia’s symptoms. Dr. Brunzell children who are primarily socially with- may pose to a developing fetus. Dr. believes that better understanding the drawn and anxious, with those who have Brown will utilize a unique resource for brain’s nicotine receptors may shed new Constance E. Lieber conduct disorder. Significantly, the the study – blood samples that have been light on an individual’s susceptibility to study will also examine whether chil- in storage for decades. From 1959 the disorder. dren's brain function is related to genes through 1967 a group of pregnant revention and treatment. The that have been implicated in schizophre- women participated in a study, and the New Treatment Directions Explored approach medical science takes nia. The findings of the study will con- prenatal blood samples taken from them to illness centers on these two tribute to understanding how and why have been frozen since that time. Dr. Clinicians treating people with fundamental principles – pre- schizophrenia develops, and will inform Brown has conducted previous follow- schizophrenia today have vastly better ventingP susceptible individuals from the design of specialized treatment pro- up schizophrenia studies of the children drugs and therapies at their disposal than becoming ill, and providing the most grams aimed at preventing schizophrenia that resulted from these pregnancies, and those available a mere twenty-five years effective treatments with the fewest side- in high-risk children. is now looking to identify additional, ago. Nevertheless, the search for improved effects for those who are sick. Schizo- specific pre-natal risk factors. The find- approaches continues, with researchers phrenia, among the most devastating of Genetics: A family study of the ings from his work could help point the experimenting with new drugs, and ways of brain and behavior disorders, often genes associated with psychosis way toward schizophrenia prevention, combining older therapies with new ones. strikes adolescents and young adults. and help us better understand the bio- NARSAD investigators are among those Research scientists funded by NARSAD Elvira Bramon, M.D., Institute of logical events that contribute to the de- leading the effort in exploring novel ways are studying the problem of schizophre- Psychiatry, King's College London velopment of the illness. of treating schizophrenia. nia from the perspectives of prevention (NARSAD 2005 Young Investigator), is Joseph Levine, M.D., Ben Gurion and treatment. Scientists are seeking to leading a study aimed at better under- Understanding Susceptibility University (NARSAD 2004 Independent better understand early risk factors for standing genetic susceptibility to psy- Investigator), is conducting a double- the disorder and find clues in the brain chosis. Prior research has shown that Substance Use blind trial study of creatine as a possible that may indicate susceptibility to it. psychotic disorders – such as schizo- in Schizophrenia Patients new treatment for schizophrenia. Many researchers are studying possible phrenia and bipolar illness – run in fami- Creatine plays a critical role in maintain- new treatments for schizophrenia and lies and are strongly influenced by ge- With schizophrenia patients twice as ing the stability of brain energy. Widely novel drug therapies. The dedicated netic factors. However, only recently likely as healthy individuals to smoke used for enhancing sports performance, efforts of these scientists continue to have the first susceptibility genes marijuana, Lynn L. Johnson, Pharm.D., creatine has been studied for treating advance our understanding of the human (Neuregulin and Dysbindin) been identi- University of Colorado Health Sciences neurological, neuromuscular and heart brain and lay the groundwork for break- fied. There is no single gene for psycho- Center, (NARSAD 2005 Young Investi- disease, with patients experiencing few throughs to come. sis. Rather, there are a number of genes gator) seeks to better understand the rea- side effects. Results from previous stud- that have been implicated, each one of sons that make marijuana use so attrac- ies of people taking creatine orally for Identifying Early Risk Factors which adds to an individual’s vulnerabil- tive to this population. One reason often several weeks, show a significant in- ity to developing psychosis. suggested is that many schizophrenia crease in concentrations of the chemical Understanding Childhood Dr. Bramon’s team has set out to patients use marijuana in an effort to across brain regions. Dr. Levine be- Brain Abnormalities study families with members who suffer relieve some of the disorder’s troubling lieves these findings suggest that from schizophrenia, bipolar disorder and symptoms. These may include auditory creatine may be useful for modifying Identifying brain abnormalities in other forms of psychosis. Three- or visual hallucinations (hearing voices brain metabolism in people with various children who are at high risk for schizo- hundred individuals in seventy families – or seeing things that are not present), brain disorders – including schizophre- phrenia may offer one of the best ways one third of them affected by psychosis – delusions, or the depression and anxiety nia and major depression. He and his to develop targeted, early intervention volunteered to participate. They donated that these symptoms bring on. team aim to help determine if creatine – programs. Kristin R. Laurens, Ph.D., DNA samples and underwent an assess- When healthy people are under the which affects brain energy metabolism Institute of Psychiatry, Kings College ment of brain function. By testing brain influence of marijuana they are less able and may also enhance cognition – offers London (NARSAD 2005 Young Investi- function and measuring symptoms and to recall words, experience reduced reac- promise as a new therapeutic strategy for gator) is conducting a study aimed at diagnosis, the team hopes to clarify how tion time, are distractible, and may be schizophrenia treatment. advancing knowledge in this area. She Neuregulin and Dysbindin impact on inappropriately uninhibited. However, For treatment-resistant schizophrenia plans to study the brain structure and psychosis. Dr. Bramon also hopes to marijuana (cannabis) may affect people patients, Pesach Lichtenberg, M.D., function of 11 year-old children who are help identify some of the other elusive with schizophrenia differently. Recep- at an increased risk for developing genes that confer risk for psychosis. tors for cannabis are concentrated in the see NARSAD on page 15

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 15

NARSAD from page 14 given the complexities of the human brain. Over the past twenty-five Sarah Herzog Memorial Hospital years, research scientists have (NARSAD 2005 Young Investigator) amassed vast new knowledge of the You Recognize This Warning Sign, is researching possible uses of D- brain, which has led to significant, Serine. The search for more effec- concrete improvements in treatments And You Take Action. tive schizophrenia drugs has led re- available for schizophrenia and other searchers to examine the role of brain and behavior disorders. New glutamine receptors in the brain. understanding of schizophrenia risk Can You Recognize Glutamine is an amino acid consid- factors and underlying susceptibili- ered to be a brain fuel. Glutamine ties may help make it possible to A Problem With Your has been used therapeutically for identify those individuals who are at alcoholism, mild depression and to risk for the illness, and prevent them reduce the craving for sweets, and is from developing it. For those living Child’s Mental Health important for metabolic functioning with schizophrenia, new treatment and muscle maintenance. Drugs approaches offer hope for fuller, As Well? which inhibit glutamine receptors, more productive lives. □ such as phencyclidine – commonly known as PCP or “angel dust” – cause schizophrenia-like symptoms. NARSAD The Mental Health Re- To Help A Child On the other hand, substances which search Association, is the largest stimulate these receptors, such as donor-supported organization in the You glycine or D-Serine, when added to world devoted exclusively to sup- newer antipsychotic drugs reduce the porting scientific research on brain Know, depression, cognitive, and other and behavior disorders. Since 1987, negative symptoms of schizophrenia. NARSAD has awarded $180.3 mil- Call Dr. Lichtenberg’s team will study lion in research grants to 2,090 sci- whether D-Serine alone – rather than in combination with antipsychotic entists at 336 leading universities, (914) 636-4440 drugs – might benefit schizophrenia institutions and teaching hospitals in

patients. His project will enhance the United States and in 23 other ext. 200 understanding of the role of gluta- countries. By raising and distribut- mine receptors in schizophrenia, and ing funds for research on psychiatric may lead the way toward innovative brain disorders, the pace has accel- treatment strategies. erated resulting in greater knowl- edge of brain functioning, neuro- Conclusions chemistry, new/improved treatments and genetic origins. Constance E. Schizophrenia is a uniquely chal- Lieber has served as President of lenging illness to understand and treat, NARSAD since 1989.

PAGE 16 MENTAL HEALTH NEWS ~ FALL 2005

Initiatives from page 9

“A Voice of Sanity” routine prescription of such a regimen. Therefore, OMH recently implemented a policy at all State-operated psychiatric A Consumer Advocacy Column centers which states that if a treating psychiatrist determines that a third an- tipsychotic medication is necessary for an individual, prior approval must be obtained from both the facility Clinical Back to Being Disabled Director and OMH Chief Medical Offi- cer. Facilities were also asked to de- By Joshua Koerner and as one of the “working disabled” one of these in years. Reading it made velop plans for review and monitoring Executive Director, CHOICE there wasn’t any sense in not taking ad- me queasy. of multiple antipsychotic use. vantage of the one benefit I had left. Not only will this new policy possi- My Medicare benefit finally ran out bly reduce problems with side effects or in April. If I wanted to continue receiv- drug-drug interactions, it will make ing it, I would have to pay an out of “Recreational Activities and people’s medication regimens practical pocket premium of roughly $300 a in terms of everyday life and after dis- month. Wow, that’s a bite, isn’t it? I Hobbies (TV, radio, newspa- charge, make it easier for them to fol- called Social Security to check it out; pers, books, fishing, bowling, low their physician’s prescribed recom- they said it was an obscure provision of mendations. Living with schizophrenia the law of which most people did not musical instruments, etc.)” or another serious mental illness in it- take advantage: anyone who could af- self presents numerous challenges, and ford it was working and covered under Fishing? Bowling? I guess it makes sense that clinicians make their company plan. that’s what the government every effort to minimize those chal- I liked the sound of that. This, fi- lenges by simplifying an individual’s nally, would be the complete and total thinks disabled people do; we life in terms of medication and dosing end of my disabled status. I talked to my regimens. □ psychiatrist about it; when I was no go bowling. We fish, because longer on Medicare, he would be billing it doesn’t stress us out me his full rate of $175; insurance would too much. Second Chance from page 6 pay half, and at four sessions a month that comes to $350, just a little more evidence on treatment effectiveness Joshua Koerner than the Medicare premium. involves rehabilitative treatment of seri- Of course, the reason private insur- ously mentally ill persons; these inter- ance only pays half is that the State if “In the areas below, describe your ventions are rarely used outside of aca- ntil April of this year I was a New York has never shown the political daily activities and state what and how demic medical centers. Creating a sys- Medicare beneficiary. Soon will to pass parity legislation. Whenever much you do of each; how often you do tem wherein evidence-based interven- after becoming the director of I speak at colleges and explain advocacy it, and any assistance you require. tions are used across the continuum of U a mental health agency I issues, I point out that Rosa Parks’ re- “PERSONAL MOBILITY (walking, care for individuals with disabling psy- ceased to qualify for Medicaid or Sec- fusal to ride in the back of the bus was moving about, exercising your legs, chiatric conditions would have major tion 8 or SSI, but the Social Security the beginning of the modern civil rights etc.)” Well, let’s see: I’ve been doing a public health and financial benefits, work incentives laws are such that de- movement, but at least Ms. Parks got to lot of pacing back and forth, trying to including lowered relapse rates. It is, spite a steady income and a work history ride all the way to her destination; it figure out how I’m going to pay my therefore, an extremely important next going back to October 1996 I continued wasn’t as if they threw her out halfway shrink bill. Does that count? step to dedicate monies to the training to qualify for Medicare until a few there. But never mind: that’s an injus- “PERSONAL NEEDS (dressing, and supervision of staff at both the months ago. tice every working person seeking men- bathing, etc).” I take a shower every housing provider and day treatment I made full use of it. Medicare was tal health treatment faces, and now I was day. I don’t shave on the weekends. settings to provide a more seamless my primary insurance. I also had com- going to be just another working person. OK, I don’t always shower on the week- continuum of care. The Second Chance pany medical insurance, but rarely if I allowed the Medicare coverage to ex- ends, either. Program is an important first step in ever did it pay for anything. This in- pire, and awaited my first bill. “RECREATIONAL ACTIVITES returning long-stay hospital patients to cludes my psychiatrist, whom I have It was a whopper. My psychiatrist is AND HOBBIES (TV, radio, newspa- the community, but much work still been seeing since 1999. When I began good at many things, but staying up to pers, books, fishing, bowling, musical needs to be done. seeing him my psychiatrist also accepted date on his billing isn’t one them. My instruments, etc.)” Fishing? Bowling? For further information, please con- my agency’s health insurance plan; he first bill was for thirteen sessions, total- I guess that’s what the government tact Andrew Bloch, MSW, Program was, as they say, “in network”. But at ing over two grand. I immediately thinks disabled people do; we go bowl- Coordinator at 914-997-5738 or some point in the last two years he be- called my health insurance company. I ing. We fish, because it doesn’t stress [email protected]. □ came fed up with my company HMO: was going to be submitting my first us out too much. apparently they take a long time to pay, claim -- me, the grown up -- non- The thought of having to describe my and they probably put doctors through disabled worker. That’s when I got an daily activities to some faceless Social all kinds of indignities. As the benefits even bigger shock. My company insur- Security bureaucrat made me ill. But Legislation from page 9 administrator for my agency, I know ance does cover 50% --- for network there was more: “I voluntarily authorize

they put me through plenty of indigni- providers. For out of network they pay and request disclosure (including paper, of the elder boom,” summed up State ties: always insisting that whatever I’m 50% to a maximum of $25 per session.. oral, and electronic interchange) of all Senator Thomas P. Morahan, a leading asking of them could be accomplished What?? Because my guy was out of my medical records, also education re- proponent of the Act, pointing out that more easily and quickly by using their network, they would only reimburse $25 cords and other information related to his district has an elderly population web site, although this is rarely the case, a session. I nearly had a heart attack (for my ability to perform tasks”. I thought, that has doubled in the past thirty years. always insisting I’ve never filed docu- which I would have been covered this is why people don’t file for SSI “I am proud to support this impor- ments I know I have. The only thing 100%). The sickening irony was that benefits. It’s gross. It’s sickening. You tant legislation. Older adults with men- they always accomplish, without fail, is several years ago I negotiated that HMO have to answer all these questions and tal illness are a diverse population who making me wait on hold. contract myself; no one else on the staff let them poke around in your life and are seriously underserved within the The fact that my doctor no longer was seeing an out of network provider, justify why you think you’re disabled. mental health system of the state and as accepted my company’s health insurance and I had Medicare, so I thought, here’s But I can’t afford $150 an hour. That’s the population grows older, so will the didn’t affect me at all; he was still being a way to save the company some money. insane. I wanted to talk to my psychiatrist need for comprehensive geriatric mental paid by Medicare. I paid nothing. The It was time to become disabled again, about it, but I couldn’t afford to. health services,” said Assemblyman idea that I was using Medicare didn’t and quickly. I called Social Security; Steven Engelbright. □ bother me; in fact, whenever I took they sent me an “application for pre- CHOICE of New Rochelle, New York, Metro North, an average of once a week, mium hospital insurance for the working is a nonprofit consumer advocacy or- I’d use my Medicare card to qualify for disabled”. It includes a ten page “report ganization dedicated to helping people the disabled rate (the ticket is stamped of continuing disability interview” that I with mental illness. You may reach Mr. www.mhnews.org with a “D”). Money is money, I thought, was supposed to fill out. I hadn’t seen Koerner at (914) 576-0173. □

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 17

The NYSPA Report

Medicare’s New Prescription Drug Benefit Heads Toward Reality

By Nick M. Meyers, Director have access to the full range of psychi- eligible for subsidies. For example, Department of Government Relations atric medications available today. By if your income is not more than American Psychiatric Association law, Part D does not cover some anti- $12,920 ($17,321/couple) AND anxiety drugs used safely and effec- your resources are below $6,000 tively. We are working to fix this in ($9,000/couple) you will be eligible ffective January 1, 2006, Medi- Congress. for subsidies that will mean you pay care will undergo the single no monthly premium and between most significant change since What can you do to be prepared for $3 and $5 for drugs. Other benefici- the program was established in Part D? Here are a few suggestions: aries with incomes of up to 150 per- theE 1960s when it offers new prescrip- cent of the federal poverty level will tion drug coverage to 42 million elderly • Pay attention to your mail and the also receive subsidies on a sliding and disabled Americans. The new bene- calendar. Advance notices to dual scale. If you need help now, APA fit is available to those people who have eligibles that they are eligible for and other groups have joined forces Medicare Part A and/or Part B, as well subsidies – and will pay little for to set up the Partnership for Pre- as “dual eligibles,” those who qualify for covered drugs -- if they enroll in scription Assistance to help eligible both Medicare and Medicaid. Part D, as Part D are well underway. About 20 individuals with their medication the drug benefit will be known, offers million beneficiaries will receive needs. Call toll-free 1-888-477- promise to help defray the increasing information about applying for a 2669 for help. cost of drugs. Those with limited in- subsidy by the end of August. In comes will pay little, in some cases October, Medicare will notify dual- • Know where to go for information none, of the cost. Others will pay more, eligibles that they need to enroll in and help. For official information, but the Medicare drug benefit may still Medicare Part D and should do so go to http://www.medicare.gov, also be a good bargain. If you already have before the open enrollment date of 1-800-633-4227. Many other or- drug coverage, you may wish to keep Nick M. Meyers November 15 or else they will be ganizations offer helpful informa- it, but you should carefully compare auto-enrolled, but can switch plans tion. Among the best are: NAMI, what you are paying now against what quired to offer at least two drugs in each on or after January 2006. Open http://www.nami.org; and, NMHA, you are likely to pay if you take Medi- therapeutic class or category. Physi- enrollment for everyone else com- http://nmha.org. For general clear- care Part D instead, and you should be cians and patients can ask for a non- mences November 15, 2005 and inghouse information, try the Medi- aware that if you do not enroll in Part preferred drug to be covered, and there continues through May 2006. You care Rx Education Network, D by May, 2006, you may face added is an appeals process if beneficiaries will receive additional information http://MedicareRxEducation.org. financial costs. are turned down. APA, our members – in the fall. As with any new program of this particularly including the members of It’s prudent to expect rough spots as magnitude, implementation is daunting the New York Psychiatric Association • Be aware that you may be eligible the Part D benefit gets up and running. and is likely to be confusing. Although -- and our allies such as NAMI and for subsidies that reduce your costs. Don’t be afraid to ask for help, and the law covers all drugs and injectables NMHA, have expressed particular con- If you are a low-income beneficiary above all else, don’t ignore mail from (with limited exceptions), plans are re- cern about the need for patients to (and not a dual-eligible) you may be Medicare. □

New York State Psychiatric Association

Area II of the American Psychiatric Association Representing 4500 Psychiatrists in New York

Advancing the Scientific and Ethical Practice of Psychiatric Medicine

Advocating for Full Parity in the Treatment of Mental Illness

Advancing the Principle that all Persons with Mental Illness Deserve an Evaluation with a Psychiatric Physician to Determine Appropriate Care and Treatment

Please Visit Our Website At: www.nyspsych.org

PAGE 18 MENTAL HEALTH NEWS ~ FALL 2005 Media Award from page 11

things working against me above and The NAMI-NYS Corner beyond the already relentless grip that Providing support to families and friends of individuals with mental illness the illness of depression had on my life. Those three things were stigma, lack of and working to improve the quality of life for individuals with mental illness. information and a lack of hope that I Helpline: 800-950-3228 (NY Only) ● www.naminys.org ● Families Helping Families would ever be well again.” It was your own experience and struggle that energized you to become a leader in the fight against all three ob- stacles to a life of empowerment and Research: inspiration to others. In that determina- tion was born the idea that grew into Mental Health News. Our Hope For The Future Mental Health News now has spread from Westchester to New York City By J. David Seay, Esquire ity,” for example) about the disease. one has over a lifetime, the more se- and beyond. It has spawned a Span- Executive Director, NAMI-NYS The World Health Organization has verely damaged the brain becomes. ish/bilingual language newspaper, identified schizophrenia as one of the ten NAMI strongly believe that Salud Mental that speaks to the Latino most debilitating diseases affecting hu- “research is our hope for the future,” and Hispanic communities in their man beings worldwide. and perhaps nowhere does this hold own language, breaking down cultural Symptoms of schizophrenia range more promise than with the disease barriers to hope and recovery from mental illness. from delusions and hallucinations, schizophrenia. It is also a very impor- In Mental Health News, you bring to known as positive symptoms for their tant issue for NAMI since so many of your readership the personal stories of overt presence, to emotional flatness and our ill loved ones and members suffer consumers and the opinions of academ- a lack of interest in life, known as nega- from it. We commend Ira Minot and ics and practitioners about the many tive symptoms for their lack of certain Mental Health News for shining the aspects and manifestations of mental characteristics that should be there but spotlight on schizophrenia. The most illness. You show the variety of people are not. Schizophrenia can also signifi- seriously mentally ill always run the affected by mental illness and the varie- cantly affect the cognitive abilities of risk of being forgotten by society and ties of people and services available in individuals, from the ability to remember policy makers or shunted aside by pro- our communities for helping people live and accomplish tasks, to attention span viders who would prefer to deal with with their illnesses and create lives of and staying motivated to achieve goals. less sick and easier to treat patients. meaning and hope. You are an in- While we still do not know the spe- Priority and funding must continue to former and a provocateur; a bridge cific causes of schizophrenia – leading be given to the seriously and persis- builder and a helper, an energizer and a researchers believe that is caused by a tently mentally ill for it is they who guide. Mental Health News has brought combination of problems including ge- need it the most. consumers and providers together as netic vulnerability and environmental Mark you calendar now for and make J. David Seay, JD rd partners, an achievement which I have factors – it is clear that this no-fault dis- plans to attend NAMI-NYS’s 23 An- admired enormously. order is not caused by bad parenting or nual Meeting and Educational Confer- By taking your personal struggles chizophrenia is the topic fea- personal weakness. Recent research ence, “Navigating in Rough Seas: Find- and bringing them into the light for oth- tured in this issue of Mental has identified the first genes that ap- ing the Way to Recovery from Mental ers to see and understand a little better, Health News, and I am pleased pear to increase risk for schizophrenia, Illness.” It will be held October 28-30, you fight the fight against stigma. By to be able to contribute some- but like cancer and diabetes, the genes 2005, at the Desmond Hotel and Confer- bringing together in your publication S only increase the chances of becoming ence Center in Albany. Friday, October the many strands of the mental health thing to it. Schizophrenia is one of the th more onerous and difficult of the diagno- ill, and do not cause the illness all by 28 will be an all-day session on mental community, you proclaim the value of diversity; by bringing the best minds ses known as Serious and Persistent themselves. illness and the criminal justice system While at present there is no cure for and will feature panel presentations on and best ideas to light in your publica- Mental Illness, or SPMI. Once thought tions, you are educating and informing to be a degenerative and incurable dis- schizophrenia, it is a highly treatable and the Special Housing Units (SHUs) in manageable illness, thanks to break- prisons, revisiting the insanity defense in the mental health world and the general ease, schizophrenia is now seen in a dif- public. throughs in medication and treatment New York and services for MICA and ferent light. Early diagnosis and consis- For all this and more, we salute you tent and persistent treatment can now research. Through a combination of other dual-diagnosed consumers. Satur- as a journalist and colleague. The Coa- allow persons with the diagnosis to re- medication, therapy, and psychosocial day morning will feature the annual lition is proud to present you with its cover or at least stabilize in a way that rehabilitation, individuals with schizo- meeting and election of NAMI-NYS 2005 Media Award for “helping to in- allows them to lead satisfying and pro- phrenia can and do lead productive lives. Directors. NYSOMH Commissioner crease community awareness of mental ductive lives in their communities. No However, people may stop treatment Sharon Carpinello will speak at 11:00 health issues, for promoting the impor- longer does schizophrenia need to be because of medication side effects, dis- that morning followed by a panel presen- tance and effectiveness of community seen as a death sentence or a diagnosis organized thinking, or because they feel tation on multicultural family perspec- mental health and for advancing mental with no help, relegating its victims to the medication is no longer working. tives on mental illness, a prominent health policy reform.” □ lives locked away in institutions like People with schizophrenia who stop tak- luncheon speaker, twelve afternoon By Alan B. Siskind, Ph.D. they once were. ing prescribed medication are at a high workshops and a reception and banquet. June 15, 2005 Despite these strides in understanding risk of relapse into an acute psychotic The banquet will feature Dr. Jeffrey Lie- the disease and in diagnosis and treat- episode, which can lead to self- berman, Director of the Psychiatric Insti- ment, schizophrenia remains a devastat- endangerment, hospitalization, or run-ins tute in New York City and world- ing brain disorder that, according to with the law. This is exacerbated by an- renowned psychiatric research scientist NAMI National, affects approximately other physical symptom of the disease and clinician, as well as presentation of 2.2 Million American adults, or about known as anosognosia, or the lack of the 2005 NAMI-NYS Awards. Sunday, th 1.1 percent of the population 18 and awareness of the illness. Persons with October 30 will feature an all medical older. Schizophrenia interferes with a anosognosia literally do not know that plenary session as well as the ever- Mental Health person’s ability to think clearly, to dis- they are sick, thus not understanding popular “Ask the Doctor” session with tinguish reality from fantasy, to manage why others, such as their doctors and Dr. Lewis Opler. Look for the brochure emotions, make decisions, and relate to family, think they should seek treatment in the mail or call us to get one, at (800) Is About All Of Us others. Most people with schizophrenia or therapy or take medications. Those 952-FACT or (518) 462-2000. People suffer chronically or episodically individuals are most at risk for the will also be able to register on line at our throughout their lives, and are often stig- downward spirals of decompensation website www.naminys.org. matized by a lack of public understand- and relapse. And research shows that the ing or misunderstanding (“split personal- more relapses and untreated episodes Enjoy the fall and the holidays. □

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 19

THE MENTAL HEALTH LAWYER

Why A Forum For Legal Discussion Is So Important

By Carolyn Reinach Wolf, Esq. While this article should not be con- Once you have committed to an attor- Since the last issue, our firm strued as legal advice, it should provide ney, what are your rights? You have the name has changed from the Law Of- a foundation from which the reader can right to courteous and respectful service. fices of Carolyn Reinach Wolf, P.C., make meaningful decisions and choose You have the right to periodic updates to the law firm of Reinach Wolf, an appropriate course of action. We on the progress of your case and the Rothman, and Stern LLP. Our firm’s cannot respond to every question but status of any proposed settlements. Most members, Carolyn Reinach Wolf, will strive to create articles that address a importantly, you have the right to com- Valerie Meakin Rothman, Alcine broad range of legal issues. When sub- petent representation. Panton, and myself remain commit- mitting a question, please provide as With so many things to consider, one ted to the mental health community much information as possible. Personal can never have enough information. and legal issues that touch our lives. information will not be published and Hopefully, this forum will get the reader Please feel free to e-mail any ques- names will be changed to insure privacy. heading in the right direction toward tions to [email protected] or In the past, readers have inquired making fully informed decisions. Please [email protected]. I will con- about a broad range of legal topics from keep those letters and e-mails coming. firm receipt of your e-mail. □ Mental Health Warrants to Kendra’s Law to Guardianships, as well as a vari- ety of other issues relating to the Mental Hygiene Law. Other areas of interest which often relate to mental health issues come within the criminal or The Law Firm of family law context or those issues re- lating to advance planning tools such Reinach Wolf, Rothman, and Stern, LLP as the Supplemental Needs Trust, Carolyn Reinach Wolf, Esq. Healthcare Proxy, Living Will or Power-of-Attorney. Devoted to the Practice Another area of questions about s many readers may already which we have received concern is the of Mental Health Law know, this space is devoted to hiring of legal counsel. Although we the “Ask the Lawyer” col- have not yet devoted one of our columns A umn, a forum for readers to to this yet, here are some suggestions… The Law Firm of Reinach, Wolf, Rothman, and Stern LLP, represents submit questions regarding legal issues If the need arises for you to hire legal more than twenty major medical centers, as well as community hospi- that invariably prove to be important to counsel, be sure to choose an attorney tals, nursing homes and outpatient clinics, in the New York metropoli- the majority of readers. We would like who comes to you highly recommended. to take this opportunity to reintroduce Do not choose one by chance, out of the tan area in the field of mental health litigation, consultation, advocacy, the objectives of the “Ask the Lawyer” phone book, or from a billboard. The and related disciplines. forum and call upon you to submit ques- majority of issues that concern our read- tions or topics that you would like to be ers are far too important to be handled In addition, our team of attorneys, with more than forty years combined addressed. by an attorney who lacks familiarity or experience, offers legal representation to families and individuals affected Why is a forum for legal discussion does not have expertise with the subject by mental illness. We provide a broad range of legal services and counsel important? The laws in New York gov- matter. Be sure to speak directly with on such matters as: mental health case management and continuity of erning Mental Hygiene, Elder Law, the attorney and do not sign a retainer Healthcare Law, and related topics are agreement or agree to give him/her the care; discharge planning; Assisted Outpatient Treatment (Kendra’s Law); dynamic and change with some fre- case until you feel absolutely comfort- Mental Health Warrants; Hospital Treatment over Objection and Reten- quency. Kendra’s Law was set to expire able with his/her legal skills, profession- tions; Patients’ Rights and Guardianships. in June, 2005, however the Governor alism and background. If you are having signed a five year extension to this law. difficulties finding an attorney, your Our firm regularly contributes to a number of publications concerned with Medicaid, SSI, and other disability laws local county or city bar association Mental Health and related Health Care issues and participates in seminars seem to change almost monthly and the maintains an attorney referral network. laws that govern our privacy, insurance Ask as many questions as needed before and presentations to professional organizations and community groups.

coverage, and access to healthcare im- committing to an attorney. An attorney pact individuals with mental illnesses who lacks the patience or time to address and their loved ones on an ongoing ba- your concerns is not worth hiring. Do 60 Cutter Mill Road - Suite 407 sis. We believe it is important to have a not hesitate to request a fee schedule or Great Neck, New York 11021 forum where individuals can share their explanation of a quote for legal services. questions or concerns with other readers An attorney must be forthcoming with you (516) 829-3838 and receive a response that is authorita- regarding the cost of legal services, court tive and provides meaningful guidance. fees and other related disbursements.

Call Attention to Your Vital Programs and Services Advertise in Mental Health News and Reach Out: See Page 47

PAGE 20 MENTAL HEALTH NEWS ~ FALL 2005

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 21 Family Involvement Improves Outcomes in Schizophrenia

By Carla Quail, LCSW tions about the nature of the program. Assistant Executive Director Once families committed to the program, The Mental Health Association the facilitators began joining sessions of Westchester County with families. This is where the relation- ships are established that connect the family to the facilitator and begin to ac- he New York State Office of culturate the family to the model. Fi- Mental Health has made a nally, all of the families come together commitment to families and for a Survival Skills Workshop. This consumers throughout the state workshop educates families about all toT provide evidence-based family treat- facets of schizophrenia and from here ment. A partnership between the Office the formal groups begin. of Mental Health and The University of MHA has been running Multi-Family Rochester Medical Center’s Family In- Psycho-education Groups for most of stitute and in collaboration with NAMI, this year. Families make a commitment The Family Psycho-education Project to attend for eighteen months and to date sought qualified agencies to implement we have not had any families drop out of multi-family psycho-education groups. the program. Many families site the edu- This evidence-based practice has proven cation piece of the program as the most to lower rates of relapse, improve voca- novel and helpful component. Others tional and independent living outcomes, find the problem solving techniques to as well as, enhance the coping skills and be useful in many areas of their lives. communication of families. In the fall of Not enough time has elapsed to assess 2003, the Office of Mental Health selected outcomes, but our next project is to look The Mental Health Association of West- at relapse rates and vocational/ chester County Inc., (MHA) to be one of independent living status of participants only twenty-one sites in the state to provide at the beginning and one-year mark. We this service to consumers and families. anticipate seeing some positive changes. MHA of Westchester has long been a In addition to the benefits to consum- leader in the treatment of people with ers and families, staff have benefited serious mental illnesses. The Family greatly from this program. The opportu- Psycho-education Project offered MHA nity to work collaboratively with people of Westchester and the families we serve from across the agency, the chance to try a wonderful opportunity to implement something new and see it through to truly effective family interventions. implementation, the input of regular con- MHA’s plan, which the Project firmly tact and supervision from an outside supported, was to train staff representa- consultant, and the significant benefit to tives from as many programs as possible consumers and their families has contrib- within the agency in order to disseminate uted to high staff morale. Just as all of this service as comprehensively as possi- the families have remained engaged and bly. In January of 2004, eight staff at- active in the program, so have the staff. tended a two-day training in the Multi- Many models of family involvement Family Psycho-education Model. Today, and solution driven methods. Facilitators most of the clients and families have exist in the treatment and support group thanks to the commitment and enthusi- of Multi-family Psycho-education been in treatment for some time. MHA community, all providing wonderful asm of MHA’s consumers, families and groups form collegial relationships with reached out to families through direct opportunities for consumers and fami- staff, we have two multi-family groups families and consumers. The model is conversations with our clients, through lies. MHA has found this particular running and are planning a third. dependent upon the successful restruc- letters to people the clients identified as model to offer our families and staff Multi-Family Psycho-education is not turing of the traditional therapist role. “family”, and finally through invitations much needed support, education and a new program. William McFarland, the Staff, families and consumers work to- to what we called “Family Nights”. solutions. MHA anticipates that this originator of the model, developed gether as equal parts of a triangle, in an MHA’s Family Nights became a very model will grow within our agency and, multi-family psycho-education groups at effort to improve the quality of life of successful vehicle by which we engaged hopefully, other agencies will take on least twenty years ago. The model pro- the consumer and family. families. At least 75% of the families this initiative as well. vides families and consumers with edu- The original model was developed for that attended a Family Night joined a For more information about the cation about mental illness and methods families going through the first episode Multi-Family Psycho-education Group. Multi-Family Psycho-education program of coping and support in a structured of a family member’s illness. MHA had At Family Nights, we would meet and please contact Carla Quail, LCSW Pro- environment. Families learn to address to modify some of the original model to socialize with families, describe the ject Coordinator at MHA of Westchester problems through concrete, strategic, adapt to an outpatient setting, where model and its benefits and answer ques- (9140345-5900 x244). □

P.O. Box 635 Orangeburg, NY 10965 (845) 359-8787

PAGE 22 MENTAL HEALTH NEWS ~ FALL 2005

Schizophrenia from page 1 of the symptoms before concluding that by others around them. Living in a world Delusions may take on different themes. a person has schizophrenia. In addition, distorted by hallucinations and delusions, For example, patients suffering from remember how involved or vivacious a since commonly abused drugs may cause individuals with schizophrenia may feel paranoid-type symptoms—roughly one- person was before they became ill. The symptoms resembling schizophrenia, frightened, anxious, and confused. third of people with schizophrenia— sudden onset of severe psychotic symp- blood or urine samples from the person In part because of the unusual reali- often have delusions of persecution, or toms is referred to as an “acute” phase of can be tested at hospitals or physicians’ ties they experience, people with schizo- false and irrational beliefs that they are schizophrenia. “Psychosis,” a common offices for the presence of these drugs. phrenia may behave very differently at being cheated, harassed, poisoned, or condition in schizophrenia, is a state of At times, it is difficult to tell one various times. Sometimes they may conspired against. These patients may mental impairment marked by hallucina- mental disorder from another. For in- seem distant, detached, or preoccupied believe that they, or a member of the tions, which are disturbances of sensory stance, some people with symptoms of and may even sit as rigidly as a stone, family or someone close to them, are the perception, and/or delusions, which are schizophrenia exhibit prolonged ex- not moving for hours or uttering a sound. focus of this persecution. In addition, false yet strongly held personal beliefs tremes of elated or depressed mood, and Other times they may move about con- delusions of grandeur, in which a person that result from an inability to separate it is important to determine whether such stantly—always occupied, appearing may believe he or she is a famous or real from unreal experiences. Less obvi- a patient has schizophrenia or actually wide-awake, vigilant, and alert. important figure, may occur in schizo- ous symptoms, such as social isolation or has a manic-depressive (or bipolar) dis- Hallucinations and Illusions phrenia. Sometimes the delusions experi- withdrawal, or unusual speech, thinking, order or major depressive disorder. Per- Hallucinations and illusions are dis- enced by people with schizophrenia are or behavior, may precede, be seen along sons whose symptoms cannot be clearly turbances of perception that are common quite bizarre; for instance, believing that with, or follow the psychotic symp- categorized are sometimes diagnosed as in people suffering from schizophrenia. a neighbor is controlling their behavior toms. Some people have only one having a “schizoaffective disorder.” Hallucinations are perceptions that occur with magnetic waves; that people on such psychotic episode; others have many without connection to an appropriate television are directing special messages episodes during a lifetime, but lead rela- Can Children Have Schizophrenia? source. Although hallucinations can oc- to them; or that their thoughts are being tively normal lives during the interim cur in any sensory form—auditory broadcast aloud to others. periods. However, the individual with Children over the age of five can de- (sound), visual (sight), tactile (touch), “chronic” schizophrenia, or a continuous velop schizophrenia, but it is very rare gustatory (taste), and olfactory (smell)— Disordered Thinking or recurring pattern of illness, often does before adolescence. Although some peo- hearing voices that other people do not not fully recover normal functioning and ple who later develop schizophrenia may hear is the most common type of halluci- Schizophrenia often affects a person’s typically requires long-term treatment, have seemed different from other chil- nation in schizophrenia. Voices may ability to “think straight.” Thoughts may generally including medication, to con- dren at an early age, the psychotic symp- describe the patient’s activities, carry on come and go rapidly; the person may not trol the symptoms. toms of schizophrenia—hallucinations a conversation, warn of impending dan- be able to concentrate on one thought for and delusions—are extremely uncom- gers, or even issue orders to the individ- very long and may be easily distracted, Making a Diagnosis mon before adolescence. ual. Illusions, on the other hand, occur unable to focus attention. when a sensory stimulus is present but is People with schizophrenia may not be It is important to rule out other ill- The World of People With incorrectly interpreted by the individual. able to sort out what is relevant and what nesses, as sometimes people suffer se- Schizophrenia is not relevant to a situation. The person vere mental symptoms or even psychosis Delusions may be unable to connect thoughts into due to undetected underlying medical Distorted Perceptions of Reality logical sequences, with thoughts becom- conditions. For this reason, a medical Delusions are false personal beliefs ing disorganized and fragmented. This history should be taken and a physical People with schizophrenia may have that are not subject to reason or contra- lack of logical continuity of thought, examination and laboratory tests should perceptions of reality that are strikingly dictory evidence and are not explained be done to rule out other possible causes different from the reality seen and shared by a person’s usual cultural concepts. see Schizophrenia on page 41

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“Fawns in Gorilla Suits” Strategies and Techniques for Working with Aggressive Children

By David A. Crenshaw, PhD, ABPP ing bridges to a child’s inner-life, and thy, in my view the most important of those that will stimulate other therapists all the pro-social skills. to develop their own strategies to con- The Invitational Track invites the n my 35-plus years of treating trou- nect with these “disconnected” children, child to go as far as she/he can at any bled children, I have identified a have now been compiled in three re- one point in time in approaching the group of children that I have come cently published books: Understanding painful, disturbing, or traumatic events to refer to as “fawns in gorilla and Treating the Aggression of Chil- of his or her life. Criteria for determining Isuits.” These are the children whose hor- dren: Fawns in Gorilla Suits and the when a child is ready for the Coping or ror-show-harsh lives have exposed them Handbook of Play Therapy with Aggres- Invitational Tracks are also spelled out to repeated abuse, deprivation, severe sive Children (published by Jason in A Handbook for Play Therapy with trauma, and often multiple out-of-home Aronson, 2005) which are co-authored Aggressive Children. The decision grid placements. Their sense of trust is shat- with my long-time colleague John B. is intended to guide therapists in a fluid tered. Mordock, and Engaging Resistant and dynamic manner that allows for the Like a fawn, their core self is very Children in Therapy (published by flexibility needed when working with vulnerable – they are often frightened, Rhinebeck Child and Family Center children. The arrows in both tracks point but, paradoxically, they put on the go- Publications, 2004.) – the first Volume both up and down, as well as across rilla suit (aggression) to keep others, in The Child and Family Therapy tracks, because when a child is dealing even those who seek to help and befriend Guidebook Series. with some topics he/she may be able to them, at a distance – because they can’t work within the Invitational Track al- bear to be hurt again. For 30 years I The Decision Grid though the pace may need to be slowed worked in two different residential treat- or stepped up, but with other emotion- ment centers, and many of the children David A. Crenshaw, PhD, ABPP One of the strategies for deciding the ally evocative topics she/he may need that I treated during that time fit this pace at which a child should be engaged to move back to the Coping Track for profile. My professional quest has been in therapy can be found in The Child/ more work with building defenses since to help this population of children – to express their feelings, thoughts, and fan- Play Therapy Decision Grid, which is she/he may become overwhelmed or identify strategies that will reach the tasies. Sometimes, what therapists con- explained more succinctly in A Hand- emotionally flooded. “fawn”, and to create opportunities for sider as ‘resistance’ is actually the thera- book for Play Therapy with Aggressive the fawn to learn when it is safe and pru- pist’s failure to provide the proper struc- Children. This was developed to guide Goal-Directed Intervention Groups dent “to take off the gorilla suit” and ture, within an appropriate context, that child therapists in titrating the level and when it is not. The goal is not to take the facilitates communication leading to intensity of therapy for a specific child at Another feature of the ever-evolving gorilla suit away; that would be too big a meaningful dialogue – and it is a particular point in time taking into ac- “fawn project” is to organize the practi- step and leave the child too exposed. “dialogue” that is critical for healing. count the child’s resources including cal strategies within goal-directed inter- Rather, the objective is to teach children Aggressive and anxious children, often coping skills, sophistication and maturity vention groups. Attention is being paid to discriminate between people and distrustful of others, are usually reluctant of defenses, family and interpersonal to areas where extremely aggressive situations that can be trusted and when to share their private thoughts, feelings, supports, ego strengths, and degree of children are particularly deficient, in- mistrust and caution is adaptive and war- and fantasies. Often, they lack the skills external stress in current life. These cluding: 1) Establishing a therapeutic ranted. to identify and label the sometimes factors can change and shift as the ther- alliance; 2) Building, modeling, teach- And, so, many years ago, with the frightening inhabitants of their inner- apy proceeds and sometimes adjustments ing, identifying, highlighting and rein- “fawn in the gorilla suit” in mind, I be- world. Others may be in touch with the are required even within a single session. forcing defenses and coping resources; gan the project of gathering information thoughts and feelings that trouble them, Two tracks of therapy are identified 3) Teaching the language of feelings; 4) and practical ideas that would serve to but are unable to find the words to ex- within the Grid, the Coping Track and Facilitating expression and modulation engage children who are highly anxious, press them. In addition, they often feel the Invitational Track. This model was of affect; 5) Modeling and teaching of aggressive, defiant, oppositional, and that their inner-world is too scary to share inspired by the work of Beverly James symbolization; 6) “Tickling” the self- resistant to the therapeutic process. with another, even a trusted person. who discussed similar concepts without observer; 7) Accessing the inner world As a child and family therapist, I be- I have always approached the under- integrating them into a decision grid. of the child; 8) Addressing profound gan developing specific strategies to use standing and treatment of children from The Coping Track is basically a psy- losses; 9) Confronting traumatic events in my practice to address the wounds of an integrative theoretical framework. choeducational approach to therapy through contained trauma-re-enactments the “fawns.” Verbal skills are rarely the Much can be learned from a wide range with emphasis on building ego and development of a trauma narrative; strong suit of anxious and/or impulsive, of theoretical and practical approaches to strengths, coping skills, defenses, 10) Addressing shame and guilt; action-oriented kids, but given the therapy. The techniques and strategies problem-solving skills, and pro-social proper tools, these same children can that I have found most effective in build- skills with special emphasis on empa- see Strategies on page 26

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Strategies from page 23 Techniques Intervention Groups strategies in my book were designed with this purpose in mind, to embed CBT strategies in a playful, engag- 11) Facilitating the development of empathy; 12) Re- ing, and child-responsive format. working identity, seeking meaning, and perspective; Color-Your-Life Same as above 13) Facilitating and preparing for termination of therapy. (O’Connor) Not a Cookbook Approach In light of Alan Kazdin’s recent review indicating that there are now over two thousand studies support- The Endless Search Loss/Attachment These interventions are not meant to be used in a ing the crucial role of the therapeutic alliance in psy- cookbook approach or to be a substitute for training chotherapy outcome research, these interventions A Tale of Revenge Symbolization/ Accessing and supervised experience. I wish to emphasize that offer potentially valuable tools to strengthen the Inner World/Affect entering the inner world of troubled children, a world therapeutic alliance as a result of their child-friendly Expression/Modulation filled with emotionally laden material, especially format, and their focus on emotionally meaningful trauma related material, should be undertaken only by themes and issues. therapists who have met rigorous standards of training

On May 6, 2005 during a Grand Rounds presenta- and experience and who have been supervised by The Little Pig Addressing Loss Issues, tion at Four Winds Hospital on “25 of the Best Play qualified child clinicians licensed and credentialed in a Therapy Techniques for Working with Aggressive that Didn’t Fit Symbolization, Affect mental health discipline. The work can be arduous and Children” the following strategies and techniques were Expression/Modulation emotionally taxing, but if we are able to reach ‘the presented to an audience of nearly 200 fellow clini- fawn” it will also be rewarding and we will grow in cians. You may be familiar with some of these ideas, The Misunderstood Same as above clinical courage and confidence. □ the use of therapeutic stories as an effective tool in Mouse child therapy, and the use of projective drawings are a David A. Crenshaw, PhD, ABPP, RPT-S is Foun- series of techniques designed to enable even the most The Animal that Same as above der and Director of Rhinebeck Child and Family Cen- inhibited, guarded, or uncooperative child to find a Nobody Could Hug ter, LLC. Visit his website at www.rhinebeckcfc.com face-saving way to meaningfully participate in ther- for more information on his writings, published books, apy. To many children, therapy is similar to being Blow-Up Bernie Symbolization/Affect speaking engagements and how to contact him. brought to the principal’s office! Therapy is related to Expression/Modulation/ punishment. Perhaps the most important intervention Coping Skills a therapist can make is to change the adversarial orien- tation of the child toward the therapist to a collabora- Behind Closed Doors Same as above tive one. The projective drawing and storytelling se- ries can be used in both family and group therapy, as The Fair Trial Addressing Shame/Guilt well as individual therapy. Projective Drawing and

Storytelling Techniques are explained further in Engag- Godzilla has Gone Affect Modulation/ ing Resistant Children in Therapy, but some of the ideas, TooFar this Time! Re-Working Identity and the goals of the exercises are briefly outlined here:

Party Hats Affect Modulation/ Techniques Intervention Groups on Monsters Symbolization/ Trauma Work

Wave Breathing Building Defenses/Coping (O’Connor) Engaging the Hearts of Kids

Angry Arthur “Tickling” the Self-Observer The strategies discussed in this article have been (Ornam) developed for the purpose of engaging not just the minds, but also the hearts of children. If therapy is

sterile, dry, and too cerebral, let alone manualized, it Furious Fredâ Building Defenses, will not reach the inner place where children in their (Franklin Learning Coping, Affect Modulation essence live. It will not reach the inner recesses of Systems) their hearts and souls that is the home of what James Garbarino (1999) calls “the divine spark.” To engage The “Volcano Speaks” Building Defenses/ children in a meaningful way, to create moments of Language of Feelings/ transformation and change in the therapy process, we Modulation have to learn the language of the heart.

Storm Clouds Same as above Integrative Model

Dragon Breathing Fire Same as above These specific techniques can fit logically and co- herently within any number of models of psychother- Angry Monster Roars Same as above apy that are empirically supported. I do not advocate for one approach or another but rather describe strate- The Alligator Flips Affect Expression/ gies that may be used in such diverse therapy ap- its Lid Modulation; Teaching the proaches as psychodynamic, narrative, cognitive- Language of Feelings behavior, trauma-informed treatment, solution-focused therapies, Ericksonian approaches, family systems, Tommy Turtle’s Building Defenses/ play therapy, Gestalt, and creative arts therapies as Secret Coping Club Language of Feelings well as others. This is not a stand-alone or all encompassing ap- Reaming Them Out! Affect Expression/ proach to therapy but a compilation of clinically useful Modulation; Teaching the strategies that can thoughtfully be included in a wide Language of Feelings variety of treatment approaches and protocols to ad- dress specific issues and facilitate progress toward a Movie Auditions Affect Expression/ defined goal. Modulation Child-Friendly Cognitive Behavioral Therapy The Magic Key Symbolization/Accessing Inner World/Addressing Loss The purpose of the “fawn project” is to offer practi- cal ideas to help therapists engage children who are The Boat in a Storm Accessing Inner World/ highly anxious, aggressive, defiant, oppositional, and (Oaklander) Symbolization “resistant” to the therapeutic process. Some of the strategies have been developed in response to Janine Your Place Same as above Shelby’s characterization of CBT techniques as not (Oaklander) being “child-friendly.” A number of the evocative

Mental Health News - New York City Section: Fall 2005 Page 27 The Mental Health News New York City Section

Regaining A Life: Orlando’s Story

By Denise Kreitzman Schizophrenia is a chronic, severe human being...an easy prey for sneak The Mental Health Association and disabling brain disease. In the attacks of paranoia that frightened him of Nassau County United States, approximately 1 percent and, in turn, frightened others. (Not eve- of the population develops schizophrenia ryone with schizophrenia experiences during their lifetime – and more than 2 Orlando's fate. With a combination of he skies threaten rain and it’s million Americans suffer from the illness therapy, medication and support, people uncertain whether the State in a given year. serious mental illnesses can live a digni- University of New York at Old Uncontrollably gripped by this seri- fied life in the community). Westbury will hold their ous disorder, Orlando’s day-to-day life Striving to keep him from harm’s graduationT ceremony outdoors. Orlando was an unrelenting nightmare. For years, way, Orlando was sent to yet another Morales waits in cap and gown with resisting treatment, schizophrenia ruled psychiatric hospital. Determined to re- hundreds of other graduating seniors. Orlando’s world. He was either in jail, lieve his symptoms, the staff at Pilgrim Somewhere in the overflowing crowd on a psychiatric ward or wandering the State Hospital endeavored to maintain sits Orlando’s family. But there’s a gulf streets. Internal voices controlled his Orlando’s compliance with medications of difference in the meaning of this day thoughts and his behavior. They told and therapy. Several months after ad- for their son and the families that sur- Orlando unimaginable things - burying mission, Orlando picked up a pamphlet round them. his rational thinking in a toxic dust. The on group homes in the day room. Unbe- Orlando, in his early thirties, is older voices said his food was poisoned and knownst to him and others, Orlando was than most graduates, but for those who ordered Orlando not to eat; they pro- beginning to separate real from unreal know him, he is one of the most spec- nounced him the King of Puerto Rico experience. The pamphlet triggered pre- tacularly successful students of the day. and warned that people were conspiring illness memories. Orlando remembered His experiences stray far from those of to kill him. His irrational beliefs, delu- how much he had loved mathematics in his peers. Diagnosed with schizophrenia sions and hallucinations, (all symptoms high school and how he excelled as a in his late teens, Orlando has been to a of his disturbance), transformed Orlando terrifying hell and back. from a bright young man into a chaotic Orlando Morales see Orlando’s Story on page 40

New Medicare “Part D” Prescription Drug Plan Coming This January Could Have Profound Impact on Individuals Receiving Mental Health Services

By Karyn Krampitz 2006, will be subject to a lifelong pen- ated primarily with cardiovascular IT Projects Director, The Coalition of alty of 1% for each month that enroll- agents, yet are often used for other Voluntary Mental Health Agencies ment is delayed. Dual eligibles will be indications as well.) allowed to change plans as often as once A few states, including New York, a month, as plan formularies may change have agreed to offer some sort of a n January 1, 2006, as part of during the year. All others will only be “wrap-around” prescription drug pro- the Medicare Prescription able to change plans once a year. gram. The New York State wrap-around Drug, Improvement and Initially there was great concern that will at a minimum include some of the O Modernization Act of 2003, a a limited number of drugs would be drugs which are currently available new voluntary Medicare prescription made available in each drug class and through Medicaid but which have been drug program referred to as Medicare what effect this would have on the be- specifically excluded from the Medicare Part D, goes into effect for all Medicare havioral heath community. This concern program (such as the benzodiazepines eligible consumers. The program, ad- was based directly on the initial regula- and barbiturates). The New York State ministered by the Centers for Medicare tions which only required a plan to in- Department of Health has also indicated and Medicaid Services (CMS), will offer clude at least two drugs in each class. that they may cover drugs not included in a prescription drugs to all Medicare recipi- There are also entire classes of drugs plan’s formulary, but has not yet deter- ents at a relatively low premium cost. which are excluded from any Medicare mined how this will be implemented. Medicare recipients include the elderly Part D plan such as benzodiazepines over 65 as well as disabled individuals (anti-anxiety) and barbiturates. Major Change who are below the federal poverty level In response to outcries from the men- who are under 65 and who are eligible tal heath community and others, CMS The major thrust is that all Medicare for both Medicare and Medicaid Karyn Krampitz recently clarified their policy to state that recipients who currently receive pre- (referred to as dual eligibles). It is esti- plans should offer “all or substantially scriptions through Medicaid will lose mated that there are 7 million dual eligi- eral government or a state government. all” drugs in the following 6 categories: their Medicaid prescription benefit on ble consumers nationwide; more than We expect there will be many different antidepressant, antipsychotic, anticon- December 31, 2005. So, while the half a million – 570,000 - reside in New plan offerings in New York State; mak- vulsant, anticancer, immunosuppressant Medicare Part D program is “voluntary” York State many of which live with psy- ing a choice may be difficult for con- and HIV/AIDS. These categories for most Medicare recipients it will be chiatric disabilities. sumers. Adding to the confusion, insur- should include both generic and older the only prescription drug program avail- ers will bombard the market with their branded drugs. (Pharmacological able to those dual eligible individuals Prescription Plans drug plan solicitations in October 2005. classes are associated with therapeutic losing their Medicaid coverage. This The enrollment period begins November categories. Some classes may be asso- could have a profound impact on Part D prescription plans will be of- 15, 2005 and runs until May 15, 2006. ciated with multiple categories, like fered by private companies, not the fed- Individuals who enroll after May 15, Beta Blockers which are a class associ- see Medicare on page 38

Page 28 Mental Health News - New York City Section: Fall 2005 Innovations in The Treatment of Schizophrenia: One Size Does Not Fit All

By Ellen Stoller, Assistant VP toms. More recently, we are finding Family Psychoeducation Community Services, Training that progress in regaining thinking & Consumer Affairs, F.E.G.S. skills can be accelerated through the William McFarlane, M.D. Professor Health and Human Services System use of computers by clients, guided by of Psychiatry at the University of Ver- professionals, who use learning soft- mont, designed Family Psychoeducation ware programs to promote cognitive specifically for families where one fam- ust as we understand philosophi- rehabilitation. When clients use these ily member has schizophrenia. Origi- cally the principle that every hu- programs, they stimulate the parts of nally researched over twenty years ago, man being is unique, we remain their brains that are needed to function when Dr. McFarlane was Director of the J sensitive that every adult with in the world, such as concentration and Biosocial Treatment Research Division schizophrenia is unique. During the mid- memory, sequencing, logical analysis of the New York State Psychiatric Insti- twentieth century – a period of large- and task management.” tute it is an Evidence Based Practice. scale institutionalization-- this reality Working closely with a team of For the past year or so, F.E.G.S. has was often forgotten under the pressure to neuropsychological specialists, our Re- been using Family Psychoeducation deal with large populations. habilitation Practitioners have been techniques and Multi-Family groups to In today’s community programs, the trained to provide the innovative clinical reconnect clients with their families and uniqueness of the person at the center of techniques developed by Alice Medalia, educate families about the illness and treatment planning needs to be under- Ph.D., Director of Neuropsychology at how to cope with it. This technique has scored at every stage. Once a person is the Department of Psychiatry at Albert proven to be an enormous boon to our stable on medication, treatment profes- Einstein College of Medicine in the clients. As a staff member reported about sionals focus on finding out who this Dr. Jonas Waizer Bronx, an authority in the field of cogni- a group he co-led in July 2005: person is and what motivates him/her. tive rehabilitation. We use popular com- “Our second family session went ex- We all have “on buttons”…what buttons “When people experience a puter software such as Where in the tremely well. We had 21 in attendance need to be pushed to turn you on, to help long-term serious psychiatric World is Carmen Sandiego?, Stocktopus, and only one absence. The group started you do your best work, and to motivate and Sim City that are experienced by with 10 minutes of easy socialization, you to achieve your goals? These ques- illness, and their illness is further consumers as fun and games while pro- followed by the prescribed go around to tions led F.E.G.S. Health and Human Ser- compounded by becoming moting the necessary skills. We find that each person discussing how the illness vices System to seek new approaches for removed from day-to-day life, either damaged or unused thinking skills has impacted their lives. The input was dealing with individual differences when their thinking skills may be can be repaired in the context of an en- abundant, emotional, and varied. Some working with adults with schizophrenia. impaired and affect their ability joyable learning experience. Memory of the responses: for sustained and organized retention, sustaining attention, problem Medication thought. Fortunately, the bleak solving, concentration, sequential plan- • “It has been so difficult to know prognosis for full recovery has ning and even reading skills all improve. how to talk with him (the client) not Although medication can help us with dramatically improved in the past Michael B. wrote in the Consumer knowing how he will react” much of the management and treatment several years because of new Lab Newsletter “I like the program Math of schizophrenia, negative symptoms of for the Real World because it has many • “My illness has been the major bur- the illness can continue to impede suc- psychotropic medications that features and different ways of answering den of my life and has affected eve- cess in attaining life goals such as allow them to better manage their problems. The way they do it is really rything” schooling, jobs, relationships, etc. These symptoms. More recently, we are fun and helps me with my problem negative symptoms include: finding that progress in regaining solving and attention and how to man- • “When I first got sick and went into thinking skills can be accelerated age money!” the hospital, I thought—this is it, • Loss of motivation through the use of computers by Consumers attend the Cognitive Re- this is where I will spend the rest of clients, guided by professionals, habilitation center twice a week for one my life.” • Inability to experience pleasure who use learning software hour under the tutelage of a professional. programs to promote cognitive Consumers experience the computers as • “We never even really realized my • Blunted affect and communication rehabilitation. When clients use their personal, patient teachers, who of- son's illness or talked about it until fer consistent feedback that is non- we came here” • Lack of concentration these programs, they stimulate the judgmental and non-threatening. The parts of their brains that are feedback is designed not only to tell con- • “My brother is very dependent and • Inability to stay on task needed to function in the world, sumers if they are not doing something my mother is always enabling him. such as concentration and right, but more importantly to offer sug- It makes me so angry—it's so hard • Lack of problem solving skills memory, sequencing, logical gestions on how to approach the problem to have patience with them.” analysis and task management.” when done again. In order to help reverse these symp- In general, the psychiatric recovery Gaining a better understanding of toms, we need to find the actions or rela- Dr. Jonas Waizer program assists consumers in making what schizophrenia is, talking about and tionships that motivate people to care Chief Operating Officer informed choices about where they wish dispelling the myth that the family is to about themselves and others. Psychia- F.E.G.S. to live, learn, work or socialize in the blame, and learning problem solving trists, as part of the treatment team, con- community, while providing the support skills has helped our families and clients Health and Human Services System sider which medications are more effec- and skills to achieve these goals. The begin to work together. tive in addressing the symptoms of skills gained in the cognitive training schizophrenia. Then comes reconnecting Cognitive Remediation accelerate consumers’ progress toward Creative Arts to people, interests and the world; these greater autonomy for desired life goals -- are key components in the treatment of According to Dr. Jonas Waizer, Chief built around independent living skills A third way that F.E.G.S. helps ame- any illness. Operating Officer at F.E.G.S., “When that require planning ahead, organizing liorate the negative effects of schizo- Currently there are three areas we people experience a long-term serious and keeping a schedule, budgeting, shop- phrenia is through creative arts interven- focus on to help our clients cope with psychiatric illness, and their illness is ping, paying the bills, and educational tions. From September 2004 to February their illness, succeed in their life goals, further compounded by becoming re- and vocational pursuits. 2005, 12 clients with severe and persis- and make new connections to others. moved from day-to-day life, their think- Consumers who have gone through tent mental illness met once a week to These are: ing skills may be impaired and affect the cognitive training demonstrate sig- work on a drama project with resident their ability for sustained and organized nificant improvement in their ability to artist, Arthur Stimling, a theater director • Cognitive Remediation thought. Fortunately, the bleak prognosis make plans, carry out complex tasks, and by profession, and three staff members. for full recovery has dramatically im- think in a more organized way. An over- The final result of the five months of • Family Psychoeducation proved in the past several years because all improvement of their psychiatric pic- warm-ups, acting exercises and discussions of new psychotropic medications that ture helps them to rebuild more produc- • Creative Arts allow them to better manage their symp- tive and fulfilling lives. see Innovations on page 29

Mental Health News - New York City Section: Fall 2005 Page 29

Innovations from page 28 in, and passionate about acting. It helped them grow, learn things about was a play called “The Guest House” themselves, and connect to other peo- that was performed twice for peers, ple in a new way. Similar results can family, friends, and the executive staff be found helping clients connect to of F.E.G.S. As one of the staff partici- music, poetry, painting, and drawing. pants in this project, I watched first Schizophrenia is still not an easy hand as clients “came out of their illness to treat. While medications are shells.” I saw clients learn new skills. key, people with schizophrenia need to I saw clients who previously slept be presented with a spectrum of op- through group staying wide awake and tions for treatment and management of participating for the full two-hour their illness. workshop. Staff noticed that clients’ To make treatment work, staff must attendance improved, anxiety de- have high expectations and a willing- creased, and impulse control in- ness to become expert in many treat- creased. Clients talked to each other, ment modalities. No one size fits all not just the group leader and staff, clients. At F.E.G.S., we use a variety they supported each other, shared of approaches and continue to learn, scripts, shared praise, and took risks. from others in the professional field This group of seriously mentally ill and from our clients and their families, adults became connected to, involved just what works for each individual. □

Mental Health News Metro-New York Leadership Committee

Peter C. Campanelli, PsyD, President & CEO Institute for Community Living

Amy Chalfy, Mental Health Director - Bronx District JASA

Marianne Coughlin, Vice President Program Development The Mount Sinai Medical Center

Kenneth J. Dudek, Executive Director Fountain House

Mary Guardino, Founder & Executive Director Freedom From Fear

Mark D. Gustin, MBA, Senior Associate Director Kings County Hospital Center

Mary Hanrahan, Director, Treatment Services New York Presbyterian Hospital - Payne Whitney Division

Rhona Hetsrony, Executive Director North Shore LIJ Health System - Zucker Hillside Hospital

Joseph Lazar, Director, New York City Field Office New York State Office of Mental Health

Peg E. Moran, CSW, VP Administrative Services Behavioral Health Svcs. - St. Vincent’s Catholic Medical Centers

Evelyn J. Nieves, PhD, Executive Director Fordham-Tremont Community Mental Health Center

Evelyn Roberts, PhD, Executive Director NAMI - New York City Metro

Phillip Saperia, Executive Director Coalition of Voluntary Mental Health Agencies

Alan B. Siskind, PhD, Executive Vice President & CEO Jewish Board of Family & Children’s Services

Giselle Stolper, Executive Director Mental Health Association of New York City

Jonas Waizer, PhD, Chief Operating Officer F.E.G.S. Health and Human Services System

Joyce Wale, Assistant Vice President - Behavioral Health New York City Health & Hospitals Corporation

Page 30 Mental Health News - New York City Section: Fall 2005

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Mental Health News - New York City Section: Fall 2005 Page 31

Delivering Science-Based Information About Schizophrenia to Providers and Consumers

By Giselle Stolper, Executive Director acceptance that other mental illnesses, The NIMH has eight studies currently The Mental Health Association such as depression or bipolar disorder, in progress addressing the origins and Of New York City have acquired in recent years. Not only About the National Institute treatment alternatives for schizophrenia for is depression more common, thanks to of Mental Health Outreach people of all ages. Two treatment studies the public disclosure of celebrities in- are underway to test the effectiveness of cluding Brooke Shields, Terry Brad- Partnership Program particular medications on children ages 8 shaw and Mike Wallace, more people through 19 with schizophrenia or other than ever are aware of the symptoms psychoses. Six evaluation studies now in of depression and how to get treat- This program is a vital element in progress will assess the effect of medica- ment. Jane Pauley now considers her- the broad NIMH outreach effort to tions on memory retention and brain func- self a spokesperson for bipolar disor- deliver science-based information to tioning; ascertain the impact of genetics on der, an admirable role for her to as- the public, health professionals, an individual’s predisposition toward sume as one of our nation’s leading constituency groups, and all inter- schizophrenia; and identify the underlying media personalities. ested stakeholders. Through its Out- biology of the illness overall. To learn While schizophrenia may still have reach Partners and the National more about the studies underway or to a ways to go to achieve broad-scale Partners the program strives to: volunteer as a participant, visit the NIMH understanding and acceptance, in the Web site at www.nimh.nih.gov. past 20 years mental health advocates, • Disseminate science-based in- Information dissemination to consumers agencies, researchers, and consumers formation on mental illnesses, through a network of national, state and have built a strong support network for alcoholism, and drug abuse to local partners also assists in dispelling those who are diagnosed with the dis- consumers, families, and policy myths about mental illness and promoting order. In addition, research is rigor- makers at the state and local access to treatment. The NIMH offers ously underway to help us understand level. high-quality brochures and fact sheets ad- schizophrenia’s cause and cure. dressing the full range of emotional disor- The Mental Health Association of • Support the understanding of ders. The MHA of NYC’s public educa- Giselle Stolper New York City is honored to play an brain disorders, specifically tion team distributes these materials at active role in these efforts as a partici- mental illnesses and substance mental health screenings, health fairs and pant in the National Institute of Mental abuse disorders, and the impor- seminars. Clients of the MHA of NYC’s he National Institute of Men- Health (NIMH) Outreach Partnership tance of accurate diagnosis and family service programs may gather rele- tal Health estimates that 1.1 Program. As a partner to NIMH, the treatment. vant materials at our fully stocked resource percent of Americans suffer MHA of NYC works in tandem with libraries located at MHA of NYC sites in from schizophrenia. In New other mental health associations • Reduce the stigma and dis- Manhattan and the Bronx. YorkT State, we can then estimate that around the state to disseminate impor- crimination associated with As an outreach partner with the Na- approximately 220,000 residents are tant information about research under- mental disorders, alcoholism, tional Institute of Mental Health, the diagnosed with the illness, 58,000 of way both to inform practitioners and and drug addiction. MHA of NYC is working to promote whom live in New York City. Many consumers of studies in progress, and research, education and access to treat- more individuals are diagnosed with to recruit volunteers for clinical trials • Encourage individuals with ment for people with mental illness. depression or other anxiety-related and other projects. symptoms of mental disorders, Learn more about the NIMH includ- disorders, but these illnesses do not The NIMH Outreach Partnership alcoholism, and drug addiction ing the Partnership Outreach Program, come with the stigma associated with Program acts as a nationwide network to seek help. research studies underway and how to an illness like schizophrenia. of mental health organizations like participate as a subject, and available Schizophrenia remains a mysterious ours to build the bridge between re- • Eliminate disparities that exist materials for all mental illnesses, at and frightening disease to many peo- search and practice, while shedding in access to care and health www.nimh.nih.gov. To find out about ple, who may not know that the illness light on diseases such as schizophre- outcomes due to race, culture, support networks for people diagnosed rarely results in violent or destructive nia. In New York State, the MHA of NYC age, geographical location, with schizophrenia, or for referrals to behavior, for instance, and that treat- works with other mental health organiza- and gender. treatment call 1-800-LIFENET, the mental ment works. Part of the problem is that tions, MHA affiliates, to bring information health crisis, information and referral hot- schizophrenia lacks the mainstream about the latest research to all stakeholders. line operated by the MHA of NYC. □

“Salud Mental” Your Bilingual and Bicultural Source of Mental Health Education Serving The Latino Community visit us on the web at: www.mhnews-latino.org

Page 32 Mental Health News - New York City Section: Fall 2005

Mental Health News - New York City Section: Fall 2005 Page 33 A Self-help Model to Serve The Dually Diagnosed

By The Jewish Board of Family The Bronx REAL Recovery Con- and Children’s Services sumer Self-Help Program, beginning its seventh year of operation, is a MICA (mentally ill/chemically addicted) pro- o meet the needs of individuals gram known as REAL Recovery. It was being discharged from psychi- designed to increase the overall effective- atric hospitals during the dein- ness of the Center by improving its out- stitutionalization of the early reach to and collaboration with those 1980s,T the Jewish Board of Family and consumers with both a psychiatric disor- Children's Services opened its first day der and histories of substance abuse who treatment program in the Bronx. Today desire support in order to maintain their that program, the Bronx REAL, is a com- abstinence. The staff has created an envi- prehensive center offering a full range of ronment where consumers of the Self- support, rehabilitation, and housing ser- Help Program facilitate a helping support vices. It stands as a model for the provi- system for other consumers who may be sion of meaningful and effective services at greater risk of psychiatric or substance for individuals living with a serious men- abuse relapses and inpatient treatments. tal illness. It is part of the agency's city- wide array of treatment and residential REEAL Recovery was designed to: programs located in Brooklyn, Manhattan and Queens, in addition to the Bronx. • Facilitate the opportunity for con- The division, led by director Susan Bear, sumers with dual diagnoses to includes continuing day treatment, inten- achieve dual recovery and prevent sive psychiatric rehabilitation, intensive relapses of both disorders case management, consumer self-help programs, mental health clinics, transi- • Stress the importance of clients help- tion and supportive housing. ing each other in the formal setting JBFCS programs offer services tai- of groups and peer counseling and in lored to meet each consumer's individual the informal connection of the mi- needs and reflect the communities in lieu. The program strives to provide which they are located. Over the past an atmosphere for rehabilitation twenty years, with advances in our under- through goal attainment, selfempow- standing of the treatment of psychiatric erment, and skill mastery by allow- illness, JBFCS programs have continu- ing consumers to consistently par- ally changed to meet the evolving needs ticipate and take leadership roles in of its consumers. Experience has led to the running of the program refinement of programming and develop- ment of new approaches to treatment. • Assist members in obtaining better One such area which has developed in integration into existing community recent years is the treatment of those with supports and treatments in order to dual diagnoses, mental illness and chemi- achieve improved stability in their cal addiction. One such program has dual disorders made an enormous difference and is now an integral part of the Bronx REAL con- tinuum of services. • Provide a forum for members to The Br on x REA L Cen ter carry a message of recovery to oth- (Rehabilitation and Education in the Art ers who experience dual disorders of Living) offers a full range of support and to support healthful and drug- services. Founded on a deep respect for free endeavors (social, recreational, the individual person and the healing educational, and vocational) in all power of community, the Center provides members a continuum of care for individuals diag- nosed with a serious and persistent men- The program aims to increase the tal illness The program serves adults 18 length of time in drug/alcohol sobriety; years and older who demonstrate func- reduce the frequency of inpatient psychi- tional impairments such as difficulties in atric and detoxification interventions, self-care, daily living and social and vo- help consumers better articulate their cational functioning. By offering its full drug/alcohol cravings to peers and staff; range of services "under one roof", the increase consumers medication compli- Center stands as a model for effectively ance; increase the availability and fre- meeting the changing needs of individu- quency of peer socialization experiences als living with persistent mental illness. among recovery-minded consumers; and Seamless movement between programs increase use of community supports. gives consumers a sense of security and REAL Recovery is a program which confidence in staff they have come to has seen a great deal of success over the know and trust, in a building that for seven years since it was created helping many feels like home. Having this com- consumers live more productive lives prehensive center has strengthened each while coping with a mental illness, par- of the individual programs of the Bronx ticularly schizophrenia, and an addiction. REAL. Consumers and staff together have cre- Staff came to appreciate the ever- ated a safe and supportive community growing evidence that Bronx REAL con- based on trust and caring which inte- sumers diagnosed with schizophrenia grates the latest thinking in the field of were also combatting addiction. The psychiatry and integrates the tools Bronx REAL faced this challenge head on, learned over the 20 years since the Bronx leading to the creation of REAL Recovery. REAL first opened its doors. □

PAGE 34 MENTAL HEALTH NEWS ~ FALL 2005

Westchester County Department M of Community Mental Health “Here To Help You” Can Your

Staff Writer ENTAL Mental Health News Community

he Westchester County De- Afford partment of Community Men- tal Health (DCMH) has been helping individuals and fami- liesT living with schizophrenia for the To Not Have past fifty-one years. We not only pro- vide direct clinical services but have instituted structures that enable those An Assertive individuals to obtain case management and housing services throughout the county through our single point of ac- Mental Health cess system (SPOA). We have devel- oped programs to help individuals who have been involved with the criminal Education justice system to get appropriate mental health and/or substance abuse treatment thus avoiding recidivism. The TASC Jennifer Schaffer, PhD Program? program (Treatment Alternatives for Safer Communities) and Alternatives to provide mental health services to indi- Incarceration are two voluntary pro- viduals who have both mental health H grams offered to help individuals with problems and developmental disabilities. mental illness avoid jail. We also have Various types of insurance and Medicaid developed programs to help homeless are accepted and no one is refused help Let Us individuals with mental illness to gain if unable to pay. supports and seek out treatment with the DCMH is also the single point of help of our case managers. access for persons with mental illness Help You EALTH Westchester County also works seeking housing and/or case manage- through not for profit agencies located in ment services. We have an application your community to deliver quality ser- process and work with all agencies in vices. Our department obtains and man- the county who provide these services. Reach Out ages funding for services from New We have staff available to help you with York State offices and other sources this as well. Please call (914) 995-5278. such as the federal government. We help If you or anyone in your family has To Those local agencies meet financial and legal re- trouble with alcohol and/or substance quirements for using public monies. abuse problems, our department can assist According to Dr. Jennifer Schaffer, you in finding the right place for you to Who Are Commissioner of DCMH, “our goal is to begin getting help. We can also refer fam- help anyone who may be suffering from ily members looking for support and gen- serious mental illness,” Types of these eral information to the appropriate places At Risk illnesses include schizophrenia, bi-polar to learn about addiction disorders. For disorder, major depression schizo- more information please call (914) 995- affective disorder, developmental dis- 5258. If you or your family member is abilities, and mental retardation. In ad- suffering from both a mental illness and an dition, people with alcohol, and sub- alcohol substance abuse disorder please stance abuse problems are helped. call (914) 995-2703 for help. (914) 948-6699 “We also help individuals with anxiety, The Westchester County Department depression, phobias, adjustment disor- of Community Mental Health is a re- ders, and other psychiatric disorders— source for all those who live in West-

and our mission in all of these areas is to chester County. We are here to help you N make sure that individuals and families find the services that you and your fam- receive the necessary treatment and sup- ily may need. Many services are now ports needed, added Dr. Schaffer. available for Spanish speaking individu- Westchester County DCMH offers als and families. Our main number is direct mental health treatment services (914) 995-5221 and our website, to our residents. We have four outpa- www.westchestergov.com/mentalhealth/

tient clinics that serve children, adoles- has valuable information. EWS cents and adults. Our clinics are located Mary DeVivo, C.S.W., is the Coordi- in Mount Vernon (914) 813-6220, nator of Community Education for our Yonkers (914) 231-2925, Mount Kisco department; she can be reached at (914) (914) 864-7101, and Peekskill (914) 995-4534. She is also available to assist 862-5130. All of our clinics are able to in finding speakers for local groups to provide evaluations for medication, ver- educate you about our department and/or bal therapies and Spanish speaking ser- any mental health topics that groups vices. Our Peekskill clinic is also able to may interested in. □ For Suicide Help

Call (800) 273-TALK

Mental Health News - Connecticut Section: Fall 2005 Page 35 Mental Health News The Connecticut Section Greenwich Hartford BRIDGEPORT Stamford Kent New London We Are Not Our Illnesses, We Are Not Our Diagnoses: Lessons About Mental Illness Taught by Residents of A Forensic Program

By David M. Howe, LCSW, Director Speaks group (RS) assisted by a social In the words of the panel members, as soon they didn’t come in.” One Organizational & Staff Development worker, a chaplain, and an advocacy in- stigma is transformed from an abstract speaker eloquently described the value Connecticut Valley Hospital structor decided to develop a video account concept to a painful reality. One panel of “compassionate challenges” and Whiting Forensic Division of their experience with illness. member recalled his family driving by a “being real”. Examples were given of Connecticut Department of Mental "Understanding Schizophrenia" is a 30- place identified as “the insane asy- the positive impact of “focusing on what Health and Addiction Services minute DVD. All group members have lum…crazy people live there.” Experi- you can do” and that “diamond in the struggled with schizophrenic illness or ences with family and friends, following rough who helped you set goals.” another psychotic illness. RS worked on the onset of illness, were described with Recovery is described in a very real ore than two hundred peo- the project for two hours every other week the sensitivity of reaction apparent. and personal language that touches view- ple call the Whiting Foren- for a few months. RS used the outline of One of the most powerful moments in ers. From the plea that “it is so very, sic Division of Connecti- the program "Illness Management & Re- the presentation was the segment on the very important to be encouraged” to the cut Valley Hospital home. covery" (IMR) as a rough template of top- impact of treatment and hospital staff benefits of developing coping and peo- MHalf live under conditions of maximum ics to cover. That program was chosen upon the course of hospitalization. Any- ple-skills, and the recognition that “we security, half in medium security. Most because of its clear language and its one experienced with healthcare settings brought ourselves here, but we can also were found not guilty by reason of men- enlightening descriptions of symptoms. can appreciate the statement: “some staff help ourselves out of here”, the tal disease or defect; a smaller group was The group also benefited from the valuable members, I’m excited when they come found not competent to stand trial. In its input of the primary author of the program, in and I look forward to it. Others, I just see Lessons on page 36 thirty-year history, Whiting has transi- Susan Gingerich. tioned from an autonomous institute with In an initial version of the video, RS a primary mission of custody, to a divi- members read the text of the IMR pro- sion within a larger state psychiatric hos- gram in front of a digital camera manned Mental Health News pital whose primary mission is to pro- by our chaplain, speaking into a hand- mote the recovery of individuals with held microphone. After a rough start, Connecticut Leadership Committee severe and persistent mental illness. members got increasingly comfortable In recent years, the recovery mission with the written material and with the Thomas E. Smith, MD, Medical Director and treatment philosophy of the Con- camera. As the group practiced, it cut Hall-Brooke Hospital necticut Department of Mental Health back on the text reading. Speakers be- Chairman and Addiction Services have made excit- came increasingly adept at selecting per- ing inroads in the forensic arena, result- sonal experiences to speak directly and Committee Members ing in a transition from one culture to extemporaneously to the audience. In another. Although many staff ap- the final version, all on-screen reading proached the transition away from cus- was eliminated. Video chapter titles that Sigurd H. Ackerman, MD, President & Medical Director William J. Hass PhD, Executive Vice President Silver Hill Hospital Family Services Woodfield tody and control with trepidation, a grad- describe symptoms are read off-screen ual shift is taking place that is benefiting by members of the group. As the project Alan D. Barry PhD, Administrative Director Kristin A. Lue King, LCSW, Executive Director residents, staff, and administrators alike. evolved, participants also became in- Norwalk Hospital Department of Psychiatry Southwest Regional Mental Health Board A number of emblematic activities have creasingly thoughtful about and at ease taken place that illustrate the benefits of with giving feedback to other members Alexander J. Berardi, LCSW, Executive Director Florence R. Kraut, LCSW, President & CEO KEYSTONE Family & Children's Agency the new culture. They include the crea- about how to communicate effectively tion of a resident/staff steering commit- with the audience through the camera. Richard Maiberger, MD, Chairman Remi G. Kyek, Director Residential Services tee that represents all residents and com- The strength of this presentation lies Norwalk Hospital Department of Psychiatry Mental Health Association of Connecticut municates and negotiates with staff and in its unscripted nature and its spontane- administrators around all aspects of their ity, which is the format participants Selma Buchsbaum, Member Charles Morgan, MD, Chairman Southwest Regional Mental Health Board lives at Whiting; the development of a chose. They clearly communicate their Bridgeport Hospital Department of Psychiatry

staff training curriculum focused on the eagerness to participate in a dialogue Douglas Bunnell, PhD, Director James M. Pisciotta, ACSW, CEO indignities of institutional life entitled built on “here I am” and “this is who I The Renfrew Center of Connecticut Southwest Connecticut Mental Health System “Through the Eyes of Another”; and am.” There is no window dressing or another focused on the adverse impact of concern for choosing comments for a Joseph A. Deltito MD, Clinical Prof. Psychiatry Selby P. Ruggiero, LCSW, Associate Director hallucinatory experiences, entitled particular audience. & Behavioral Science, NY Medical College Clinical Services, New Learning Therapy Center

“Coping with Disturbing Voices”. We As soon as the first presenter starts speak- Steve Dougherty, Executive Director Marcie Schneider, MD, Director describe below another such activity, ing, an intimate connection is established Laurel House Greenwich Hospital Adolescent Medicine namely the creation of a film containing between the panel members and the audi- personal accounts of residents’ struggles ence. It is borne of the very personal accounts Stephen P. Fahey, President & CEO Janet Z. Segal, CSW, Chief Operating Officer with mental illness. of the symptoms of schizophrenia each Hall-Brooke Behavioral Health Services Four Winds Hospital Systematic institutional self-examination speaker gives. The comments hit home Susan Fredrick Edward Spauster, PhD. President & CEO revealed that nurses and mental health work- because the audience can read in the pre- Family Advocate LMG Programs ers possessed solid psychiatric knowledge senters’ facial expressions, tone of voice, about severe mental illness but a limited ap- and body language, the feelings behind Carla Gisolfi, Director Wilfredo Torres, MSW, Site Director preciation of its impact on people's lives. To them. As one speaker relates that “I didn’t Dr. R. E. Appleby School Based Health Centers F.S. DuBois Center overcome this, we turned to the “experts” know what schizophrenia was….even after Margot O’Hara Hampson, APRN, Manager for help, namely our patients. A number of I had it…it was very vague to me”, he Greenwich Hospital Outpatient Center committee in formation them had completed an advocacy program opens the door for viewers to appreciate entitled “Recovery Speaks”. The Recovery the individual manifestation of illness.

Page 36 Mental Health News - Connecticut Section: Fall 2005

The Story of L.A. A Client at Connecticut Valley Hospital

By L.A. looking up different materials for arti- Middletown, Connecticut cles for this newsletter. I have learned a lot about things doing this. About a month ago I went to a recov- y name is L.A. I am a ery council. There was a lady named client on the Traumatic Mary Ellen Copeland. She was talking Brain Injury unit at Con- about recovery. Listening to her I knew I necticut Valley Hospital had a chance. M(CVH). I was asked to talk about how She has a book out called WRAP: my recovery process is going. Wellness Recovery Action Plan. It has Let me tell you a little about my his- helped me very much. tory. I have had a mental illness since I would like to thank CVH for all the the age of 20. I was put in a psych hos- work they have done for me and other pital because I was a suicide risk. I spent clients. They take us all in the commu- 3 years at Norwich State Hospital which nity to movies, horseback riding, fish- was a really hard life for me back then. I ing, shopping, sailing, and more. don’t really want to talk about it. Let’s I really enjoyed the horseback rid- just say I have come a long way. ing we got to do. It was my favorite. It I have been at CVH for 3 years now. helped my self confidence and self When I first got here I was a total wreck. esteem. I was very depressed and stayed in bed a We get to go to Page Hall a lot. lot not caring about myself. I was a total There is a social club two times a wreck until the past year. week there. It’s so fun seeing people Now I look forward to life. Each day there and playing games with staff and is a new beginning. I have developed a friends. We also go to Recovery relationship with my heavenly father. Council there once a month. I spoke Plus I love to read spiritual books as about things that interest me once at well as the “Chicken Soup Books” se- the council. ries. I’ve learned to love myself more I have a lot more friends now includ- and hate myself less. I’ve been doing ing staff who will take some time to talk really well now. I stay real busy by to me when I need it. They tell me working at separate things. I like feel- “good job L.A., Keep it up!” I plan not ing like this inside—happy and con- to let them down or myself. tent! Plus I don’t feel so stupid any- CVH has a lot of wonderful people more. I take that bad attention off my- working here: The doctors, nurses, men- self and put it on things I know I can tal health workers, and the whole treat- do and I do them. ment team. The support I get from eve- Our unit has a monthly newsletter ryone here helps me so much. called “Cottage Press”. I really enjoy doing it each month. I look forward to God bless you all very much. □

Mental Health News Offers Discount Advertising Packages See Page 47 For Details (914) 948-6699

Lessons from page 35 fied sense of pride and accomplishment, as do the project facilitators. They de- discussants take proud responsibility for scribe their feat as a personal victory themselves without pointing fingers. As and as solid evidence of their progress we hear “I’m one of the lucky ones who on the road to recovery. The project had the opportunity to work on the qual- represents a significant move away from ity of my life,” the audience feels the an old paternalistic stance in patient care threads of relatedness that connect us towards a collaborative one. We are finally all. letting our patients inform us of what helps About 350 people have seen the them, and we are all the better for it. video thus far. Consumers, advocates, clinicians, CT Dept. of Mental Health We wish to give special thanks for and Addiction Services dignitaries, com- help in writing to: Richard N. Bennett, munity members, medical residents, MPA, Director, Whiting Forensic Divi- newly hired CVH employees, and others sion, CT Valley Hospital, and Marc have reacted overwhelmingly with en- Hillbrand, Ph.D., Chair of Psychology, thusiasm. The RS members feel a justi- CT Valley Hospital □

Mental Health News - Connecticut Section: Fall 2005 Page 37

PAGE 38 MENTAL HEALTH NEWS ~ FALL 2005 Platz from page 11 level of services. Joyce made signifi- Medicare from page 27 deductibles required of others enrolling cant contributions to Hall-Brooke in in Medicare Part D. The dual eligibles, enabling them to live independently,” various roles over the years and her individuals receiving mental health along with Medicare consumers who Ms. Platz adds. expertise in mental health manage- services, as they may lose coverage for have Medicare Savings Plans (MSP) or Stephen P. Fahey, President and ment, budgeting, grants management, some of the drugs upon which they receive Supplemental Security Income CEO, notes “I am pleased that Joyce and program development, has been have relied. (SSI), will be automatically enrolled in will lead expansion of our community invaluable.” By the middle of November 2005, the Low Income Subsidy program. Dual residential services and look forward Ms. Platz holds a degree from the CMS will automatically enroll the dual eligibles will be required to make small to Hall-Brooke continuing to make University of Connecticut in Human eligible population (Medicare/caid) into co-payments of either $1 to $3 or $2 to significant contributions in promoting Development and Family Relations and one of the low cost Medicare Part D $5, depending on their particular income the health and well-being for persons a Certificate of Advanced Study from plans in their region. Unfortunately the levels. They will not be responsible for with behavioral health issues. I can Fairfield University in Health Care Ad- enrollment process will not take into annual premiums or deductibles. think of no person better qualified to ministration. She lives in Fairfield with consideration the unique medication For non-dual eligible individuals lead Hall-Brooke in this important her husband and their daughter. □ needs of an individual. It will instead with incomes between 135% and 150% be a random plan which has a low cost of the Federal Poverty Level (FPL) and factor for the federal government. assets below $10,000 for individuals Dually eligible individuals will have ($20,000 for couples), there will be a Read Back Issues of Mental Health News the opportunity during the six weeks sliding scale premium, $50 deductible, from November 15 to December 31, 15% co-pay for drug costs between $50 visit us at: www.mhnews,org 2005 to look at the various plans of- and $5,100 and co-pays of $2 to $5 for fered and select another one if it better catastrophic coverage over $5,100. Peo- suits their needs. ple whose incomes are under 135% with Reflections from page 5 failed to recognize my brother who had assets below $6,000 for individuals come to visit me, he was pulled aside by Potential Pitfalls ($9,000 for couples), will have no an- littering of empty paper candy wrappers. staff and told, “get used to seeing your nual premium, no deductible, $2 / $5 co- There were no poems written by her hand, sister like this because this is how she The Coalition is concerned about the payments up to $5,100 and 100% cover- the only evidence of her life was her ill- will always be.” My father, a few years effect these changes will have, particu- age over $5,100. ness and her overwhelming obsessions. later, was told in front of me, that I larly on the dual eligibles and especially The entire process will likely be very My father left home when I was nine- would probably be institutionalized for on mental health consumers. While it is confusing to Medicare consumers. Pro- teen. Filled with, among other things, the remainder of my life. believed that drug plans will offer a viders will need to be prepared to assist guilt about his genes and the disease that Today, as I sit here in my home of broad choice in the six categories spe- consumers applying for the low income he believed he had passed on to me. twenty years, it is a beautifully serene, cifically identified by CMS, there is still subsidy and in making the appropriate When all is said and done, he has been bright summer day. My cat, Africa, is a strong possibility that certain other decisions regarding plan selection. The my greatest loss. Yet, what saved me sound asleep at my side and I am per- necessary drugs will not be available Coalition has many resources listed on from the depths of mental illness was fectly content. and this will put the consumer at risk. our website www.cvmha.org. Just click my own passionate determination to find Were they wrong with their diagno- Provider agencies will need to be pre- on the Medicare Part D button. some form of communication with the sis? If so, how does one explain ten pared to assist the consumer in making The Coalition questions CMS’s deci- outside world. I was driven towards the years of severe psychosis and deteriora- the best choice possible to minimize sion to include dual eligibles in Part D at desire to create and to touch fingertips tion and twenty years of reinvention and potential destabilization. all. Consumers with both Medicare and with an attendant soul. Luckily, there recovery? Learning how to brush my Consumers will have several oppor- Medicaid coverage did not need were those nearby who were waiting. teeth, change my underwear, speak, eat, tunities to have non-formulary drugs “fixing;” their services and prescriptions Art is a universal language made viable walk, and think differently? How does covered by their plan. First the con- were already covered. So why did CMS and authentic by it’s propensity towards one explain an ego that is left thoroughly sumer or his/her doctor may ask the plan include them? The speculation is be- an immediate connection. The acknowl- ravaged with more holes than Swiss provider for an exception (coverage de- cause there was minimal enrollment in edgment and receiving of that connec- cheese? Had they miscalculated some- termination) for a drug not included in prescription discount drug card pro- tion can be a profound experience for an how? Certainly, if you meet me today, the plan’s listing. The response from the grams, CMS needed “buy-in” from con- individual in isolation. Despite family you might think so. Or, was the diagno- plan provider should be issued within 24 sumers to encourage insurance plans to genetics and the thirty years of arduous sis right and their expectations for hu- hours for an expedited case or within 72 participate. The 7 million dually eligible and unrelenting perseverance through a man survival wrong?? hours for a standard review. If that fails, individuals around the country who lose gamut of dysfunction, I survived and I Even under the enormous weight we the consumer may go through an appeals their Medicaid pharmacy coverage on emerged. As a small child I often all carry, we are the ones ultimately re- process which goes beyond the plan December 31, 2005 would guarantee an dreamed about saving a human life, in- sponsible to reevaluate the fate of the provider to an Independent Review En- initial enrollment. Now the dual eligible cluding the fallen birds in the woods human mind and heart. How we experi- tity, then an Administrative Law Judge population will be subject to co-pays, outside my family home. I wanted to be ence our reality is our own. If we are and finally the Medicare Appeals Coun- which may be a hardship, and potential a doctor and a healer. I wanted to make determined to move beyond limitations, cil. The Coalition is very concerned that destabilizing changes and interruptions a difference in someone else’s life. Little we must question our expectations. NY State has not finalized any safety net in medication. did I know at that time, that it was my There is enough evidence out there to plans to provide the necessary medica- The Coalition of Voluntary Mental life that I had to save. suggest immense human resilience. tions to a consumer during what could Health Agencies, Inc. is the umbrella ad- Left with a major loss, perhaps, but Like the tiny ants, dragging around be an extended appeals process. vocacy organization of New York’s mental despite my father’s absence, despite his their daily burdens under the weight of health community, representing over 100 own limitations and his own personal those gigantic rocks. Or the tree limb The Cost non-profit community based mental health vulnerabilities, he managed to pass on to that wraps itself around a fence to get to agencies that serve more than 300,000 me in the years I had with him as a the light. We underestimate the poten- For a general policy, expect premiums to clients in the five boroughs of New York child, was the one tool that would help tial, the enormous vitality, resourceful- be about $37 per month, or about $444 City and its environs. Founded in 1972, pry me out from the grips of psychosis. ness and creativity of life. A thrust to- per year. After an initial $250 deducti- The Coalition is membership supported It’s the one tool that each and every one wards optimism is what is needed. To ble, individuals will pay a 25% co- along with foundation and government of us need so desperately in this chang- build a fire underneath ourselves and to payment for drug costs between $250 funding for special purpose advocacy and ing world in which we live. He gave me finally acknowledge and give honor to and $2,250. Individuals then pay 100% assistance projects. □ a love of art and a profound respect for the individual unique strength in each of of the next $2,850 in drug costs, up to nature and the creative spirit! us to survive, endure and excel. $5,100. After that, “catastrophic” cover- Turning over rocks as a child, I was In 2004, Susan Weinreich received the age kicks in and Medicaid will cover always amazed how so many intricate, Eli Lilly Reintegration Award for “Artistic 95% of the drug costs with the individ- little creatures could survive and carry Achievement” and the Westchester ual responsible for a co-pay of between on their daily routines under such an County Mental Health Award. Ms. Wein- $2 to $5. enormous weight. reich’s work is in the collection of countless Turning over the human mind can be individuals and institutions including Four Financial Help as equally bewildering. Being diagnosed Winds Hospital in Katonah, NY and Eli repeatedly with Paranoid Schizophrenia Lilly and Company in Indianapolis, Indiana. Because the dual eligible population was like being given a death sentence. Her upcoming exhibition of drawings opens by definition consists of individuals with Though I was never actually told my October 7, 2005 at the Northern Westchester low incomes, the government created a diagnosis until years later. In 1976, dur- Center for the Arts in Mt. Kisco, NY. for Low Income Subsidy (LIS) program ing an inpatient stay at Butler Hospital more information about her work please which will eliminate the premiums and in Providence, Rhode Island, when I visit www.susanweinreich.com □

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 39 Stopping The Stigma of Schizophrenia

By Glenn Liebman identifies stigma issues throughout legislature that would create a tax check Executive Director, Mental Health the country---the National Stigma off in the New York State Tax forms that Association in New York State Clearinghouse. would provide for a specific funding Then when we have celebrities who stream dedicated to a public awareness have the courage to come forward and campaign to end the stigma of mental s a follow up to the Presi- talk about their mental illness such as illness. There are other ways as well. We dent’s New Freedom Report, a Brooke Shields, Carrie Fisher and must continue to go out to the community group of national advocacy Lorraine Bracco. Then you have other and talk to our friends and colleagues in A organizations including the celebrities like Tom Cruise and Kristie other fields about mental illness. Another National Mental Health Association put Alley, (who are about as much experts on great avenue for ending stigma is by join- out a roadmap for transformation. The psychiatry as I am on acting), telling the ing the Timothy's Law Campaign which lead quote from the report was that, "1 world that there is no such thing as men- calls for the ending of discriminatory out of every 2 Americans who need men- tal illness and that antidepressants and practices in insurance coverage for men- tal health treatment does not receive it." other medication don't work. Talk about tal illness. That is a startling number. We already adding to the stigma of mental illness. There is such a compelling message of know from prior statistics that in a given We have to use all of our resources to hope and recovery to tell to the general year, that there are over 20% of Ameri- combat this stigma and tell people the public and to the large number of people cans who have mental illness. If you real story about mental illness and recov- with mental illness who do not seek treat- combine these two numbers, it means ery. We throw around the word hero a lot ment because of the stigma associated that ten percent of the population (close in our society. I am a sports fanatic but do with the illness. We need all of us in the to thirty million people) of the United I think that Derek Jeter or Peyton Man- field to work together to end this stigma. States have a diagnosable mental illness Glenn Liebman ning are heroes--of course not. The real Please contact us and support our efforts that goes untreated every year. heroes are the individuals with schizo- to create tax check-off to fund anti stigma The number one reason cited for not wear to the movies we see. One of the phrenia and other mental illnesses who efforts. seeking treatment is the stigma associated most popular selling tee shirts and sweat- openly talk about their illness and work To help show your support for our mis- with mental illness. Nowhere is this more shirts among teenagers is one that says-- hard to get better every day. Because of sion and anti-stigma efforts, we invite you evident than with individuals with schizo- Psych Ward. All you have to do is turn on their examples of hard work and courage to participate in our upcoming events. phrenia. In a society, where people are the television or go to the movies to see on daily basis, we know that people do On the evening of October 20th at the willing to speak out and our open about examples of people with mental illness as recover. There are arrays of services Marriott Hotel in Albany, we will be many things, few still have the courage to violent, out of control maniacs who are available to help enhance recovery--- holding our awards dinner and the show- openly talk about mental illness. Mental likely to kill their victims for no good case management, psychosocial sup- ing of the documentary Out of the Shad- illness continues to be one of the last bas- reason. ports, self help, drop in centers, hous- ows, a compelling story about one tions of stigma in our society. The worst stigma of all happens at the ing, employment, education, counseling women's journey through the mental Everywhere in society, we see ex- earliest of age. Television shows geared and better medications with fewer side health system as detailed by her daughter, amples of the stigma of mental illness. to children are filled with references to effects than in the past. The recovery film maker, Susan Smiley . For those who Many of us are familiar with the Crazy people being crazy, psycho, nuts, wacko, rate for mental illness, based on research have not seen the documentary, we urge Vermont Teddy Bear who came with etc. As the father of a ten year old son, I from the National Advisory Mental you to see it and witness this moving his own commitment papers. Due to the find that very offensive and I am glad my Health Council, is higher than the treat- story about perseverance and hope. work of the Vermont MHA and Ver- son is also cognizant of this stigma. Much ment success rate for many physical ill- On October 21st, also at the Marriott mont NAMI, they were able to raise the of the conversations that I here in my nesses. Hotel, our organization is holding a one visibility of this issue and point out son's school and among his peers is de- We need to get out the message of day conference on topics that are relevant how offensive it is to the millions of scribing people as nuts and psycho. How recovery and engage those millions of to all of use in the mental health system people with mental illness and their can we ask people to be courageous Americans who are afraid to seek treat- including Medicare Part D, PROS, Juve- loved ones including the over 2.5 mil- and openly talk about their mental ment. How do we do this? We must cre- nile Justice and Childhood Depression. lion Americans with a schizophrenia illness when even at the earliest of ate a statewide campaign to end the For more information, contact us at diagnosis. ages, there is such stigma associated stigma of mental illness. The Mental (518) 434--0439, ext. 22 or log onto our Stigma examples are rampant in all with the illness. Thankfully, there has Health Association in New York State is web page at mhanys.org. We hope to see aspects of society from the clothes we long been an invaluable resource that fighting for a bill in the New York State you there. □

New Context from page 1 obnoxious to the hideously appalling. Many forces, then, have led mental that is, after all, what we know how to To assume, however, that the beacon of health providers to unintentionally do. What, then, must we do differently? useful ways. In the recovery paradigm, science has now been cast on the dark hap- undermine the efforts of people to re- My first suggestion involves a change these contributions are seen as important penings of past years would be to miss cover aspects of their lives lost of attitude. To whatever extent our edu- parts of a person’s broader efforts to some essential human dilemmas involved through the ravages of psychiatric ill- cations have left us feeling like powerful reclaim his or her life. Treatment con- in delivering mental health services. nesses like schizophrenia. It seems healers, we should replace this with a tributes to recovery, but should not be It should probably not come as a likely that it will require relatively sense of being humble technical consult- confused with it. Mental health provid- complete surprise that delivering mental dramatic measures to change this situa- ants. If we have somehow come to view ers offer treatment; the authority and health services has sometimes strayed tion. Making these efforts even more the people with whom we work with responsibility for recovery remains in the into practices that are not helpful to peo- elusive are the rising expectations of discouragement and pity, we should try hands of the person trying to recover. ple. Originally, mental health care was insurance and accrediting agencies. to replace this with respect for the cour- When mental health providers first more about protecting society than car- Insurers, after all, are accustomed to age that so many people maintain in the hear about recovery principles, they of- ing for people with illnesses. When paying for “treating illnesses,” not for face of daunting disappointments and ten insist that this is what they have been doors are locked and not everyone has helping people realize their hopes and challenges. If we have become infused doing all along. As early as the late the keys, bad things sometimes happen. dreams. with excitement about the glorious sci- Eighteenth Century, didn’t Pinel unchain People have always had a tendency to Before suggesting what sorts of ence that guides our work, we should psychiatric patients and begin espousing abuse power under these circumstances. measures might result in useful remind ourselves of how crude it re- what came to be called “moral treat- Western Medicine has always leaned changes to how mental health services mains. And finally, if the foolish and ment”? At the beginning of the Nine- towards authoritarian traditions. Anyone are delivered, it is important to empha- highly-publicized assaults on our profes- teenth Century, did not this movement who has spent time in any sort of hospi- size that we are not considering here sions have rendered us defensively self- give rise to hospitals where people were tal knows the experience of staff barging changes in treatment; we are talking righteous, we should remember the dark- to be treated with greater kindness and into rooms without knocking and other about changes in the CONTEXT for ness that repeatedly creeps into our of- dignity than had been the custom? All deviations from common courtesy. In treatment. It remains the province of fices and hospitals. true; and yet many people who have our society, also, respect is largely based mental health providers to provide the If all we change is our attitude, how- experienced our mental health system on money, power and position. People same sorts of pharmacological, psy- ever, it would be safe to predict that first-hand have terrible stories to tell. who cannot compete successfully for these chological and psychosocial interven- These experiences range from the subtly currencies are often felt to lack character. tions that we have offered for years; see New Context on page 40

PAGE 40 MENTAL HEALTH NEWS ~ FALL 2005 New Context from page 39 of the treatment plan must be discussed least the person, family members and/or oriented treatment requires a commit- explicitly. significant others, a Peer Support staff ment to profound changes. change would be subtle at best. Let me At Capitol Region Mental Health member, and the clinician. The main System change, however, is compli- suggest a few examples of concrete Center, in Hartford, Connecticut, we purpose of this meeting is to collect the cated, difficult, painful, expensive and changes in clinical practice that might have begun the ambitious task of defin- goals for the treatment plan. Without unpopular. In an environment of con- make a difference. ing the very real practice changes re- dwelling on technical details, suffice it to strained resources, only the most critical I have suggested that the problems quired to integrate excellent clinical care say that these “goals” drive the treatment changes can be prioritized. At Capitol with traditional practice lie not so much into more meaningful life contexts. plan “objectives,” which, in turn, drive Region, we made a clear decision to es- in the technical interventions themselves, While it would be pretentious at this the structure of everyday progress notes. tablish implementation of recovery prin- but rather in the lack of a clear context early stage to attempt to define the best The interests of the person in recovery ciples as a major strategy. Eventually, for treatment. Look, for example, at a way to compose treatment plans, it drive the process, since the structure of the we hope to be able to demonstrate that competently composed treatment plan seems relevant to report on how we have treatment plan and subsequent progress this has increased our effectiveness in and you will tend to see an adequate reached a point of genuine optimism. notes are both built on the list of goals. helping people regain valued aspects of accounting of the relevant clinical inter- Over the past few years, several peo- For those who have never had the their lives. Already, we are experiencing ventions (e.g., medications, psychothera- ple who have struggled with severe psy- pleasure of constructing a more tradi- a growing vitality in our treatment plan- pies, rehabilitative work, case manage- chiatric illness have worked their way on tional treatment plan, it might be helpful ning. Initially received with polite skep- ment, etc.). It is much less likely, how- to the staff of Capitol Region. They to explain that these documents tend to ticism, the recovery movement has ever, that you will find an accounting of form what we call the Peer Support Pro- be built on a “problem list” designed by firmly taken root. With just the right the person’s hopes and dreams and a gram, and have come to be accepted as the clinicians. (A person whose main combination of water and sunlight – and coherent roadmap for their pursuit. important members of our treatment interest is to “get off all meds,” for ex- a sophisticated sprinkling of fertilizer – Practical readers might well be roll- teams. (The considerable challenges inherent ample, might find this translated into a we anticipate the growth of a whole new ing their eyes at this point and asking a in this process warrant separate discussion.) “problem” like “Medication non- way of working, and, for persons in re- realistic question like, “Has this moron A plan to interject their input into our compliance” and a matching “goal” like covery, of finding more fulfillment in forgotten that we need to get paid, and existing treatment planning process was “Medication compliance.”) their lives. that we face JCAHO accreditation every implemented and studied over a six- Our group recognizes the need to We have come to believe that it is few years?” Clearly, these issues cannot month period. To our disappointment include such traditional constructs as critical to keep “goals” and “problems” be ignored. If anything, our treatment and surprise, we discovered that our “problems” in our new treatment plans distinct. Goals have to do with living; plans need to be more attuned with the treatment plans continued to reflect little (since insurers are accustomed to paying problems have to do with treatment. “best practices” being constantly rede- recovery-oriented thinking. for treating them). We have come to These two concepts are related, and that fined by research. And we need to jus- A work group was assembled, includ- believe, however, that it is critical to relationship needs to be expressed in the tify continuation of expensive interven- ing Peer Support staff and clinical staff keep “goals” and “problems” distinct. treatment plan. To confuse them, how- tions more than ever before. who were considered to be both excel- Goals have to do with living; problems ever, is to guarantee the creation of a So here’s the point: treatment plans lent authors of clinical documentation have to do with treatment. These two treatment plan into which the life of a (and everyday progress notes, for that and receptive to recovery principles. concepts are related, and that relation- person seems to dissolve. □ matter) need to accomplish both sorts of With refreshing ease, we concluded that ship needs to be expressed in the treat- tasks: the technical justification for treat- our treatment plans would include recov- ment plan. To confuse them, however, Capitol Region Mental Health Center ment (not new) and the human context ery principles only if we made funda- is to guarantee the creation of a treat- is the local mental health authority of the for treatment (definitely new). These mental changes both to the structure of ment plan into which the life of a person State of Connecticut Department of Men- two distinct challenges cannot be ad- the documents themselves and to the seems to dissolve. tal Health and Addiction Services serv- dressed through an artistic blending of process by which treatment plans are If your eyes, Gentle Reader, weren’t ing the towns of Hartford, West Hart- clinically sophisticated and “client- written. Although it would be premature rolling earlier, they are certainly glazed ford, Farmington, Avon, Canton, and centered” language. Instead, we need to to report on the details of our efforts, it over by now. The point here, however, Simsbury. It is located at 500 Vine recognize that a treatment plan needs to might be helpful to provide an example of is not to argue for particular approaches Street, Hartford, Connecticut. For fur- include both kinds of elements. They a concrete change that is being introduced. to treatment planning or its documenta- ther information about services, please need to be addressed separately, and the Before a treatment plan is begun, we tion. It is, instead, to suggest that a contact us at (860) 297-0800 or visit us relationships between these two aspects will schedule a meeting that includes at meaningful shift towards recovery- at www.dmhas.state.ct.us/crmhc.homepage.htm

Expand Your Mental Health Education: www.mhnews.org

Orlando’s Story from page 27 to enter a two-year academic program with with schizophrenia can recover com- the advantage of attending college in self- pletely. Orlando made the cut. No student before his dreams lost their alti- “Recovery is a combination of contained classrooms with specially se- longer locked in the isolation of his ill- tude to a mental illness. lected professors. Experienced staff mem- ness, he has become a soft-spoken, ar- After years of battling his disorder, Or- things. Getting better happens bers attend classes with students and are ticulate and thoughtful young man who lando was ready to recover - break through when you utilize the system to available to tutor them after class. Support wants to be a physician because, as he the force field of schizophrenia and iden- your advantage…to the best of groups are also provided to help students says, “I’ve been on both sides.” tify a plan. Advocating for himself after your capabilities. That means prepare to enter the world of work or con- At the SUNY graduation, the skies years of personal disregard, he requested, compliance with meds, therapy tinue their academic studies in a traditional brightened and students, their families and upon completion of his present treatment, and the internal drive to want to college format. friends were bathed in sunshine. It was a to move to a group home close to his fam- recover. I had to hit rock bottom Orlando embarked upon an ambitious day of invigoration, of joy and hope for ily on Long Island. Orlando’s goal was to quest. He would continue his therapy everyone, but especially for Orlando make up for years of lost opportunities. He before I came around and saw and medication management and attend Morales. His new-found confidence, his transitioned to Garvey House, an adult things realistically again. When Nassau Community College. He would achievements, his ambitions and even his group residence operated by the Mental that happened I wanted the sta- work to keep the ghosts of his past at bay scars were all hard-earned. Orlando’s take Health Association of Nassau County. bility, I wanted to be at my best. and receive a two-year degree. From on recovery says it best, “I believe in mira- There he was encouraged to choose be- Once you start to get your old there, he would transfer to a four-year cles, because I’m one of them.” tween a day program, vocational training, feelings back…feelings of well- school and perhaps, with a little luck and The Mental Health Association of employment or College Bound, an intro- ness, you don't want any other a great deal of grit and determination, go Nassau County has produced a short ductory program for young adults with a onto medical school. film chronicling Orlando’s recovery psychiatric disability who want to start or conscious state. You want to be Orlando kept his eye on the prize—a entitled Orlando’s Story: Regaining A return to college. alert, vibrant and as far away new life and recovery. With College Life. If you are interested in obtaining a Orlando opted for College Bound, a from an altered state as possible. Bound, Garvey House and his family at copy, please contact the MHA at cooperative venture between the Mental Most importantly, knowing that his side, Orlando graduated from Nassau 516.489-2322, ext. 113. The Mental Health Association, Nassau Community there's hope - that I could get Community College and entered SUNY Health Association of Nassau County is College, the Nassau County Department of better - kept me striving.” (while also volunteering his time at a a not-for-profit membership organiza- Mental Health, Mental Retardation and local hospital). He’s the first one to say tion dedicated to improving mental Developmental Disabilities and the New Orlando Morales that “you just don’t know what you’re health through advocacy, education, York State Office of Mental Health. Col- capable of until you get started.” program development and the delivery of lege Bound offers students an opportunity One in five individuals diagnosed direct services. □

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 41

Schizophrenia from page 22 sometimes be unable to “think straight.” paranoid and psychotic symptoms, the U.S. population is about 25 to 30 They may become extremely anxious, which can become worse if medications percent, the prevalence among people termed “thought disorder,” can make con- for example, when speaking in front of are discontinued, may also be at higher with schizophrenia is approximately versation very difficult and may contribute groups and may feel confused, be unable risk for violent behavior. When violence three times as high. Research has shown to social isolation. If people cannot make to pull their thoughts together, and forget does occur, it is most frequently targeted that the relationship between smoking sense of what an individual is saying, they what they had intended to say. This is at family members and friends, and more and schizophrenia is complex. Although are likely to become uncomfortable and not schizophrenia. At the same time, often takes place at home. people with schizophrenia may smoke to tend to leave that person alone. people with schizophrenia do not always self medicate their symptoms, smoking act abnormally. Indeed, some people Substance Abuse interferes with the response to antipsy- Emotional Expression with the illness can appear completely chotic drugs. Several studies have found normal and be perfectly responsible, Substance abuse is a common con- that schizophrenia patients who smoke People with schizophrenia often show even while they experience hallucina- cern of the family and friends of people need higher doses of antipsychotic medi- “blunted” or “flat” affect. This refers to a tions or delusions. An individual’s be- with schizophrenia. Since some people cation. Quitting smoking may be espe- severe reduction in emotional expres- havior may change over time, becoming who abuse drugs may show symptoms cially difficult for people with schizo- siveness. A person with schizophrenia bizarre if medication is stopped and re- similar to those of schizophrenia, people phrenia, because the symptoms of nico- may not show the signs of normal emo- turning closer to normal when receiving with schizophrenia may be mistaken for tine withdrawal may cause a temporary tion, perhaps may speak in a monoto- appropriate treatment. people “high on drugs.” while most re- worsening of schizophrenia symptoms. nous voice, have diminished facial ex- searchers do not believe that substance However, smoking cessation strategies pressions, and appear extremely apa- Are People With Schizophrenia abuse causes schizophrenia, people who that include nicotine replacement meth- thetic. The person may withdraw so- Likely To Be Violent? have schizophrenia often abuse alcohol ods may be effective. Doctors should cially, avoiding contact with others; and and/or drugs, and may have particularly carefully monitor medication dosage and when forced to interact, he or she may News and entertainment media tend bad reactions to certain drugs. Substance response when patients with schizophre- have nothing to say, reflecting to link mental illness and criminal vio- abuse can reduce the effectiveness of nia either start or stop smoking. “impoverished thought.” Motivation can lence; however, studies indicate that treatment for schizophrenia. Stimulants be greatly decreased, as can interest in or except for those persons with a record of (such as amphetamines or cocaine) may What About Suicide? enjoyment of life. In some severe cases, criminal violence before becoming ill, cause major problems for patients with a person can spend entire days doing and those with substance abuse or alco- schizophrenia, as may PCP or marijuana. Suicide is a serious danger in people nothing at all, even neglecting basic hy- hol problems, people with Schizophrenia In fact, some people experience a wors- who have schizophrenia. If an individual giene. These problems with emotional are not especially prone to violence. ening of their schizophrenic symptoms tries to commit suicide or threatens to do expression and motivation, which may Most individuals with schizophrenia when they are taking such drugs. Sub- so, professional help should be sought be extremely troubling to family mem- are not violent; more typically, they are stance abuse also reduces the likelihood immediately. People with schizophrenia bers and friends, are symptoms of withdrawn and prefer to be left alone. that patients will follow the treatment have a higher rate of suicide than the schizophrenia—not character flaws or Most violent crimes are not committed plans recommended by their doctors. general population. Approximately 10 personal weaknesses. by persons with schizophrenia, and most percent of people with schizophrenia persons with schizophrenia do not com- Schizophrenia and Nicotine (especially younger adult males) commit Normal Versus Abnormal mit violent crimes. suicide. Unfortunately, the prediction of Substance abuse significantly raises The most common form of substance suicide in people with schizophrenia can At times, normal individuals may the rate of violence in people with use disorder in people with schizophre- be especially difficult. feel, think, or act in ways that resemble schizophrenia but also in people who do nia is nicotine dependence due to smok- schizophrenia. Normal people may not have any mental illness. People with ing. While the prevalence of smoking in see Schizophrenia on page 42

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PAGE 42 MENTAL HEALTH NEWS ~ FALL 2005 Schizophrenia from page 41 and various nonspecific stressors, seem This area of research is promising. versely with the faulty connections. This to influence the development of schizo- research has spurred efforts to identify What Causes Schizophrenia? phrenia. However, it is not yet under- Is Schizophrenia Caused by prenatal factors that may have some stood how the genetic predisposition is a Physical Abnormality in the Brain? bearing on the apparent developmental There is no known single cause of transmitted, and it cannot yet be accu- abnormality. schizophrenia. Many diseases, such as rately predicted whether a given person There have been dramatic advances In other studies, investigators using heart disease, result from an interplay of will or will not develop the disorder. in neuroimaging technology that permit brain-imaging techniques have found genetic, environmental, and behavioral Several regions of the human genome scientists to study brain structure and evidence of early biochemical changes factors; and this may be the case for are being investigated to identify genes function in living individuals. Many that may precede the onset of disease schizophrenia as well. Scientists do not that may confer susceptibility for schizo- studies of people with schizophrenia symptoms, prompting examination of the yet understand all of the factors neces- phrenia. The strongest evidence to date have found abnormalities in brain struc- neural circuits that are most likely to be sary to produce schizophrenia, but all the leads to chromosomes 13 and 6 but re- ture (for example, enlargement of the involved in producing those symptoms. tools of modern biomedical research are mains unconfirmed. Identification of fluid-filled cavities, called the ventricles, Scientists working at the molecular being used to search for genes, critical specific genes involved in the develop- in the interior of the brain, and decreased level, meanwhile, are exploring the ge- moments in brain development, and en- ment of schizophrenia will provide im- size of certain brain regions) or function netic basis for abnormalities in brain vironmental factors that may lead to the portant clues into what goes wrong in the (for example, decreased metabolic activ- development and in the neurotransmitter illness. brain to produce and sustain the illness ity in certain brain regions). It should be systems regulating brain function. and will guide the development of new emphasized that these abnormalities are Is Schizophrenia Inherited? and better treatments. To learn more quite subtle and are not characteristic of How Is It Treated? about the genetic basis for schizophre- all people with schizophrenia, nor do It has long been known that schizo- nia, the NIMH has established a Schizo- they occur only in individuals with this Since schizophrenia may not be a phrenia runs in families. People who phrenia Genetics Initiative that is gather- illness. Microscopic studies of brain tis- single condition and its causes are not have a close relative with schizophrenia ing data from a large number of families sue after death have also shown small yet known, current treatment methods are more likely to develop the disorder of people with the illness. changes in distribution or number of are based on both clinical research and than are people who have no relatives brain cells in people with schizophrenia. experience. These approaches are chosen with the illness. For example, a monozy- Is Schizophrenia Associated It appears that many (but probably not on the basis of their ability to reduce the gotic (identical) twin of a person with With a Chemical Defect in the Brain? all) of these changes are present before symptoms of schizophrenia and to lessen schizophrenia has the highest risk—40 to an individual becomes ill, and schizo- the chances that symptoms will return. 50 percent—of developing the illness. A Basic knowledge about brain chemis- phrenia may be, in part, a disorder in child whose parent has schizophrenia has try and its link to schizophrenia is ex- development of the brain. What About Medications? about a 10 percent chance. By compari- panding rapidly. Neurotransmitters, sub- Developmental neurobiologists son, the risk of schizophrenia in the gen- stances that allow communication be- funded by the National Institute of Men- Antipsychotic medications have been eral population is about 1 percent. tween nerve cells, have long been tal Health (NIMH) have found that available since the mid-1950s. They Scientists are studying genetic factors thought to be involved in the develop- schizophrenia may be a developmental have greatly improved the outlook for in schizophrenia. It appears likely that ment of schizophrenia. It is likely, al- disorder resulting when neurons form individual patients. These medications multiple genes are involved in creating a though not yet certain, that the disorder inappropriate connections during fetal reduce the psychotic symptoms of predisposition to develop the disorder. In is associated with some imbalance of the development. These errors may lie dor- schizophrenia and usually allow the pa- addition, factors such as prenatal diffi- complex, interrelated chemical systems mant until puberty, when changes in the tient to function more effectively and culties like intrauterine starvation or of the brain, perhaps involving the neu- brain that occur normally during this viral infections, perinatal complications, rotransmitters dopamine and glutamate. critical stage of maturation interact ad- see Schizophrenia on page 43

Mental Health Association in Putnam County, Inc. 1620 Route 22 Brewster, NY 10509

Promoting a vision of recovery for individuals and families coping with mental health issues

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MENTAL HEALTH NEWS ~ FALL 2005 PAGE 43

Schizophrenia from page 42 appropriate dosage do not “knock out” people or take away their free will. appropriately. Antipsychotic drugs are While these medications can be sedat- the best treatment now available, but ing, and while this effect can be useful they do not “cure” schizophrenia or en- when treatment is initiated particularly if sure that there will be no further psy- an individual is quite agitated, the utility chotic episodes. The choice and dosage of the drugs is not due to sedation but to of medication can be made only by a their ability to diminish the hallucina- qualified physician who is well trained tions, agitation, confusion, and delusions When you need help, Westchester Jewish Community Services is here for you in the medical treatment of mental disor- of a psychotic episode. Thus, antipsy- ders. The dosage of medication is indi- chotic medications should eventually WJCS offers comprehensive mental health services vidualized for each patient, since people help an individual with schizophrenia to may vary a great deal in the amount of deal with the world more rationally. drug needed to reduce symptoms with- out producing troublesome side effects. How Long Should People With Out-patient Treatment for People of All Ages The large majority of people with Schizophrenia Take Antipsychotic Drugs? schizophrenia show substantial improve- Specialized services for individuals ment when treated with antipsychotic Antipsychotic medications reduce the with developmental disabilities drugs. Some patients, however, are not risk of future psychotic episodes in pa- helped very much by the medications tients who have recovered from an acute Intensive Community–based Services and a few do not seem to need them. It is episode. Even with continued drug treat- difficult to predict which patients will ment, some people who have recovered for Children and Their Families fall into these two groups and to distin- will suffer relapses. Far higher relapse Learning Center for children and adults guish them from the large majority of rates are seen when medication is dis- patients who do benefit from treatment continued. In most cases, it would not be with antipsychotic drugs. accurate to say that continued drug treat- Geriatric Care A number of new antipsychotic drugs ment “prevents” relapses; rather, it re- Continuing Day Treatment (the so-called “atypical antipsychotics”) duces their intensity and frequency. The have been introduced since 1990. The treatment of severe psychotic symptoms Mobile clinical services first of these, clozapine (Clozaril®), has generally requires higher dosages than Case management been shown to be more effective than those used for maintenance treatment. If other antipsychotics, although the possi- symptoms reappear on a lower dosage, a Social Clubs bility of severe side effects—in particu- temporary increase in dosage may pre- lar, a condition called agranulocytosis vent a full-blown relapse. COMPEER (loss of the white blood cells that fight Because relapse of illness is more All services are offered on a non-sectarian basis infection)—requires that patients be likely when antipsychotic medications monitored with blood tests every one or are discontinued or taken irregularly, it two weeks. Even newer antipsychotic is very important that people with drugs, such as risperidone (Risperdal®) schizophrenia work together with their and olanzapine (Zyprexa®), are safer doctors and family members to adhere to Call WJCS at (914) 761-0600 than the older drugs or clozapine, and their treatment plan. Adherence to treat- they also may be better tolerated. They ment refers to the degree to which pa- may or may not treat the illness as well as tients follow the treatment plans decided Prepare Now from page 13 ric disabilities will not be easy. But clozapine, however. Several additional antip- upon with their doctors. Good adherence these challenges will not emerge over- sychotics are currently under development. involves taking prescribed medication at special program design and training they night. They will unfold gradually over Antipsychotic drugs are often very the correct dose and proper times each can play valuable roles helping older the next quarter century. There is time effective in treating certain symptoms of day, attending clinic appointments, adults with psychiatric disabilities. for energetic and innovative planning. schizophrenia, particularly hallucina- and/or carefully following other treat- Think of the enormous expansion and

tions and delusions; unfortunately, the ment procedures. Treatment adherence 10. Create new financing models: Devel- reconfiguration of services for working- drugs may not be as helpful with other is often difficult for people with schizo- oping the capacity to serve a rapidly grow- age adults (redesigned housing, rehabili- symptoms, such as reduced motivation phrenia, but it can be made easier with ing population and to use the best medical tation, case management, peer support and emotional expressiveness. Indeed, the help of several strategies and can and psychosocial service models hinges on etc.) over the past quarter century. A the older antipsychotics (which also lead to improved quality of life. financing. Medicare reform is essential to similar transformation, focused on older went by the name of “neuroleptics”), There are a variety of reasons why overcome lack of parity, to assure ade- adults, is needed, and possible, today. medicines like haloperidol (Haldol®) or people with schizophrenia may not ad- quate prescription drug coverage, to pro- The Geriatric Mental Health Act lays the chlorpromazine (Thorazine®), may even here to treatment. Patients may not be- vide funding for innovative home and groundwork; now policy makers and produce side effects that resemble the lieve they are ill and may deny the need community-based psychosocial services, stakeholders must seize the opportunity. more difficult to treat symptoms. Often, for medication, or they may have such and to develop incentives or mandates for We can get this done—if we start now. lowering the dose or switching to a dif- disorganized thinking that they cannot psychiatrists and other mental health pro- ferent medicine may reduce these side remember to take their daily doses. Fam- fessionals to serve Medicare beneficiaries. effects; the newer medicines, including ily members or friends may not under- Changes are also needed in Medicaid, Michael B. Friedman is the Director olanzapine (Zyprexa®), quetiapine stand schizophrenia and may inappropri- especially to support home-based mental of the Center for Policy and Advocacy of (Seroquel®), and risperidone ately advise the person with schizophre- health services and high quality mental The Mental Health Associations of NYC (Risperdal®), appear less likely to have nia to stop treatment when he or she is health services in nursing homes and home and Westchester. The opinions ex- this problem. Sometimes when people feeling better. Physicians, who play an health care. pressed in this column are his own and with schizophrenia become depressed, important role in helping their patients do not necessarily reflect the positions other symptoms can appear to worsen. The adhere to treatment, may neglect to ask Meeting the challenges posed by the of the MHAs. Mr. Friedman can be symptoms may improve with the addition patients how often they are taking their aging of people with long-term psychiat- reached at [email protected].) □ of an antidepressant medication. medications, or may be unwilling to Patients and families sometimes be- accommodate a patient’s request to come worried about the antipsychotic change dosages or try a new treatment. medications used to treat schizophrenia. Some patients report that side effects of In addition to concern about side effects, the medications seem worse than the Help Us Provide they may worry that such drugs could illness itself. Further, substance abuse lead to addiction. However, antipsy- can interfere with the effectiveness of Vital Mental Health Education chotic medications do not produce a treatment, leading patients to discon- “high” (euphoria) or addictive behavior tinue medications. When a complicated in people who take them. treatment plan is added to any of these fac- Support The Upcoming Another misconception about antip- tors, good adherence may become even sychotic drugs is that they act as a kind more challenging. of mind control, or a “chemical strait- Mental Health News Fall Appeal jacket.” Anti-psychotic drugs used at the see Schizophrenia on page 44

PAGE 44 MENTAL HEALTH NEWS ~ FALL 2005 Schizophrenia from page 43 produce side effects of their own such as weight gain. In addition, if given at too Fortunately, there are many strategies high of a dose, the newer medications that patients, doctors, and families can may lead to problems such as social use to improve adherence and prevent withdrawal and symptoms resembling worsening of the illness. Some antipsy- Parkinson’s disease, a disorder that af- chotic medications, including haloperi- fects movement. Nevertheless, the dol (Haldol®), fluphenazine newer antipsychotics are a significant (Prolixin®), perphenazine (Trilafon®) advance in treatment, and their optimal and others, are available in long-acting use in people with schizophrenia is a injectable forms that eliminate the need subject of much current research. to take pills every day. A major goal of current research on treatments for What About Psychosocial Treatments? schizophrenia is to develop a wider vari- ety of long-acting antipsychotics, espe- Antipsychotic drugs have proven to cially the newer agents with milder side be crucial in relieving the psychotic effects, which can be delivered through symptoms of schizophrenia—hallucinations, injection. Medication calendars or pill delusions, and incoherence—but are not boxes labeled with the days of the week consistent in relieving the behavioral symp- can help patients and caregivers know toms of the disorder. Even when patients when medications have or have not been with schizophrenia are relatively free of psy- taken. Using electronic timers that beep chotic symptoms, many still have extraordi- when medications should be taken, or nary difficulty with communication, motiva- pairing medication taking with routine tion, self-care, and establishing and maintain- daily events like meals, can help patients ing relationships with others. Moreover, remember and adhere to their dosing because patients with schizophrenia fre- schedule. Engaging family members in quently become ill during the critical observing oral medication taking by career-forming years of life (e.g., ages patients can help ensure adherence. In 18 to 35), they are less likely to com- addition, through a variety of other plete the training required for skilled methods of adherence monitoring, doc- work. As a result, many with schizo- tors can identify when pill taking is a phrenia not only suffer thinking and problem for their patients and can work emotional difficulties, but lack social with them to make adherence easier. It is and work skills and experience as well. important to help motivate patients to It is with these psychological, social, continue taking their medications prop- and occupational problems that psycho- erly. social treatments may help most. While In addition to any of these adherence psychosocial approaches have limited strategies, patient and family education value for acutely psychotic patients about schizophrenia, its symptoms, and (those who are out of touch with reality the medications being prescribed to treat or have prominent hallucinations or de- the disease is an important part of the lusions), they may be useful for patients treatment process and helps support the with less severe symptoms or for pa- rationale for good adherence. tients whose psychotic symptoms are The Center for Career Freedom under control. Numerous forms of psy- What About Side Effects? chosocial therapy are available for peo- ple with schizophrenia, and most focus On & Off Site Computer Applications Training for Persons with Disabilities Antipsychotic drugs, like virtually all on improving the patient’s social func- medications, have unwanted effects tioning—whether in the hospital or com- Microsoft® Certified Office Specialist Training Center along with their beneficial effects. Dur- munity, at home, or on the job. Some of Licensed by NYS Department of Education ing the early phases of drug treatment, these approaches are described here. patients may be troubled by side effects Unfortunately, the availability of differ- DCMH Drop-in Center such as drowsiness, restlessness, muscle ent forms of treatment varies greatly

spasms, tremor, dry mouth, or blurring from place to place. Consumer Survey Research of vision. Most of these can be corrected Case Management Aids: Form-Link - 2004 Benefits Guide by lowering the dosage or can be con- Schizophrenia trolled by other medications. Different Is Not "Split Personality" (914) 288-9763 patients have different treatment re- sponses and side effects to various antip- There is a common notion that One East Post Road, White Plains, New York ● www.freecenter.org sychotic drugs. A patient may do better schizophrenia is the same as "split per- with one drug than another. sonality"—a Dr. Jekyll-Mr. Hyde switch The long-term side effects of antipsy- in character. This is not correct. chotic drugs may pose a considerably “Search for Change has been rebuilding lives for more than more serious problem. Tardive dyskine- Rehabilitation 25 years and continues to be a major force that provides a sia (TD) is a disorder characterized by safe haven for individuals recovering from mental illness.” involuntary movements most often af- Broadly defined, rehabilitation in- fecting the mouth, lips, and tongue, and cludes a wide array of non-medical in- sometimes the trunk or other parts of the terventions for those with schizophrenia. body such as arms and legs. It occurs in Rehabilitation programs emphasize so- about 15 to 20 percent of patients who cial and vocational training to help pa- Residential Services have been receiving the older, “typical” tients and former patients overcome antipsychotic drugs for many years, but difficulties in these areas. Programs may Career Support Services “Rebuilding lives TD can also develop in patients who include vocational counseling, job train- and strengthening Private Case Management have been treated with these drugs for ing, problem-solving and money man- communities since 24 Hour Staff Support shorter periods of time. In most cases, the agement skills, use of public transporta- 1975.” symptoms of TD are mild, and the patient tion, and social skills training. These may be unaware of the movements. approaches are important for the success 95 Church St., Suite 200 Antipsychotic medications developed of the community-centered treatment of White Plains, NY 10601 in recent years all appear to have a much schizophrenia, because they provide (914) 428-5600 fax: (914) 428-5642 lower risk of producing TD than the discharged patients with the skills Or visit us on the web at www.searchforchange.com older, traditional antipsychotics. The risk is not zero, however, and they can see Schizophrenia on page 45

MENTAL HEALTH NEWS ~ FALL 2005 PAGE 45

Schizophrenia from page 44 churches and synagogues, and others. Be- cause many patients live with their families, necessary to lead productive lives outside the the following discussion frequently uses the sheltered confines of a mental hospital. term "family." However, this should not be taken to imply that families ought to be the Individual Psychotherapy primary support system. There are numerous situations in which Individual psychotherapy involves patients with schizophrenia may need help regularly scheduled talks between the pa- from people in their family or community. tient and a mental health professional such Often, a person with schizophrenia will as a psychiatrist, psychologist, psychiatric resist treatment, believing that delusions or social worker, or nurse. The sessions may hallucinations are real and that psychiatric focus on current or past problems, experi- help is not required. At times, family or ences, thoughts, feelings, or relationships. friends may need to take an active role in By sharing experiences with a trained em- having them seen and evaluated by a pro- pathic person—talking about their world fessional. The issue of civil rights enters with someone outside it—individuals with into any attempts to provide treatment. schizophrenia may gradually come to un- Laws protecting patients from involuntary derstand more about themselves and their commitment have become very strict, and problems. They can also learn to sort out families and community organizations the real from the unreal and distorted. Re- may be frustrated in their efforts to see cent studies indicate that supportive, real- that a severely mentally ill individual gets ity-oriented, individual psychotherapy, needed help. These laws vary from state to and cognitive-behavioral approaches that state; but generally, when people are dan- teach coping and problem-solving skills, gerous to themselves or others due to a can be beneficial for outpatients with mental disorder, the police can assist in schizophrenia. However, psychotherapy is getting them an emergency psychiatric INFO LINE PSYCH not a substitute for antipsychotic medica- evaluation and, if necessary, hospitaliza- tion; it is most helpful once drug treatment tion. In some places, staff from a local com- A SERVICE OF THE PSYCHIATRIC SOCIETY OF WESTCHESTER first has relieved a patient’s psychotic munity mental health center can evaluate an symptoms. individual's illness at home if he or she will not voluntarily go in for treatment. 914-967-6810 Family Education Sometimes only the family or others This is an information and referral service sponsored by the Westchester close to the person with schizophrenia will District Branch of the American Psychiatric Association. Very often, patients with schizophrenia be aware of strange behavior or ideas that are discharged from the hospital into the the person has expressed. Since patients Psychiatrists of this organization are dedicated to providing treatment for care of their family; so it is important that may not volunteer such information during mental disorders and advocating for equal health care for mental family members learn all they can about an examination, family members or and physical conditions. schizophrenia and understand the difficul- friends should ask to speak with the per- ties and problems associated with the ill- son evaluating the patient so that all rele- If you need information about psychiatry or assistance in finding ness. It is also helpful for family members vant information can be taken into ac- a psychiatric physician - please call us. to learn ways to minimize the patient’s count. chance of relapse—for example, by using Ensuring that a person with schizophre- different treatment adherence strategies— nia continues to get treatment after hospi- THE PSYCHIATRIC SOCIETY OF WESTCHESTER and to be aware of the various kinds of talization is also important. A patient may 555 THEODORE FREMD AVENUE • SUITE B-100 • RYE • NEW YORK outpatient and family services available in discontinue medications or stop going for the period after hospitalization. Family follow-up treatment, often leading to a “psychoeducation,” which includes return of psychotic symptoms. Encourag- of psychosis may be detected early and groups of patients are studied, certain fac- teaching various coping strategies and ing the patient to continue treatment and treatment may prevent a full-blown re- tors tend to be associated with a better problem-solving skills, may help fami- assisting him or her in the treatment proc- lapse. Also, by knowing which medica- outcome—for example, a pre-illness his- lies deal more effectively with their ill ess can positively influence recovery. tions have helped and which have caused tory of normal social, school, and work relative and may contribute to an im- Without treatment, some people with troublesome side effects in the past, the adjustment. However, the current state of proved outcome for the patient. schizophrenia become so psychotic and family can help those treating the patient knowledge does not allow for a suffi- disorganized that they cannot care for their to find the best treatment more quickly. ciently accurate prediction of long-term Self-Help Groups basic needs, such as food, clothing, and In addition to involvement in seeking outcome. shelter. All too often, people with severe help, family, friends, and peer groups can Given the complexity of schizophrenia, Self-help groups for people and fami- mental illnesses such as schizophrenia end provide support and encourage the person the major questions about this disorder— lies dealing with schizophrenia are becom- up on the streets or in jails, where they rarely with schizophrenia to regain his or her its cause or causes, prevention, and treat- ing increasingly common. Although not receive the kinds of treatment they need. abilities. It is important that goals be at- ment—must be addressed with research. led by a professional therapist, these Those close to people with schizophre- tainable, since a patient who feels pres- The public should beware of those offer- groups may be therapeutic because mem- nia are often unsure of how to respond sured and/or repeatedly criticized by oth- ing "the cure" for (or "the cause" of) bers provide continuing mutual support as when patients make statements that seem ers will probably experience stress that schizophrenia. Such claims can provoke well as comfort in knowing that they are strange or are clearly false. For the indi- may lead to a worsening of symptoms. unrealistic expectations that, when unful- not alone in the problems they face. Self- vidual with schizophrenia, the bizarre be- Like anyone else, people with schizophre- filled, lead to further disappointment. Al- help groups may also serve other impor- liefs or hallucinations seem quite real— nia need to know when they are doing though progress has been made toward tant functions. Families working together they are not just "imaginary fantasies." things right. A positive approach may be better understanding and treatment of can more effectively serve as advocates Instead of “going along with ” a person's helpful and perhaps more effective in the schizophrenia, continued investigation is for needed research and hospital and com- delusions, family members or friends can long run than criticism. This advice applies urgently needed. As the lead Federal munity treatment programs. Patients act- tell the person that they do not see things to everyone who interacts with the person. agency for research on mental disorders, ing as a group rather than individually the same way or do not agree with his or NIMH conducts and supports a broad may be better able to dispel stigma and her conclusions, while acknowledging that What Is The Outlook? spectrum of mental illness research from draw public attention to such abuses as things may appear otherwise to the patient. molecular genetics to large-scale epidemi- discrimination against the mentally ill. It may also be useful for those who The outlook for people with schizo- ologic studies of populations. It is thought Family and peer support and advocacy know the person with schizophrenia well phrenia has improved over the last 25 that this wide-ranging research effort, in- groups are very active and provide useful to keep a record of what types of symp- years. Although no totally effective ther- cluding basic studies on the brain, will information and assistance for patients and toms have appeared, what medications apy has yet been devised, it is important to continue to illuminate processes and prin- families of patients with schizophrenia and (including dosage) have been taken, and remember that many people with the ill- ciples important for understanding the other mental disorders. what effects various treatments have had. ness improve enough to lead independent, causes of schizophrenia and for develop- By knowing what symptoms have been satisfying lives. As we learn more about the ing more effective treatments. □ How Can Other People Help? present before, family members may know causes and treatments of schizophrenia, we better what to look for in the future. Fami- should be able to help more patients achieve This article was written by Melissa K. A patient's support system may come lies may even be able to identify some successful outcomes. Spearing, M.H.S., of the Office of Commu- from several sources, including the family, "early warning signs" of potential relapses, Studies that have followed people with nications, NIMH. Scientific information a professional residential or day program such as increased withdrawal or changes schizophrenia for long periods, from the and review were provided by NIMH staff provider, shelter operators, friends or in sleep patterns, even better and earlier first episode to old age, reveal that a wide members David Shore, M.D. and John K. roommates, professional case managers, than the patients themselves. Thus, return range of outcomes is possible. When large Hsiao, M.D.

PAGE 46 MENTAL HEALTH NEWS ~ FALL 2005

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