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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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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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.

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

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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.

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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?

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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/

Even New Mexico Identifies PCG Audits as “Unreliable!” http://medicaidlawnc.wordpress.com/2013/07/15/even-new-mexico-identifies-pcg-audits-as-unreliable/

Big names in health care audit released http://www.abqjournal.com/214653/news/big-names-in-health-care-audit-released.html

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