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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?

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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,
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I learned this notion, that processes are not things, from Dominic Barter, in the course of a conference call this past week. 

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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.

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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.

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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

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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?

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