Bipolar 2 From Inside and Out

Posts tagged ‘anosognosia’

The School Shooter Problem and the Mental Healthcare System

It’s been reported lately that there is a mental health crisis among young people in the US. Depression and anxiety are on the rise. Some claim they know what causes it, and some don’t. The usual suspects include social media, bullying (especially bullying on social media), academic pressure, the COVID-19 pandemic, isolation, and uncertainty about the future. Fear of and reactions to school shootings are in the mix, too. The problem has garnered interest among the people who have the capacity to address, if not actually solve, the problems.

President Joe Biden announced in his 2023 State of the Union address that the Department of Education will divvy up $240 million in grants to help schools tackle the crisis. If you average that by 50 states, it comes to around $50 million per state. A more accurate estimation considers that, since there are 16,800 school districts in the US, that, on average, each district would get roughly $141,000 for youth mental health to be spread around all the schools in each district – not really very much. That money, plus the billion dollars invested last year, is earmarked for more mental health counselors and mental health professionals in the schools.

All that is well and wonderful, but what are the problems that lawmakers want those funds to solve? Apparently, many lawmakers and public policy boffins think that preventing school shooters should be the primary goal. Identifying the kids that are likely to resort to weapons to settle their differences with schoolmates and teachers seems to them to be the most effective use of the funds. The basic debate is whether those funds should be used to identify and treat potential school shooters or help the students who are traumatized by the incidents and by the looming threat of more – prevention of violence versus reaction to the threat itself. In general, Republicans want to address finding and preventing the shooters, while Democrats seem to prefer ministering to those affected by the shootings – and enacting gun control. (I’m not getting into the gun control debate right now.)

Democratic senator Chris Murphy raised the issue in the wake of the school shooting deaths in Uvalde, Texas. “Spare me the bullshit about mental illness,” Murphy said. “We don’t have any more mental illness than any other country in the world. You cannot explain this through a prism of mental illness because we’re not an outlier on mental illness.” Biden also played up the necessity of dealing with the repercussions of the school shootings: “Address the mental health crisis deepening the trauma of gun violence and as a consequence of that violence.”

When it comes to getting shooters into treatment, though, there are problems. Differences in opinion are rampant on whether psychological treatment can prevent school shootings. Partly, it’s a problem of anosognosia. The potential and actual school shooters do not think they have a problem – and the same can be said for many of their parents – so they’re not very likely to make it into the mental healthcare system or gain any benefit from it if they do.

Another reason is that CBT, the currently favored treatment option, really doesn’t have anything that would address the incipient violence of students who are so troubled that they think it would solve their problems of anger, isolation, revenge, desire for fame, bullying, or whatever other factors may be implicated. It’s also worth noting that many, many students are bullied, mocked, ostracized, or otherwise demeaned. The vast majority of them do not go on to become school shooters, or the problem would be worse than it already is. (Personally, I was subject to some extreme bullying in school – and had access to guns and no access to mental healthcare at the time. I never shot anyone or ever thought about it.)

Perhaps the best that can be expected of mental healthcare right now is ministering to the bereaved and the traumatized. Until or unless we come up with some way of more reliably identifying and treating potential shooters before they become actual shooters – something that has yet to be accomplished – we’ll be more adept at cleaning up the aftermath.

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When You Don’t Realize You’re Mentally Ill

You’ve heard the stories: A homeless man who has been diagnosed as schizophrenic panhandles for change, though few people stop because of his bizarre behavior. He refuses help from a governmental or charitable organization. His family finds him, but he won’t let them do anything to help.

Or this one: A bipolar woman has manic psychosis. She is convinced that her coworkers and people on the street are reading her mind and planting thoughts in her head. She refuses to take her medications because she thinks she doesn’t need them.

Or, perhaps worst of all, this one: A teenager who has been struggling with undiagnosed schizophrenia is convinced his mother is trying to kill him. He threatens her with a knife. The police are called and they shoot the boy.

Extreme stories? Yes. But these tragedies occur nearly every day. Most of them don’t make headlines, but they still cause suffering and even death for countless individuals and families across the US and around the world.

What these three people – and many others – are suffering from is “anosognosia.” It literally means “lack of insight,” but anosognosia is much more than that. It means that a person has so little insight that they don’t even realize that they are mentally ill. They don’t know that their behavior and thoughts are part of an illness.

Anosognosia is not the same thing as denial. Denial is when someone avoids something that is unpleasant or distressing to them. They do realize that there is something wrong – they just don’t want to deal with it. A person with anosognosia doesn’t even realize that there is anything wrong at all. They don’t realize they are mentally ill. Their brains don’t let them see that their thoughts and perceptions are not in line with reality. They don’t realize that their functioning is impaired. They think that they are perfectly normal. If anything, they think that the people around them are clueless and deluded.

Anosognosia is the number one reason that people with schizophrenia or bipolar disorder do not seek treatment or take their necessary medications. By some estimates, it occurs in up to 98% of people with schizophrenia and 40% of people with bipolar disorder. It’s also common in people with Alzheimer’s or dementia. People with anosognosia don’t get the help they need. Their condition doesn’t improve – in fact, it worsens.

So, what’s to be done? One solution may be a program that California Governor Gavin Newsom recently signed into law. It establishes CARE Courts – Community Assistance, Recovery, and Empowerment courts that make it easier for family members, first responders, outreach workers, and others to institute civil proceedings that make it possible to obtain up to two years of mental health services. The person being judged by the court will have access to a clinical team, lawyer, and “volunteer supporter.” Up to 12,000 of the most vulnerable people in California are expected to be helped by the CARE courts.

The program is controversial, however. Critics have said that the plan amounts essentially to forced treatment. Civil rights and disability groups are not in favor, though the program has been described as “voluntary.” In theory, a person would still be able to refuse treatment. And if the person has anosognosia, that might well be the case. The CARE courts plan is similar to another potential solution recommended by some clinicians – Assisted Outpatient Treatment (AOT). It’s not clear where the state would find people qualified and willing to monitor patients’ treatment and medication compliance. In Santa Clara County, AOT treatment consists of “intensive individual and group clinical services, peer support, intensive case management, housing assistance, 24/7 clinical crisis support, and medical evaluation.”

One of the most frustrating things about trying to get help for someone with anosognosia is the lack of appropriate treatment facilities, mental health workers, and other services. With many of the sickest patients being held in overcrowded emergency rooms or held for only 72 hours in a hospital ward, the situation is extremely complicated and not easy to solve. But if AOT or CARE courts keep mentally ill people out of jails and prisons, which typically provide either inadequate or no psychiatric treatment, that’s a good thing.

Most people with psychiatric disorders may hear about anosognosia and think, “Oh, that could never happen to me.” But the reality is that a person with anosognosia doesn’t realize when it is happening to them. It’s not an easy problem to solve, but educating people about anosognosia and developing plans for dealing with it are vital. It’s the most vulnerable members of society – and their families and friends – who are most affected by it. They need our help, even if they don’t realize it – or particularly when they don’t realize it.

This post first appeared on The Mighty.

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Systemic Breakdown and Involuntary Commitment

I don’t often review books in this blog, but Lynn Nanos has written one that has caused me to think long and deeply about an important topic, so I felt compelled to share my take on it.

The book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, deals with the involuntary commitment of people who experience schizophrenia, psychosis, some mood disorders, and anosognosia (lack of understanding or awareness of one’s own mental condition). Nanos lays out her thesis logically yet compassionately, with lots of references to back up her opinions.

What Nanos says is that involuntary commitment should be more widely available and easier to accomplish. Her experience as a clinician in Massachusetts involved many instances when she was involved with administering “Section 12” orders for involuntary commitment.

I’ll confess my bias up front. I’ve always been leery of involuntary commitment. As a person with bipolar disorder which was long untreated and un- or misdiagnosed, I have suffered with the fear that I might be committed at some point in my life. I’m a great believer in civil rights and believe that patients should have the right to refuse treatment.

Nanos is changing my mind, at least in the case of psychiatric disorders which prevent victims from knowing their own needs and taking care of themselves. She makes an excellent case that schizophrenic and psychotic patients, especially those with anosognosia, are the most likely of all psychiatric patients to commit violence and be victims of violence. This she refers to as “dying with their rights on,” a powerful phrase.

As it currently works – or doesn’t – forced commitment often leads to a revolving door of hospital emergency department stays, early release from psychiatric units, and the patients who most need help being discriminated against by psych units that turn them away because of their potential for violence and the difficulty in treating them. This results in homelessness, overuse of emergency services, release to relatives ill-equipped to handle a schizophrenic or psychotic person, and other potential dangers.

Nanos thoroughly discusses Assisted Outpatient Treatment (AOT) and other versions of court-ordered therapy and medication. Though these strategies are not without their flaws, Nanos indicates that her experience with them is that they are substantially beneficial and reduce violent behavior significantly.

Breakdown does not imply that there are simple or one-size-fits-all solutions to the serious problems with emergency psychiatry. The part insurance companies and hospitals play in not supplying adequate treatment is not ignored.

Lest one think that this is a dry, academic tome, though, Nanos fills the book with empathetic and sometimes searing stories of people that the system has failed – both patients themselves and the victims of their sometimes violent behavior.

How has Nanos’s book affected my opinions on involuntary commitment and related areas? The criteria she recommends for the procedure are far from superficial: She posits that involuntary commitment should be used only for those who are actively schizophrenic or psychotic and are unable to recognize the nature of their disorder and are unable to care for themselves – especially if they have shown signs of violent behavior or serious threats. (“Unable to care for self” takes the place of the older “danger to self” and includes conditions like homelessness, malnutrition, etc., not just being suicidal.)

Do I now think that involuntary commitment and/or AOT should be easier to accomplish? Yes, with the understanding that easier does not mean easy. We’re still talking about people’s civil rights, and those should not be broached with serious thought and safeguards in place. But my own fears of being involuntarily committed are revealed to have been irrational, a product of my bipolar disorder.

Has the psychiatric “system” broken down to the point where involuntary commitment is a necessary and even a beneficial thing? The answer, sadly, is yes. Lynn Nanos’s Breakdown has convinced me of that.

 

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