Archive for January, 2011

January 28, 2011

An Unbalanced Mind–Thoughts on Jared Loughner

by Richard Edwards

(Note: this post probably seems a little out of date, but it has taken me a while to collect my thoughts. Still not sure if I’m there…)

Jared Loughner is, in very plain terms, mentally ill. I’m not a diagnostician, but that seems to me to be the truth of it.

Immediately following the shooting of Rep. Giffords and many others at a speaking event in Arizona, there were emails and blog postings and press releases from NAMI and MHA and the National Council for Behavioral Healthcare around the lack of evidence to show that people with mental health issues are any more violent than the general population.

And research shows that that’s true–you can read about it here, here and here–and it’s important that we don’t paint all people with mental health issues as criminally violent. Studies show that mental illness does not lead to violence, although the likelihood goes way up when you add substance abuse to the mix. So let’s not stigmatize the millions of Americans with mental health issues–many of whom are successfully managing serious and persistent mental illness–by assuming they will–or even could–become the next Jared Loughner.

But in recent weeks, following President Obama’s Tucson speech, I notice the conversation turning to mental health support services….Did we do enough? Should the Community College where Jared Loughner attended classes done more? Should the community have noticed? Should his parents have noticed and taken action? Not so much discussion about whether the national discourse was to blame, but much more about the nitty gritty–at the ground level, what went wrong? This too, seems appopriate to me. In order to prevent the next Jared Loughner, we need to understand the current one.

Several national advocacy agencies are pointing to declining services in Arizona and elsewhere for people with mental health issues as cause for concern. There is also such a thing as mental health first aid, and it’s not hard to imagine how a well-informed community could have recognized the signs of Jared Loughner’s paranoia, before it reached crisis levels, and, given the tools to act, intervened. However, services to people with disabilities and mental illness cost money, and in states across the country, including NC, which faces a 3.7 billion dollar shortfall in FY11-12, money is in short supply.

But doesn’t that sound like we want it both ways? We need to improve access to mental health services for people like Jared to prevent this kind of tragedy from happening–a tragedy which, in the end, also happened to Jared. But how do we advocate for more services on that basis without playing up the potential for violence, and thereby stigmatizing the millions of Americans who deal with emotional or mental health issues everyday and have no propensity for violence whatsoever?

My angle is that Jared’s mental illness had a direct relationship to his crime, but criminal insanity is a legal term, not a diagnosis, and one charged with understandably negative feelings about loopholes and savvy criminals who walk, scot-free. But if Jared Loughner could have been helped with services because he was mentally ill, and if that intervention could have prevented the criminal and insensate act that resulted from his mental illness, and if we think we simply can’t afford those services…

What kind of wall will Arizona build now?

Jared Loughner is, in very plain terms, mentally ill. And his kind of illness took his mind and the lives of 9 people with it, not to mention the nightmare-free existence so many people in Tucson thought they would live until a few weeks ago. In making a way forward from this tragedy, there is, I believe, a middle path–service without segregation; awareness without paranoia; and yes, fiscal restraint without neglect–this is the kind of balance Jared Loughner’s mind couldn’t maintain.

But that’s just my angle. What are your thoughts?

January 27, 2011

And the choir said, “Amen!”

by Richard Edwards

This past weekend, NAMI of Orange County and MHA of the Triangle hosted their annual legislative breakfast. Over 300 people attended, including legislators, advocates, providers, persons receiving services, as well as a variety of local elected officials. It was a fantastic event, and I was proud to be a part of it.

Sitting at the Benchmarks NC table, I got a chance to speak with Rep. Floyd McKissick of Durham, and District Attorney James Woodall of Orange County, about concerns over treating juvenile offenders as adults and what could be done to address this issue.  Having participated in a recent task force themselves, they were fully on board.  In fact, I realized later, everyone present was on board. Of course, there are always disagreements within the mental health community about where dollars should or should not be allocated…Dorothea Dix Hospital, for instance. But generally, we were of one mind, and our thoughts were on protecting human services in the coming budget process.

Leaving the meeting, I had a conversation with Orange County Commissioner, Bernadette Pelissier, with whom I am on the Board of the Orange-Person-Chatham Local Management Entity. She is rotating off the OPC Board, due to other commitments, and while that’s disappointing, she pointed out that she is not the Orange County Commissioner that OPC needs to convince–she is already on board. Just like the people at the Legislative Breakfast–even the legislators, all Democrats, all re-elected, all in the minority–they have our vote. And they’re not in power.

It got me thinking about Chatham County’s recently elected County Commissioner, Brian Bock, a conservative Republican who was elected in November. He has been appointed to our mental health board as Chatham’s Commissioner representative, but he didn’t attend the most recent meeting, or the legislative breakfast, and he hasn’t returned phone calls from the LME Director.

So, even though the NC Association of County Commissioners has mental health as one of its top 5 legislative priorities for this year, I’m guessing Commissioner Bock is probably not on board.

And my angle is that this is a golden opportunity to have a conversation with someone who is not sitting in the choir pit, as it were.  Because as sad as I am that Commissioner Pelissier won’t be on the OPC Board anymore, she isn’t–and never has been–the person we needed to win over, and what’s more, she couldn’t give us access to the community of citizens who don’t see mental health services or substance abuse services or services to persons with developmental disabilities (much of which is paid for through tax dollars) as a priority.

And, so, as we prepare for what is bound to be a very difficult budget cycle–and not to take anything away from the aforementioned legislative event–my angle is that two people who genuinely disagree with each other having a one-on-one breakfast may be more critical than a 300-person rally where everyone is of the same mind.

January 7, 2011

Mental Health Reform is dead. Long live Mental Health Reform!

by Richard Edwards

Today, at a press conference, NC DHHS Secretary Lanier Cansler stated that the era of mental health reform was over. You can read about it here, here and here.  That’s a bold statement, to say the least, bordering on hyperbole, but I suppose it depends upon how you define reform and set the boundaries for the era itself.

Strictly speaking, mental health reform ended when Local Management Entities, previously community mental health centers, divested their mental health, intellectual and developmental disability and substance abuse services in an effort to increase efficiencies by privatizing the system. The vast majority of this transition occurred years ago, from 2004 to 2006 or so. So, yes, that era of mental health reform is over.

Another focus of mental health reform was to bring people living in institutions back into the community–a move that would be supported by the development of community services. This part of reform never happened–there are still many people living in institutions, and there doesn’t seem to be any inclination to support the community-based service capacity necessary to assure a safe transition. So, also, that era of mental health reform is over–in fact, it ended before it ever began.

So, I suppose, the processes that were supposed to bring about system transformation are over, if they ever really began. But the era of mental health reform is emphatically not over.

The establishment of Critical Access Behavioral Health Agencies (Kah-bas), described in the articles and press releases, is a response to the failures of mh reform, but it’s not the end of it. Far from it.

CABHAs are, in many respects, private mental health service providers who provide an array of services to a given population (adults and/or children) in at least one area of the state. Certain services can only be provided by a CABHA-certified agency, including case management and peer support, but also intensive mental health and substance abuse services. Ostensibly, the goal is to create a more professional, more competent provider network. See, when the state ordered the LMEs to divest their services, they didn’t order them (or pay for them) to divest their clinical and medical oversight. Consequently, some providers had it, and some didn’t. There was no requirement to have it, and there was no funding to support it. The CABHA certification requires that level of clinical and medical oversight to be held within the provider agency, and there is a lot of hope–as evidenced by today’s press conference–that oversight will address many of the problems in the system.

And I would agree, it might, but here’s the rub–there is no guarantee as to how many of the some 175 certified CABHA entities will survive the next 6 months. Consider the following:

Each CABHA must have a Medical Director, for which there is no additional funding.

Each CABHA must have a Clinical Director, for which there is no additional funding.

Each CABHA must have a Quality Improvement/Training Director, for which there is no additional funding.

Each CABHA must provide Outpatient Therapy and Psychiatric services, both of which are loss-leaders in the field and are inadequately supported by state rates.

The cost of the three unfunded positions could easily top $300k annually, and even if you take into account that many agencies may have had a Clinical Director or a QI Director, most small agencies were doomed from the start. Out of some 600+ provider agencies, only 175 or so made it through the certification process. Of that 175, it is almost certain that a third to a half will not survive the next year.

You could argue that the 11-12 budget will actually be to blame for that, and that’s not unfounded, but my angle is this…

In trying to assure mental health reform went over smoothly, the state made it too easy for a business to get into the mental health industry, and for the last four years, has been trying to clamp down on this proliferation.  So, call it what you will, but we are still dealing with the effects of mental health reform.

The era of mental health reform may be over, but the vision is still a long way off.