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World Dining room table Published Sector

Aug 3,, 2013: Bharat E-book Institution highlights the fresh survey, with 'Global Dining room table Published Sector to help 2017' Often the newsletter affords the sector measurement, growing in addition to prophecies within the world amount for the places:

England, Armenia, Quarterly report, Luxembourg, Azerbaijan, Bangladesh, Tokyo, Bolivia, Bulgaria, Nova scotia, Chile, Cina, Colombia, Czech Republic, Denmark, Ecuador, Egypt, Estonia, Finland, Italy, Ga, Philippines, Ghana, Portugal, Hungary, China, \, Afghanistan, Eire, France, Okazaki , japan, The nike jordan, Kazakhstan, Kyrgyzstan, Latvia, Lebanon, Lithuania, Miscuglio, Malaysia, South america, Moldova, Mongolia, Morocco, Nepal, Holland, Norway, Oman, Pakistan, Happens to be an, Peru, Dubai, Experienced, Vilela, portugal, Qatar, Romania, Senegal, Singapore, Slovakia, Slovenia, South Africa, Sth Korea, Italy, Sri Kemsyn?, Sudan, Sweden, Thailand, Bulgaria, Ukraine, In the country, Us in addition to Vietnam

The industry records comforters the years 2006-2017. The issues responded on this complete newsletter include things like:

Will be world sector measurement to get dining room table published?
Will be dining room table published sector measurement with just about 70 several places?
Are classified as the stores rising as well as restricting?
How are financial matters separated into acquiring solutions?
How are several solution teams getting?
How are financial matters predicted to create sometime soon?

The industry facts comes with the sum sector measurement to get dining room table published in addition to the sector measurement in addition to general trends for any adhering to varieties of solutions:

Dining room table published of artificial fibres
Dining room table published connected with organic cotton
Knitted in addition to crocheted dining room table published
Dining room table published connected with other materials

Often the newsletter is made for corporations who want to attain an all-inclusive view for the world dining room table published sector. That newsletter allows to compare all over several places in addition to solution teams each day come across completely new sector prospects and also considerably more money-making small business options.

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Considerations when you buy bed furniture comforters

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Magnificence in addition to health care having massage purchase a good face

On this really impure in addition to sleepless universe, no person can be un-tampered with by many necessary complications. The commonest these problems are body microbe infections, signs and symptoms, throbbing headache, strain, in addition to stress and others. Although a method to00 these kind of complications is likewise for sale in the form of massage solutions created for wholesome lifetime in addition to wonderful body. Often the invigorating practical experience presenting by means of these kind of treatment method techniques but not only rehabs often the seen scar issues but soothes as their pharmicudical counterpart in addition to rests the muscles. Thus, these kind of solutions are viewed as noteworthy with alleviating many real and intellectual complications.

Massage to get face treatment treatment method
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System rub down

Massage can often be connected to system rub down and quite a few with the massage locations give system rub down with Mississauga to the buyers handling strain as well as a volume of wellbeing diseases. Decrease in addition revealed that rub down is extremely therapeutic for health and fitness in the event used often. Furthermore, it helps the best system wood rapid the epidermis, by means of improving upon it has the level of quality in addition to wellbeing. Pushing blood through often helps as well ready for mummy by means of easing crews in addition to shortening all their lodge at infirmary. Furthermore, it delivers rest from different kinds of problems like minimize, throbbing headache in addition to joint aches. Moreover, furthermore, it works well for improving upon the blood movement in addition to maximizing often the health process.

Massage to get hair-care
Hair-care is likewise likely with different massage treatment method techniques formulated mainly to increase amount in addition to level of quality to help locks. When you are handling fizzy, dried up locks as well as separated stops you may find useful alternative by these kind of complications with massage in addition to without employing almost any unsafe compounds.

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Recovery and re-entry

In many communities, nearly every child has a parent or close relative who has been incarcerated. How can we lessen the impact of this trauma?

There’s no easy way forward. In some institutions it’s almost impossible for security reasons to send a child’s letters, pictures, and art to an incarcerated parent.

And once a parent returns home, new obstacles to rebuilding family relationships emerge.
  • Can childcare centers use parents with criminal records as staff or program volunteers?
  • In your state, can parents help coach baseball if they have a felony conviction?
  • Can you have a school picnic and invite known felons?
  • What is the minimum level of screening and precaution we must support?
  • What safety policies make sense when family reunification is the whole point?
Meanwhile, the returning parent must deal with the mental health effects of incarceration.
  • Thinking has been affected. People lose “executive function,” the ability to make plans or take action when there are no clear guidelines. The only way to get this back is to practice rational thinking: Generate options, then choose. Develop rules to help guide choices. It helps to have someone to help reality-check.
  • Feelings are affected. Shame, fear, depression, anger, trauma. These must be handled and processed, not repressed. People need a support system that helps them regain capacity to be vulnerable and trusting.
  • Relationships are critically important, but need to be rebuilt. This is unavoidable tough work.
  • Information is missing. Time and technology has moved forward while the person has been away.
  • The person must leave the unsafe community, and commit to living in a positive safe world. Prisons and jails are communities. People can miss them, and grieve over relationships and former lives. But they are neither safe nor positive.
What safe, positive places are available and welcoming in your community? What strategies can we recommend for people who return from prison having paid their debt to society?

As a practical matter, I think that the strategy for recovery from prison is exactly the same as the strategy for recovery from any other mental health problem.  People must learn about what they are facing, recruit allies, find resources, plan short term and long term, and follow their plan.

As they develop plans, people should answer four questions:
  • What helps the person make the most of their talents and capacities? 
  • What makes the person less vulnerable? 
  • What helps build capacity to handle stress? 
  • What must the person do to address the risk of something going wrong?

Recovery is a process, not a thing

Let’s get recovery right.
Recovery is a process, not a thing. A process (like learning), not a thing (like a diploma).
Recovery is experienced, like jumping in a pool is experienced, like driving a car is experienced, like washing your face is experienced, like hanging out with friends or praying is experienced. Recovery is the experience of  making decisions, learning from successes and mistakes, asserting control, making progress. Living meaningfully.
In the world of sobriety, recovery is doing what it takes to  avoid that next drink. In the world of mental health, recovery is coming to terms with the world, finding strengths,  figuring out what helps, confronting limitations, handling risks.
If recovery were a thing, clinical systems could be optimized to deliver it. People could buy it, hang it on their wall. Institutions could control it, install it in people, restrict access to it, audit its functioning, tinker with it, put it in a can. These days, we would see it branded, with a social media onslaught and offbeat commercials. 
But no one can deliver recovery.
If recovery were a thing, it might get written up into a technique. But as soon as an experience or process becomes a technique, people start quibbling about whether the technique adequately embodies the process, and about the wording of the instructions that go with it. Technique-users who go through the motions would have the experience of following instructions. Would technique-users find recovery? Maybe sometimes.
Mental health recovery as a concept (note: a concept is a thing) started as a revolution, a liberation movement from institutionalization. Institutionalization steals people’s decision-making capacity. It is inherently coercive. Inmates are controlled. That’s the whole point of living locked down,  observed 24/7, shackled,  restrained, the usual process through the 1960s, 1970s, some places even today.  Recovery showed up as the process of getting power back. The context of institutionalization may offer some historical context, but is now understood to be optional.
A person can experience recovery no matter what the starting point.
Recovery is people achieving success, the way that works for them.
Institutions have trouble understanding recovery because they are optimized to deliver things. Clinical things. Technical processes accumulate around those things. People test for consistency in delivery. Institutions have outcomes, logic models, levels of expertise, formality, rules, committees. People in the process of recovery may or may not have any of that.
An institution that is truly recovery-oriented is more like a hair salon than a hospital. Do we ask hair salons to report on the amount and quality of beauty they delivered in the course of the last month? Hair salons have licensed experts and techniques. They try to deliver positive experiences. Many of the objects and materials in hair salons are sharp or toxic, so there are rules people follow, and procedures that make the visit safe for the customer. Big deal. When customers show up, they follow the rules, and often they get what they want. Not just the haircut, but the experience of it, and even more important, the experience that follows. A compliment, a feeling of confidence, a second date, a job.
During Recovery Month, look for people experiencing the process of recovery. What do you see going on?  It's always a process, never a thing,
I learned this notion, that processes are not things, from Dominic Barter, in the course of a conference call this past week. 

Stand your social distance or I’ll shoot

It’s the subjective element of Stand Your Ground laws that makes them come out racist. Any self-defense case involves a tragedy – but when convictions turn on the killer’s subjective impression of who is threatening, the people who get killed are more likely to belong to racial minorities and other out-groups, including people with disabilities.

Human encounters are affected by social distance, a measure of relatedness, a bundle of concepts ranging from familiar, approved, trustworthy and safe, to strange, different, suspicious and unsafe. People are said to be closest to those they trust and know best, typically those who are most like them. Social distance can be seen today playing out in a benign fashion in restaurants, stadiums and other public spaces. More people gather in same-group clusters than in more diverse clusters, even when everyone in the larger setting abides peacefully and even shares interests, attitudes, educational background and motivation for gathering.

The notion of relative safety connected with one’s own family and tribe, and higher perceived risk when encountering strangers, is an artifact of human evolution built into DNA and human nature.

From our earliest moments, we construct mental models, learning who is safe, who to avoid, and how to obtain what we need. We develop and rely on patterns, lumping similar things (or similar types of people) together. Mental models are working theories of the world, approximations of what we have learned, that incorporate what we see and hear from others as well as what we experience ourselves. Mental models connected to social distance may be useful and accurate, or dead wrong. Fortunately, mental models are subject to revision as we get to know people, and as we  learn and navigate the world.

Social distance becomes embodied in social policies and plays out in individual actions. No one is immune to its effects. In American society we are expected to manage and adjust our mental models so raw prejudice doesn’t cloud our judgment or taint our actions. Each generation tends to do better at this. However, Stand Your Ground laws validate prejudice and social distance, giving everyone a license to kill.

Consider how social distance has affected people with disabilities. Human society has always included people who could not see, walk or hear, and people with limited mobility, intellect or other reduced functioning, yet the concept of disability as a phenomenon that might itself be studied or discussed arrived relatively recently to Western society, in the mid-19th century. People initially spoke of conditions that were “natural” or “normal” and contrasted these with what was considered “monstrous” or “defective.” As scientists cataloged the variations in people’s bodies and capacities, they made judgments about the value of the lives of the people they studied. In the 19th century, as the theory of evolution mixed with the era’s crude racial stereotypes, researchers began to describe both nonwhite races and disabled people as regressions or throwbacks. For example, the physician who first identified Down Syndrome called it Mongolism because he understood it as a biological reversion by Caucasians to the Mongol racial type. This mode of thought, called Social Darwinism, set the stage for the eugenics movement and the Nazi Holocaust, and also played a role in immigration laws that forbade entry both to members of ethnic groups thought to be prone to criminality or deformity and to people with mental or physical defects. The mission of state institutions for people with mental illness and developmental disabilities also changed. Promoted in the 1840s as moral reforms, by the early 20th century the institutions were more frequently described as a means of social control. They kept members of productive society safe and separated ordinary citizens from those now described as sub-normal. People receiving care in these institutions suffered a type of social death.

Even today, disability connects with stigma, an “attribute that is deeply discrediting” and that reduces the bearer “from a whole and usual person to a tainted, discounted one” in the words of sociologist Erving Goffman.  Stigma originates from a process that involves labeling, linking to negative stereotypes, separation of “us” from “them”, and status loss and discrimination that leads to unequal outcomes.

Ultimately, stigma leads to partial or complete disempowerment, and now, even increased risk of death. The rhetoric of the gun lobby is doubly disturbing to disability advocates. We see people encouraged both to fear people with mental illness and "stand their ground" against whoever is perceived as threatening.

The 33 losses of modern psychiatry

What a portrait of modern psychiatry in today’s New York Times. Psychiatrists are abandoning 45-minute therapy practice for 40 brief encounters a day. Mechanized medicine. No therapy, because the system won’t pay. The featured doctor’s wife,  a licensed social worker, gave up her own therapy practice to become the full-time office manager and copay enforcer in her husband’s practice.

Here’s a list of what modern psychiatry has given up, and what a sad thing it has become, as described in the course of the article.

1. No therapy. “Hold it. I’m not your therapist.”
2. No long appointments.
3. Less intimacy
4. Less familiarity
5. Can't know patients by name
6. Lowered goals of treatment. It used to be patients leaving “happy and fulfilled”
7. Less effective treatment. Now he tries to “keep them functional.”
8. Forced disinterest in patients. He “resists helping patients to manage their lives better.”
9. Surrender of natural capacity to care. “I had to train myself not to get too interested in their problems.”
10. Therapeutic traditions abandoned.
11. Loss of practice identity
12. Industrialized practices. “very reminiscent of primary care.”
13. Loss of mystery and intrigue
14. Loss of sense of mastery
15. Hospitals now “discharge them within days with only pills”
16. Psychologists and social workers are now economic competitors.
17. Loss of “quality of treatment” edge compared to other therapists.
18. Discovery that the “craft was no longer economically viable.”
19. Economic coercion “Nobody wants to go backwards, moneywise, in their career.”
20. Loss of competitive edge for psychiatry compared to other medical specialties.
21. Providing less potent care. He dispenses pills but “it’s the relationship that gets people better.”
22. Forced to assume a more mercenary attitude, with add-on fees and charges.
23. Less opportunity to display kindness and sympathy.
24. Less adaptability
25. Living in a culture of scarcity
26. Less access for new patients.
27. Long waiting lists.
28. Interview techniques that do not follow professional training
29. Patients “frequently ignore” advice to seek therapy
30. Forced to disclaim capacity to help people with problems.
31. Recognition that he is delivering poorer care now.
32. Feelings of shame.
33. Fear for son’s future in the family profession.

After all of these losses, what is left of what people used to call the profession of psychiatry?

I was also struck by the disconnection between office-based psychiatry and the front door of the psychiatric hospital. There is no evidence of continuity whatsoever. The hospital is an isolated, separate team. Is there a minute for a phone call if the person shows up at the hospital for help? Is that phone call in anybody’s protocols?

When police become involved with people with mental health problems, they often say they are not trained therapists, but in today's economy are there therapists anywhere? Is the economy for psychologists really so poor that there is better money to be made as an office manager for the family’s designated breadwinner than as a licensed therapist?

Given that psychiatry as we used to know it is a dead thing, a zombie profession, I am more convinced than ever that the traditional power imbalances in treatment are doomed.

Psychiatrics are mechanics now, so patients already have the power. Visit the pill dispenser of your choice. Offer your $50 buck copay, let the provider roll the dice on whether insurance will kick in anything more, see what pills are on offer. If you can get an appointment.

Meanwhile, I suspect the real market for peer specialists is as mentors, unregulated people to talk to for money. Imagine: Be a life coach, charge $50 an hour, hang out, have a relationship. It's the cost of a copay. Try to be ethical in the unregulated economy. It’s better than the $12 an hour, part-time job with a mean boss at the low end of the treatment system food chain. Plus,  since it’s the talk that’s effective, you’ll be doing your client some good, without shame.

The psychiatrists in your neighborhood will envy you.

Is it Kendra’s Law, or better care, that helps people get better?

I recognize there is a place within our society for very limited, highly regulated use of mandated mental health treatment. On the other hand, I have difficulty supporting the rhetoric of involuntary treatment advocacy. Too often, what I hear or read combines a wishful longing for a quick fix with a desire to control “those people.”

The emotional content around involuntary treatment is downright raw. Advocates speak eloquently about tragedies that occur when systems fail to act. But if humanity’s history of abuse of people with mental illness isn’t reason enough for caution, there is no shortage of counter-testimonials about how forced treatment can be horrific, whether it happens within or outside of a hospital.

Fortunately, with sympathy and support within our families and throughout our communities, it's possible to create a mental health environment that virtually eliminates the need to choose between tragedy or torture. Most people come to terms with the mental health situation they are facing, learn what works for them, and do okay, especially when they commit to a recovery process, get the right treatment and have the support of friends and family. Our communities do need complete multilevel treatment and support systems that deliver the right sort of care when needed. If there is too much risk or a person is unsafe, there should be a means of supporting safety, but that can happen at home as well as in institutions. Only a tiny proportion of the population with mental health concerns ever reaches the point where involuntary care becomes an appropriate option. When appropriate, the process around involuntary treatment should be prompt, responsive, flexible, respectful and humane. People involved should still have opportunities to make choices as the process plays out.

I did read with interest last week’s New York Times story about Kendra’s Law, the involuntary outpatient treatment statute in New York. Is the law as effective as the article stated? Today I received a copy of a letter from the New York Association of Psychiatric Rehabilitation Services, commenting on flaws in the research. Here’s the letter I received.
NYAPRS Note: Following is a larger version of a letter submitted to the New York Times following its publishing an article last Tuesday about a new study that suggested that Kendra’s Law mandated mental health treatment order were directly responsible for improved outcomes and reduced costs. While we believe the researchers have once again presented a flawed study that fails to scientifically prove their point, the Times piece has now spread across the country.

Kendra’s Law Study is Bad Science, Poor Example for States

Re: “Program Compelling Outpatient Treatment for Mental Illness Is Working, Study Says” July 30, 2013  http://www.nytimes.com/2013/07/30/us/program-compelling-outpatient-treatment-for-mental-illness-is-working-study-says.html?_r=0

The new study that claims that Kendra's Law mental health treatment orders are responsible for improved outcomes and reduced costs makes unproven and irresponsible claims that have unfortunately been blessed by the Times.

There’s plenty of research to show that people who get more and better services do better. But these researchers continue to produce claims, now and in 2009, that mandated treatment orders by themselves play a key role in improving outcomes, without scientific head to head proof.

In comparing treatment given to those with and without court orders, the study fails to ensure that both groups got the same level of improved care, instead comparing apples to oranges.

For example, Kendra’s Law patients got priority access to a significantly higher level of service than those in the voluntary group.

Further, the sample size and the details provided for the group receiving improved voluntary care is scant, resembling an afterthought.

In contrast, a 1999 Bellevue study that ensured that voluntary and mandated groups got the identical level of services found “no statistically significant differences” on “all major outcomes measures” and concluded that “the package of enhanced services” caused the improvements, not the court orders.

New York’s Medicaid Redesign plan to overhaul our entire and reward better results and decreased costs is a better example for other states to follow, one that is already showing impressive results in voluntarily engaging at risk individuals and providing strong follow up.
Harvey Rosenthal
Member, New York’s Medicaid Redesign Team
Executive Director, New York Association of Psychiatric Rehabilitation Services

The Health Foundation of Greater Cincinnati considers its legacy

I have an engraved paperweight from the Health Foundation of Greater Cincinnati, a small token for connecting Catholic Social Services with this philanthropy. It commemorates a puny little grant of $6000, one of the first times our local bishop let the agency accept money with strings attached.

My little prize is dated 1999, the first year of the Foundation’s Substance Use Disorder and Severe Mental Illness in the Criminal Justice Initiative.  From 1999 through 2008, this $12 million initiative funded ACT teams, jail diversion initiatives, mental health courts, crisis intervention teams and other efforts targeting the intersection of criminal justice and behavioral health disorders. The report that kicked off the project is still available online, and now, five years after the 2008 economic collapse put an end to the initiative, the Foundation has published a document saying what it learned.

This report is an interesting read for me, because I witnessed many of these programs as they rolled out across our region. What the Foundation says it has learned often differs from what I have observed about the various projects. The document reflects the point of view of a powerful institution manned by smart, dedicated, well-meaning professional do-gooders. My perspective is more closely aligned with small agencies, family members and service users.

The report starts by identifying why the intersection of behavioral health and criminal justice is important.
[P]eople with behavioral health issues are overrepresented in the juvenile and adult criminal justice systems. And in many cases, individuals’ behavioral health conditions directly influence their participation in crime. Unfortunately, the criminal justice system is ill-equipped to address the needs of these people effectively. Behavioral health services provided in prisons and jails are limited, and many people would be better and more effectively served by behavioral health diversion and reentry programs in the community.
The Health Foundation funded 99 separate projects to address this situation in a 20-county area including and surrounding Greater Cincinnati, a service area that includes urban, rural and suburban communities in Ohio, Kentucky and Indiana, extending even to a small part of Appalachia. The projects mostly included an extended planning process as a step one grant, and implementation as a step two grant.

The planning process was designed to make sure projects were thought through and sustainable. So-called “relevant stakeholders” were brought to projects at the planning grant stage. Unfortunately, the term “stakeholder” usually meant people with political, economic, or organizational clout – not the “client population.” The Foundation seldom promoted competing methodologies that might have suggested clients had a right to “vote with their feet.”

Relationship-building was a key part of the Foundation’s initiative. The Foundation never simply wrote a check. Its staffers stuck with projects, while grantees attended periodic meetings, submitted data, and generated reports.

From my perspective, the most important outcome of the initiative was the way that this relationship-building forced grantees to collaborate across system boundaries. After years of multi-system collaboration, local do-gooders had a chance to see whether organizational silos made sense. As the report notes:
While grantees did not often cite specific examples of changed policies and practices, the funding appears to have led to new and/or strengthened modes of contact between behavioral health and criminal justice system stakeholders.
In other words, the Foundation helped create examples of meta-systems or aggregated systems that replaced silos, the formalistic single-track systems we are usually stuck with. This is the ultimate take-away for me.

These days, when I see a silo, I see deliberate policy choices, funding choices, and mistakes of history playing out in ways that harm people or keep them from making progress. We choose to perpetuate these silos even thirty, forty, fifty years after deinstitutionalization.

Does anyone still believe that single-purpose systems make sense?

A police force stuck in the cops-and-robbers mindset is merely ignorant, not as safe as it should be.

A jail that ignores the treatment needs of prisoners is grossly deficient.

Substance abuse treatment that ignores depression or trauma is manifestly sub-par.

Shouldn’t every court or probation agency have access to relevant mental health expertise?

Healthcare innovation and the digital madhouse gulag effect

I spent the day hanging out with healthcare innovators, entrepreneurs and investors at the Innov8forhealth Business Expo at the Northern KY University METS Center, a beautiful conference center across the river from Cincinnati. I really enjoy these events. It’s an occasion for me to improve my own work, and an opportunity to compete with other startup ventures for the attention of investors and healthcare system buyers.

As I have written before, healthcare is now a galaxy.  At the center is a black hole where everything that happens is mandatory and payment is by and large measured in bulk on a population-served basis. A little farther out is a ring of fee-for-service places, the Primary Care Zone. Out beyond that is the realm of health educators and “healthy support” people. Think of the nurse that calls from your health insurance company, or the educator that shows up at the senior center. Or folks like me, with books and programs.

The space between these layers is becoming filled in with health data transaction machines, satellites really, that people in the population hook their phones, gadgets and computers up to, so the information infrastructure of the galaxy can check in and measure what the population is doing.  Or they phone back to tell you how you are doing.

Some examples: Phone apps now connect older adults to caregivers. People can know when their elderly relative has forgotten to take her pills, because the app sends an alert to the caregiver’s phone when it’s time to call and complain. (Sorry, I mean “remind the person to do better.”)  Exercise bikes can email out gift cards when a person racks up enough miles. Smartphone sensors can work like always-on stress detectors, heart rate monitors, blood gas measuring devices. Phones can even wake people at just the right time to optimize their dreams.

Within these apps, the experience is being turned into a game. Healthcare is becoming “gamified.”  If I lose a couple pounds, my scale will report in and I will get a coupon for vegetables I probably won’t eat. The coupon will let my grocer know to report in if I bought them.

As all these trends come together, people in a position to access data profiles for employment, justice system, credit, insurance, political and other economic purposes will be able to view each of us as avatars, or data constructs. (We will all check the box on some form that says this is okay.) A job applicant’s “permanent record” might include what he buys at the grocery, the books he has downloaded, the restaurants and clubs where his face has been seen, the people he travels with, how well he sleeps and more.

Over the next few years, the gamified data incursions on personal privacy will be absolutely horrifying to people concerned about personal autonomy and freedom from intrusive monitoring.

I think this has significant implications for mental health. What algorithms will we develop to track personal growth? Will people be permitted a “fresh start” in a data-dominated ultra-competitive economy?  And what will the data profiles of people experiencing trouble of one kind or another look like?

The future madhouse will, I think, be a data-driven invisible economic gulag. People with mental health concerns will be identified easily because their data profiles will reflect their relative poverty and isolation from the main stream. Mechanized online psychological pre-employment testing has already become super-inexpensive. In the past month I learned of two people applying for jobs who were required to take psychological tests. One person was applying for a first job at Pizza Hut. He spent ten or twenty minutes answering a few dozen multiple choice questions. The other was applying for an executive level position at a healthcare system. This executive spent half a day working through a barrage of questions (many of them forbidden to standard personnel departments because they are plainly discriminatory). In the future, the very near future, job seekers will check a box and employers will just look this data up.

One consolation for me on this otherwise data-driven day was the opportunity to have a chat with my own cardiologist about his life in a very busy practice involving several patient offices across the city, as well as hospital work. We talked about the disconnect between the major layers in the healthcare system, about the difficulty doctors face getting to know the people they see every day in their office caseload, plus the logistical challenges of seeing patients when they have a hospital stay.

At some point, healthcare must confront and balance out the human element in the equation. Patient encounters make more sense to people at both ends of the stethoscope when they meet each other face-to-face. We have this primitive capacity and a need to know that what needs to be said has been heard, by a real person,  not just by some robot attached to the other guy’s phone.


Learn more about healthcare innovation in Cincinnati at http://www.innov8forhealth.com.

Building a life despite tough symptoms

Barbara Altman’s memoir of a life affected by mental illness, set in the latter half of the twentieth century in the American Midwest, tells about what many people experience. Trauma is connected with substance abuse and is embedded in family life. Accomplishments also play out in intimate settings: homes, schools, churches and workplaces. Ms. Altman’s book tells the story of a someone who faced challenging mental health issues but still discovered meaning and success, and a life of grace, service and dignity.

Ms. Altman writes about her life from childhood to the middle of her sixth decade. She tells of a difficult home life centered around an alcoholic father. She experienced her father’s harsh temper, and possibly worse. At age 15, Ms. Altman became aware of vague nonspecific memories of sexual trauma when her father admitted to having sexual thoughts about young children.

As Ms. Altman worked through anxiety, psychosis, eating disorders and depression, she discovered her talent for music, and built a career in music education and music therapy. She writes about finding meaning and a place in the world through the support of other people and the consolation of her Christian faith. Overcoming anxiety was a matter of exposure in small increments. She writes about facing challenges deliberately, building up courage bit by bit, at a pace she could tolerate. It took a year for her to learn to swim a complete lap in an indoor pool, but she did it.

I like this book. It describes experiences common to many, recounts personal growth and service to others, and talks about what helps.

Recovering from Depression, Anxiety and Depression: My Journey through Mental Illness, by Barbara Altman is available through Amazon. Learn more about Barbara Altman at .


Sorry, Brian Williams, “disgusting horrific criminal” didn’t make the DSM-5

If every grieving widow has a place in the DSM-5, why not Ariel Castro?

I saw some of Castro’s remarks at his sentencing. He seemed completely disconnected from the standard world. His behavior was out of bounds, abnormal, inexcusable and, to use a word favored by some within mental health advocacy community, he appears to have anosognosia of the criminal type. If madness has a spectrum, Castro has a place within it.

I’m glad to see some awkwardness around labeling Castro. It gives us an opportunity to consider the negative effects of labeling anyone as anything.


The picture below is by Malaika Puffer, from her blog "Sort of just a person"

Even well-intentioned diagnostic labeling can hurt.

Is your mental health expert smarter than a second year college student?

If we took what we know about how mental illness plays out in the world and let some second-year college students work on fixing it, would we end up with something better than what people experience today?

Today’s experience of mental illness, such as it is, developed through accretion. It is a mishmash of good and bad intentions, a clump of attitudes and practices, a basket of  traditions, economic and political factors, plus choices made since time immemorial. We have “cures” that include home remedies, scripts for talking with people, and manufactured pills and potions. We have “lifestyles” that include disempowerment, isolation, poverty, broken families, unemployment, poor health, even death.

What if we told our students to start from scratch, rejigger the whole thing. Redesign it,  using standard design techniques, a reasonable budget and some consensus-based mental health practices. What might this design team come up with?

Here are some of the principles the design team would use.

Unification.  The team would pull elements of the proposed solution from everywhere, not just from one discipline, but many. Whatever the origin, the product would work cohesively, as a unit.

Diversity. Designers are known to be self-referential. Men design for men, women for women, everyone for their own home culture. A diverse team delivers results appropriate for more people.

Accessibility. Users would know how the product functioned. The technology would be evident to the user.

Safety. The designer would understand the human factors involved, making sure the technology is safe for the user.

Simplification. Reducing the number of paths, parts and processes.

Problem solving. Addressing the user’s concerns, delivering something that makes a person’s life better.

Waste reduction. Reduce the burden of the product on the environment and on society at large.

Responsiveness. Deliver what the user demands. Create what the consumer wants, respecting the consumer’s motivations, even when the designer does not agree.

Appropriateness. Don't confuse commercial products with consumer products. Commercial products are money and process-driven, whereas consumer products must address the human needs of product users.

Deep research. Designers must immerse themselves in the user’s world to ensure they are reflecting the user’s desires, not their own.

* * *
Yesterday I watched as these principles played out at the school where I teach, Cincinnati State Technical and Community College. Six industrial design technology students presented their capstone design projects, products ranging from bike racks to assistive devices to squeeze bottles to trash can bags. A group of experienced designers from Procter and Gamble, GE Aircraft and other local companies coached and mentored the students. Over the course of the four-hour event, the advisors highlighted additional opportunities to learn from users. What does the client want? How do you know what the client wants? Was the client satisfied with what you delivered? When something wasn’t safe, how might you fix it?  Would the fix be satisfactory to the client?

Needless to say, this was eye-opening for me. Mental health services are consumer products, after all. Why does no one listen to service users, people the system calls consumers?

This classroom of second-year undergraduate-level design technology students were figuring out how to solve any problem by listening to people, applying some basic prototyping and fabrication, and checking to see if the user’s needs were met.

How many of today's mental health experts can honestly say they do that?

Extraordinary Popular Delusions and Madness in America

One of my favorite books is Extraordinary Popular Delusions and the Madness of Crowds, written in 1841 by Charles Mackay. It’s about the herd behavior of humans: fads and crazes and financial market follies. It covers witch trials, alchemy, superstitions. The book also covers the 17th Century “tulip bubble,” when flowers were currency, more valuable than gold. The lesson in the book is that once the populace gets convinced of something that turns out to be plain wrong or completely irrational, bad things happen. People die at the stake. Awakening to the realization that your tulip bulb investment is as worthless as a sack of onions is no picnic either.

There are signs that the world of mental health is in the midst of this sort of wake-up. The ruthlessness and greed implicit in the pharmaceutical industry’s marketing strategies is undermining the credibility of medication efficacy claims. The authority of the mental health’s secondary prevention model (early detection and treatment) and tertiary prevention model (treatment forever) is being confronted by research that shows better long-term outcomes on a whole-population basis when people do not use as much medication. The DSM is even becoming untethered from neuroscience.

I think the most significant development is that we now realize that people with mood problems, delusions and hallucinations deserve to be heard when they assert that what they experience has meaning. It means that writing people off is abusive and unethical. Someone with a mental health problem is not an irrational sub-human, but a valued person, no matter what he may be experiencing. We are also learning that social support is powerful on its own. It helps people with difficult symptoms stay on course.

As I see it, here is what we are waking up to.

Authority over madness is shifting to people with symptoms and away from experts and keepers. Despite symptoms a person may have, his life remains meaningful and valid. People can tolerate some level of chronic recurring symptoms and live safely, even flourish. People deserve opportunities to figure out what works and what is tolerable, and to choose an option that is presented accurately and supports their wishes. Nearly everyone wants normalcy anyway. Expertise is important, but should be advisory, not directive.  Mental illness, practically speaking, is not that complicated. Ordinary people, friends and relatives and neighbors, are perfectly capable of supporting the people they care for. They are already doing it, in every nation and every culture on earth.

There are certainly some tough cases and more difficult situations, but even these require individualized approaches. We say we do that now, but if we have been applying bad theory, it’s time to face up to that, and reckon with society’s folly.

Our Grand Inquisitor says you can’t have treatment

Are states using targeted auditing to disrupt mental health services?

New Mexico used a recent audit to completely de-fund 15 mental health providers serving the bulk of the state’s publicly funded mental health care. Some 30,000 individuals have had their care interrupted. A number of for-profit and nonprofit providers are closing because they cannot maintain operations while fighting the proposed findings.

Although the state’s actions are authorized by law, they were not mandatory.

There’s no public access to the allegations within the audits. The audit findings are secret.

Similar events are playing out in North Carolina. According to newspaper reports, a 2012 Public Consulting Group audit that cost North Carolina $3.2 million found that North Carolina had overpaid behavioral health providers by $38.5 million, but the state found that less than 10% of the amount in question could be recovered.

Some coverage of this trend:
Administration at odds with state auditor over mental health fraud claims http://www.kob.com/article/stories/s3106244.shtml

Fraud probe update: CMS defends New Mexico's defunding amid questions about audit findings http://www.behavioral.net/article/fraud-probe-update-cms-defends-new-mexicos-defunding-amid-questions-about-audit-findings

NC Medicaid: Are New Mexico and NC Medicaid Providers Fraternal Twins? At Least, When It Comes to PCG! http://medicaidlawnc.wordpress.com/2013/07/18/nc-medicaid-are-new-mexico-and-nc-medicaid-providers-fraternal-twins-at-least-when-it-comes-to-pcg/

Company owner Has to have a Enterprise Worth

Enterprise Worth Businesses certainly are a essential part of every single enterprise business deal. They need to end up being conducted by the reliable Enterprise Worth Organization for a lot of essential causes that is to be reviewed more. The business enterprise Worth Organization utilised also needs to be considered a alternative party to guarantee objectivity in the worth. Furthermore reviewed will probably be common main reasons why a business person need to get a enterprise worth and also things that make a difference benefit.

There are numerous main reasons why a business person has to have a enterprise worth. Virtually any enterprise business deal will be needing any worth advance to be able to rationalize the particular price tag and then for any customer for taking the owner critically. With no one particular, there exists almost no possibility any customer may post a deal around the enterprise. A small business worth furthermore exhibits business people where they stand available in the market and also market. They could check out research worthwhile individuals, talents, disadvantages as well as other elements to further improve the worthiness and also salability of these enterprise. Masters also often make use of enterprise worth businesses to get a worth regarding reduced stress, lover breaks, breakup, real estate organizing and others beneficial causes.

Several business people feel they will really know what their particular enterprise will be worth. They use a straightforward calculations to generate a price. This is always a amazing blunder. There is not any one particular calculations that will correctly decide the true market value. You can find economical, industry and also surroundings elements, levels of competition, chance of progress, range regarding customer base, plenty of benefit individuals, related revenue and lots of data that will influence benefit. Any customer evaluations each of the things that influence benefit to discover their particular comfortableness self-assurance it to be a solid enterprise worthy of a deal.

A couple of tips which can be vital while receiving a enterprise worth are usually secrecy constantly comes first, a 3rd party enterprise worth should be used in fact it is essential to possess knowledgeable manifestation by the reliable Enterprise Dealer similar to a Neumann and also Colleagues. Many business people simply knowledge one particular enterprise business deal inside their term, the absence regarding business deal knowledge can cause amazingly huge blunders. Working together with a small business dealer you can trust for instance a Neumann and also Colleagues will assure secrecy.

Any Neumann and also Colleagues is included in 1000s of enterprise worth thus genuine the true market value will probably be dependant on a professional alternative party enterprise worth businesses. Their particular background as being a reliable organization several satisfied clientele will be supported by enterprise revenue usually marketed faster compared to the regular and then for genuine the true market value together with very good phrases. Business people may be cozy they're not going to depart funds up for grabs as well as the business deal might be a win for everybody.

Any Neumann and also Colleagues provides above twenty-five years regarding Mergers and also Transactions knowledge and also 435.00 office buildings across the country. Their particular determination to be able to secrecy and also superiority has turned these in to a major enterprise dealer organization.

 If you need more comprehensive explanation about business you can go to Home Business.


These days the exact vitality field your place includes establish a high00 level in such a niche. Lots of choices appear in the following niche with the significantly better procedure plus procedures. There are plenty of vitality organisations appear in forex trading nonetheless which in turn fondation is a good available for you it is the most important dilemma. Other sellers can be quite long-lasting for the reason that any fondation plus core can be stimulating per se by using upfront instruments, gives you plus tutorials for more plus people.

Company needs to generate his particular vocation in such a niche he then will go for your adequate college degree lessons understanding that very by using a reputable fondation. It will greatly enhance newcomers in such a niche with a brand new self-belief plus convenience. To be able to establish your job around vitality field you definitely should provide a most of attraction plus quantity for this niche exclusively. There's no spot for a please take a probability with all your vocation website solo negligence might prohibit all your experience and you simply could as well dislike that will damage with all your long run no matter what. There are plenty of craft institutions, vitality colleges plus video organisations are accessible by using professional déclaration plus degrees of severity. Laptop experience can be will have to during this approach because doing so has a resourceful intellect and the majority of your operate is finished around laptop related to vitality. You've got to be a precise attitude with regards to your creative thinking plus thinkings to produce outside an ideal cross. A college degree around vitality will help anyone to raise your experience plus vocation completely to another grade. There are plenty of prime grade vitality colleges provided with most effective tutorials related to the following approach plus supplying you any insignificant element which is certainly very important to many of the individuals. Any surgery, every sixty seconds ordinary element can be quite very important. The superior elegance vitality field will supply the exact working experience making sure that learner might discover more than me. It will make them to add to their whole experience plus ability in such a huge field. It requires fantastic plus pointed ability to find the best grade layouts plus visualisation influences. There are plenty of superb choices easily obtainable in area with vitality if perhaps someone can apply her / his experience within the most convenient way. The perfect college degree plus profound experience makes superb vocation plus glowing long run in such a niche. Naturally we all, realise that furthermore there a variety of SECOND plus ANIMATIONS studio are showed in this place which are usually superb plenty of with their niche along with the industry experts and not just how they makes an increasing number of choices pertaining to vitality tutorials understanding that very with good benchmarks.

Start out your job accurately in such a specialised approach and allow your long run transfer to the perfect avenue. Keep in mind to be able to make the long run in such a niche you definitely should provide a most effective plus adequate willpower to really make it attainable. The following fondation presents the finest experience plus special college degree in addition. Vitality has become the biggest pierce plus most up-to-date machines of your laptop performance this is not only very important to the best earth but it surely can be coming about with fun.

 If you want to know more about 3D animation, you can read more articles at CMetricstudio3D Animation Development Services-Architecture and Interior Design

Knowing the Indicating With Mahometismo

The saying Mahometismo features indicating during the using distinction.

1) Linguistic Indicating:
Primary around Persia terms, it signifies submissions plus giving up towards means to obey with Gud, that means obeying towards injunctions with leader while not opposition ? protest ? resistance. Prior to when the croyance Mahometismo got there as the formalised croyance, the saying utilized pertaining to denoting the meaning while not keeping any sort of speaking setting.

2) Idiomatic Indicating:
Holy Quran includes identified Holy Quran because principles with Mystic Muhammad (P. T. U. H). However Mahometismo appeared to be contemplated the exact concept of the many of the spiritual mail messages, the saying appeared to be precisely picked out pertaining to denoting an individual label. To tell the truth of which Quran developed the saying Mahometismo out of a linguistic indicating towards idiomatic indicating. However now there sits the same implication amongst each of the exact emploi. It signifies you happen to be giving up towards could with Highest Gud and even giving up that will his particular by using least opposition ? protest ? resistance. Consequently , the exact croyance of which Muhammad sent to man appeared to be also known as Mahometismo. That is used in an individual label with the principles which can be preached because of the Closure of your Messengers as well as statement bought experience it several devotional significances in addition. In advance of the following the modern world appeared to be cannot like most of these styles by way of averting all christian setting except for denoting the exact submissions plus means to obey.

Regarding women:
The one who total each testimonies express ““Ashhadu a strong votre ilaha il-lallah buenos aires ashhadu an-an Muhammadan Rasulullah”, so “ I just deal with find that there is virtually no Mycket bra help you save Gud, and I deal with of which Mystic Muhammad(P. T. U. H) is definitely the past messenger with Gud, is regarded as women. Individuals who're made towards Islamic families are likewise contemplated Muslims by way of start.

1) The exact Religion:
This is usually a most important plus primary impact which is certainly depending on the accomplish wise as well as intuitive convection plus realizing. The following college degree plus devotion of religion, as well as Muslims nobody can gain a very high penetration of connection with Gud plus devotion that will his particular guidelines. Dr. murphy is the an individual that is the exact trustworthy. Consequently , a very high college degree in comparison to the submissions currently contemplated an honest impact because of the accomplish devotion to the exact conclusions with Mahometismo that are included with devotions, guidelines, morality, models plus theories. The exact Holy Quran as well separates amongst this pair of examples of impact. Taking care of can be related to as a Islamic as well as many other can be related to as a Mumim, the exact trustworthy. The Mahometismo can simply often be known by way of looking through plus saying the exact Holy Quran by using mouvement. Them tvs a much better penetration of devotion plus religion, also, it is significantly based upon the exact cerebral flexibility of your believer as well as subconscious readiness in addition.

2) Patente:
That is contemplated your inadequate plus formalised submissions. It doesn't evaporate currently have any sort of side effects in addition, as well as being disregarded because fundamental element of handy daily life, it doesn't evaporate govern the exact cultural operations plus things to do. It is actually contemplated your baladí bond that will Mahometismo with which has virtually no root. Any assumption or simply realizing can be quite threatening towards Islamic world. This is the threatening hint of which conveys to related to change plus deterioration in addition, since this is contemplated the standard plus very first step driving which can produce ignorance. If a guy to be able to accomplish the following point with Mahometismo, next now there takes place the exact move amongst his particular ideology plus handy execute, including a superb part can occur amongst anyone plus Mahometismo. Also, it is contemplated your national standard of living.

 If you want to know more about islam, you can read more articles at Cerita Islami

Preventing the next bomb plot

Detecting suicidal thinking can stop bomb plots like Boston’s. Like every one of our recent mass killings, this was suicide with a murderous twist. 

The minimum requirements for suicide are suicidal intent and access to a means of suicide.

If the means of suicide is a weapon, there is a possibility of harming another in the course of the suicide.

If there is also an intent to murder someone, or make a statement, or respond to another person’s influence, then someone or something may likely get attacked as the suicide plays out.

If a group is promoting suicide terrorism, or if there is social shame attached to suicide but cultural approval of suicide martyrdom, then the suicide attack can become a terror strike.

National security expert Adam Lenkford writes:
Homicidal intent often increases the severity of attacks…truly homicidal suicide terrorists are motivated to maximize enemy casualties.

A sponsoring terrorist organization may increase suicidal and homicidal intent, provide access to weapons and enemy targets, and boost social approval of suicide terrorism through its use of propaganda…
Social stigmas surrounding conventional suicide and social approval of suicide terrorism often work together. When a community strongly condemns conventional suicide as a certain path to hell, it virtually disappears as a potential escape route. And when a significant percentage of people believe that suicide terrorism is justified, a new door opens for desperate individuals.  
I believe that ordinary Americans have the best opportunity to detect suicidal thinking among our friends and family members. Saving them saves us.

In 2009, at age 22, Tamerlan Tsarnaev told his uncle he was not concerned about work or studies because God had a plan for him. He was flunking out of accounting school. His boxing career was close to over. He identified himself as a very devout Muslim. In 2013, after his trip abroad, he was effectively silenced within the community of his Boston area mosque for the way he expressed his disruptive radicalism.
When a preacher at the same mosque says slain civil rights leader Martin Luther King Jr. was a great person, Tsarnaev stands up, shouts and calls him a "non-believer," the Islamic Society of Boston said. Tsarnaev accuses the preacher of "contaminating people's mind" and calls him a hypocrite. People in the congregation shout back at Tsarnaev, telling him to "leave now." Leaders of the mosque later tell him he will no longer be welcome if he continues to interrupt sermons. At future prayers, he is quiet.
Tsarnaev had become a shunned, alienated, isolated, radicalized has-been boxer, a “loser” as described by his uncle. And an outlaw. Look at the social boundaries he is willing to violate as he challenges the authority of the preacher at his mosque, demonizing, of all people, Martin Luther King Jr.

Who was the person best placed to take this young man aside, befriend him, and find out what he was facing, what he was contemplating?

What everyone can do to prevent attack-suicides

In most of these situations the only possible intervention is below the level of our formal systems. 

Prevention is the responsibility of family, friends, co-workers and neighbors. Even if reported, emergency responders can't act forcefully if the risk is not immediate and serious. Sometimes the police or a crisis team might be able to make a safety check visit to a person's home.

The best thing anyone can do is to support their friend. This helps prevent feeling isolated and helps build resiliency. You are unlikely to ever know if the steps you take to support a friend have prevented a suicide or interrupted a developing course of violence. You want the person to become more resilient and successful, so that the outcome is positive.

Try to have a brief chat in a public place but out of earshot of other people. Ask the following questions one at a time, in order. Practice the questions out loud. Yes, this is awkward. You can use your own words, but follow the pattern. Listen to the person's answer. People benefit simply by knowing they have been heard.

-- What have you accomplished since the last time we talked?
-- What are you facing?
-- Who are your allies?
-- What is your plan?

As you listen, be on the lookout for suicide risk factors. These include prior violence, substance abuse, a failure of addiction or mental health treatment, difficulty verbally expressing feelings, stress, extreme discouragement or recent shameful loss, no ability to make effective plans, trouble relating to other people's feelings, the onset of schizophrenia or another major mental illness, and lack of sources of support.

If you start to feel worried, offer to connect your friend to a more formal source of help. You may have the single most important opportunity to help your friend. If you detect tunnel vision and a sense of diminishing options, or the person talks about suicide, or expresses a lack of hope, ask the person directly about thoughts of suicide. Suicide is much more likely than violence directed against other people. Ask directly using these words: "Are you thinking about killing yourself?"

If you sense that the person is becoming suicidal, stay with the person. Try to persuade them to seek help from their doctor or visit an emergency room. Offer to help them get in contact with a crisis hotline by calling 1-800-273-8255 or dialing 911.

Effective suicide prevention training is available online through the QPR Institute at www.qprinstitute.com/ and from many community groups.

Previous posts

Teach suicide prevention where people buy guns. http://redesigningmentalillness.blogspot.com/2013/02/teach-suicide-prevention-where-people.html

Dear Vice-President Biden, Here’s What It Takes to Fix Mental Health. http://redesigningmentalillness.blogspot.com/2012/12/dear-vice-president-biden-heres-what-it.html

Mass murder is the new flavor of American suicide. http://redesigningmentalillness.blogspot.com/2012/12/mass-murder-is-new-flavor-of-american.html

Lenkford, A. (2013). The Myth of Martyrdom: What really drives suicide bombers, rampage shooters, and other self-destructive killers. NY: Palgrave Macmillan.

CNN. (2013). Timeline: A look at Tamerlan Tsarnaev’s past. Downloaded April 23, 2013 from http://www.cnn.com/2013/04/21/us/tamerlan-tsarnaev-timeline/index.html

Teach suicide prevention where people buy guns

Suicide prevention training takes an hour or two. Why not offer this training wherever lethal weapons are sold? And in states where concealed/carry is part of the equation, why not add effective suicide prevention to the curriculum?

Firearms are involved in nearly 20,000 suicides every year, in incidents that often put others at risk.

Prevention training, also known as “gatekeeper training” helps people learn what to do when someone is breaking down and becoming unsafe. Question, Persuade and Refer – or QPR training, is available online from the QPR Institute for $30. Firearms instructors can become accredited trainers. Call 1-888-726-7926 for information about how to host and customize QPR training for your organization.

Better yet, call your local community mental health center and ask them to host prevention training at your site.

If you are a community mental health worker, why aren’t you already collaborating with the people closest to potential suicide victims? Most gun ranges have meeting rooms. Find out where they are, and get started.

My book Defying Mental Illness covers suicide prevention too. It includes a simple script to help people talk about safety issues connected with emotions and reactions to the experiences of life.

Suicide prevention is not that complicated. You may be the only person with a chance to save your friend. The ultimate answer in most cases is to talk with people directly about their feelings and intentions. If you become worried, act prudently, control the environment and stay with the person to provide support as you connect with a more formal system. The US national suicide prevention hotline is 1-800-273-8255.
The photo is from http://www.clevelandinsideoutside.com/clevelandgallery.htm

Claiming some violent territory for mental illness

There’s something to be said for the old Soviet way with mental illness. If what you’re thinking is wrong, then mental illness it is and you go to the hospital for some political therapy. If you take some action (commit a crime against the State) based on your incorrect thinking, you are packed off to jail or sent to a prison camp. It’s a brutally functional approach.

As we begin working through the challenge of redesigning mental illness, we should probably start from a place that is somewhat kinder. If we truly believe we are dealing with a health issue, we ought to bring our ethics around “healing the sick” and “human dignity” with us. And so let’s start with a really basic tentative working definition of mental illness.

Let’s propose that mental illness means some phenomenon that’s not benign, and is something that someone with a rudimentary level of training in counseling or psychology or related fields might be expected to identify or try to make better. This definitely includes all the phenomena that licensed professionals in today’s “behavioral health” field are currently expected to handle, like depression, mood swings, hallucinations, anxiety and the like.

The definition also takes us into some violent territory: school shooters, workplace violence, some domestic violence cases. In other words, cases of “expressive violence” (where someone breaks down under external or internal pressure and lashes out), plus cases where people act under delusions or assumed violent identities (reacting to nonexistent threats or assuming the personality of a violent fictional character, historical figure or celebrity). We expect our mental health system to prevent these sorts of incidents, yet they happen again and again.

In the aftermath of these incidents we see missed opportunities to detect, prevent or defuse these attacks. Someone could have, should have done something.

It seems obvious that our society needs a way to actually prevent mass murder. Because we are redesigning mental illness, we get to specify how that might happen, and who might participate.

How much training should it take to recognize one of these incidents as it scales up?

Shouldn’t everyone know a little bit about this?

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