Bipolar 2 From Inside and Out

Posts tagged ‘mental illness’

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.

 

Young Children and Involuntary Commitment

Involuntary commitment. In California, it’s a 5150. In Massachusetts, it’s a Section 12. In Florida, it’s the Baker Act. But right now, we’re talking about Florida. Whatever the Baker Act was meant to do, it wasn’t meant to do it to six-year-olds. Yet in Florida, a six-year-old girl was involuntarily committed for two days of psychiatric evaluation after a temper tantrum at school. The child has attention deficit hyperactivity disorder and a mood disorder.

According to CBS News, a sheriff filed a report, and a social worker stated the girl was a “threat to herself and others,” “destroying school property” and “attacking staff.” Duval County Public Schools told CBS that “‘the decision to admit a student under the Baker Act is made by a third-party licensed mental health care professional'” and that the response was “‘compliant both with law and the best interest of this student and all other students at the school.’”

Florida’s Baker Act was established around 50 years ago and allows authorities to “force such an evaluation on anyone considered to be a danger to themselves or others.” Danger to self or others has long been the standard for involuntary commitment, but until recently, it has seldom been used on young children, especially without immediately notifying their parents.

“The number of children involuntarily transported to a mental health center in Florida has more than doubled in the last 15 years, to about 36,000,” according to a 2019 report by the Baker Act Reporting Center. In another such incident, a “12-year-old boy with autism was taken to a facility in a police cruiser. It was the boy’s first day in middle school and during a meltdown, he scratched himself and then made a suicidal reference,” according to CBS. The boy’s mother says that the school had a plan to follow if the boy made threats, but the plan was ignored.

It’s certainly true that six-year-olds have threatened suicide and some, unfortunately, have completed the act. And 12-year-old boys definitely have the potential to harm themselves and others. But for schools – with the help of law enforcement personnel and mental health professionals – to “Baker Act” children is an extreme interpretation of the law. “The law specifies that minors can only be held for 12 hours before [a mental health] examination is initiated. For minors, notification must be provided as soon as the child arrives at the facility,” according to the Family Center for Recovery. The law does not say that parents must be notified when the child is taken away from the school.

The Family Center adds, “The statute specifically calls for ‘substantial’ evidence, which is [a] much higher bar than simple suspicion. As a result, people cannot be involuntarily institutionalized simply because they’re acting strangely, refuse to seek psychiatric examinations, or have occasional mood swings or outbursts.”

Need I point out that all children, not just special needs children, experience occasional mood swings or outbursts? School personnel are supposed to be trained to handle these situations.

But “zero tolerance” policies for “acting out” and threatening school property have led to such excesses and others, such as the use of in-school restraints and seclusion. Restraints and seclusion are now being called into question, especially since they have been used capriciously and brutally, especially on children with special needs. IEP plans that specify procedures to follow if a child has a meltdown, as with the 12-year-old, and in schools that supposedly have staff trained to handle special needs children, like the six-year-old, are too often not communicated to staff or simply ignored.

Of course, such treatment is the exception rather than the rule. Some states are beginning to enact laws regarding restraint and seclusion. And many well-trained special needs educators would never countenance such treatment of mentally ill or neurodivergent students. But 36,000 children is a lot. Two-day commitment away from parents is excessive for a six-year-old. Police officers taking children away in cruisers before notifying parents is unconscionable. The law specifies that minors can be held for only 12 hours before [a mental health] examination is initiated. For minors, notification must be provided as soon as the child arrives at the facility.

Florida state lawmaker Jennifer Webb has introduced a bill to reform the Baker Act. It includes training for school officials and resource officers and establishes rules on when a parent should be notified that their child might be committed.

“[The Baker Act] should only be used as a last resort,” she told CBS.

 

What Should Medical Students Learn About Mental Illness?

I recently saw a news story reporting that a single medical school, Des Moines (IA) University, has made it mandatory for medical students to learn how to care for patients with mental illness.

Funny. I would have thought that was already happening in medical schools across the country. Apparently not. Although medical schools teach prospective doctors to diagnose mental illness, the article notes, they do not require students to learn how to care for the mentally ill. When the class started in 2018, it was an elective, but it later became a requirement.

The curriculum includes having people in recovery from mental illness, loved ones of patients, and healthcare providers speak to the class. It is hoped that this will combat the stigma that arises from student doctors only seeing mental patients on locked wards when they are in severe crisis.

Of course, confinement on a locked ward is not typical for people with SMI. Many people with bipolar disorder and even schizophrenia, for example, require inpatient treatment only occasionally, spending the majority of their lives receiving treatment, medication, and therapy as outpatients. One wonders if the stigma surrounding mental patients extends to them as well. Do some GPs tend to ignore physical disorders while focusing on the mental ones? It’s fairly well known that doctors sometimes focus on a person’s weight as being the cause of all their symptoms instead of looking for (or testing for) other conditions. Might there be a similar narrowing of focus regarding mental patients?

Looking at the course, the answer may be yes. Interestingly, the main concern in developing the course seems to be that because doctors were so uncomfortable treating psychiatric patients that they focused on the SMI and never diagnosed and treated conditions such as heart disease, hypertension, and other medical problems. Professor Dr. Lisa Streyfeller cites what she calls “really horrifying statistics that folks with severe mental illnesses die on average 15 to 30 years earlier than people who don’t have those illnesses.”

As important as it is that people with SMI receive treatment for their psychiatric conditions, physicians need to be aware that such people have physical needs and illnesses as well. And as encouraging as it is that mental patients themselves, and their loved ones and caregivers, are included in the curriculum, the article made no mention of teaching prospective doctors how to interact with mental patients they encounter in their practices. If such courses do not exist in medical schools other than DMU, where are doctors going to learn how to talk with and understand the many, many patients they will have who suffer with anxiety, depression, mania, anorexia, and the dozens of other diagnoses?

In some communities, first responders such as police and EMS workers are beginning to have mental health practitioners go on “ride-alongs” to help educate emergency personnel on how to handle situations involving the mentally distressed. Classes like the one at DMU (if others existed) could benefit from having students “ride along,” doing internships or rotations with established doctors who treat the physical as well as the mental symptoms of their patients. Perhaps psychiatric rotations in medical schools could include student practice in community or campus mental health centers instead of just locked wards. Perhaps medical schools could involve students in role-plays involving speaking with and treating the mentally ill, the way they sometimes do for prospective doctors’ encounters with terminal patients.

With NAMI reporting that 1 in 5 U.S. adults – 20% – experience mental illness each year and that
1 in 25 U.S. adults – 4% – experience serious mental illness each year, the odds are overwhelming that future doctors will need to learn how to treat patients both physically and mentally, as well as simply on a human level.

Here’s hoping that the DMU model class idea spreads – and that medical school education on mental health someday will be covered more thoroughly than a single class and a visit to the locked ward.

 

Reference:

DMU Becomes First Medical School to Require Mental Health Course for Students

Beautiful at the Broken Places

The Japanese have an art form or maybe a philosophy called kintsugi, which involves embracing the flawed or imperfect. Cracks or breaks in a pottery or ceramic vessel are repaired using gold dust and resin.

According to Wikipedia, “Japanese aesthetics values marks of wear by the use of an object. This can be seen as a rationale for keeping an object around even after it has broken and as a justification of kintsugi itself, highlighting the cracks and repairs as simply an event in the life of an object rather than allowing its service to end at the time of its damage or breakage.”

On December 29, I posted an essay titled “Broken” (https://wp.me/s4e9Hv-broken). In it, I described the despair and depression that finally hit me after a stressful year, one that ended with the news that my second book was not going to be published. It was an awful trigger for me, considering the amount of work and hope and myself I had already invested in the book, and how near it was to completion.

Instead, I have decided to embrace the philosophy of kintsugi. I may have been broken, but nothing says I can’t put myself back together and consider my mending an improvement. In fact, my therapist said something similar after I suffered an earlier breakdown: essentially, that I could choose what parts of myself I would restore and which I could cast aside. Recently I came across an old diary from that time. I have not yet decided whether to read it, keep it unread, or get rid of it. At any rate, I don’t think I’m strong enough to decide that now, given everything else that’s been going on. But there are other things I have decided to keep.

One of my decisions is to keep my first book, Bipolar Me, alive. It was went out of print this month, but I will be self-publishing it on Amazon. I won’t let the second book, Bipolar Us, die either. Right now I am exploring ways to make sure it will be published as a paperback as well as an ebook. It’s better than my first book, I think, and I want it to be available to people that might find help or hope in it.

To celebrate this decision, I have ordered a kintsugi-style bowl. (I can’t afford the real thing.) On the bottom will be written “My Story Isn’t Over,” which is also the motto that informs my semicolon tattoo. I will keep it near my desk, where I can see it often and let it remind me that beauty can come from the broken after all.

I also hope that the rebuild on our house, which was destroyed by a tornado, will make it more beautiful at the broken places. (The only thing that remained was the basement, so it’s really going to be all new.) At last I will have a home that I have had a hand in designing, choosing materials, and decorating. No more mismatched, hand-me-down furniture. No more rental-neutral walls and carpet. I can create my study as a place of comfort as well as work, one where my self-care items are readily available and the colors and decorations reflect a calm, steady mood. Again, it is a chance to rebuild something and make it better.

Most of all, though, I need to keep working on me. There are still cracks and breaks in my psyche that need to be repaired. It will take continued hard work and loving support rather than gold dust and resin, but I hope I can eventually convert my troubled life into a work of reclaimed art.

 

On Stigma Fighting and Political Advocacy

Lately, I’ve noticed a trend in mental health circles. It’s a question of philosophy on some levels. What should we, as people concerned about mental health, mental illness, and society, be doing with our time and energy?

The two choices boil down to fighting stigma and political advocacy. They each have their motivation and their adherents.

The stigma fighters (including the organization Stigma Fighters) maintain that the way to make things better for the mentally ill is to erase the stigma that surrounds mental illness (particularly serious mental illness, or SMI). And there’s no doubt that there is stigma. The mentally ill are feared and blamed for violence in society. They do not get jobs or lose jobs because of their conditions. They hesitate to enter treatment for fear that friends or family will find out.

While mental illness is no longer the “secret family shame” that led to family members being “put away quietly,” kept locked in the attic, and never mentioned, many families do still find that mental illness – in themselves or their loved ones – is something to hide. Something not to discuss in polite company. Something to ignore the existence of.

People who fight stigma usually do so with information and education. Celebrities – even the British royal family – speak openly about conditions such as bipolar disorder, depression, anxiety, eating disorders, OCD, and other of the more common diagnoses. You undoubtedly have heard the PSAs on television that explain that mental health is important and that seeking treatment is not something to be ashamed of.

Are the stigma fighters making a dent in the stigma? It’s hard to say. At least they seem to have opened a conversation about mental health, mental illness, treatments including medications, mental illness among men, suicide, and other problems we face.

Still, the political advocates say, all that stigma fighting has done nothing to increase the number of psychiatric beds available or the number of psychologists caring for rural populations, the homeless, or people with schizophrenia and other psychoses that are foreign to most people’s experience. What we need are people who will bring up these and other issues with legislators and influencers at the local, state, and national levels; who will present proposals that may do some good in increasing access and funding; and who will advocate for improvements such as training for first responders in how to address mental health concerns.

And it’s true. All these things – and more – are needed. We may debate the wisdom of involuntary commitment or compulsory medication, but they are certainly topics that need to be explored if a consensus is ever to be reached. Most people in the mental health community admit that the system is broken and needs to be fixed – or possibly re-thought from the ground up.

Where do I stand on this debate? I feel that one or the other is not enough. It’s not an either/or situation. It seems to me that unless there is some real progress made in fighting stigma, the voting public and the legislators will not understand the realities of mental illness, the need for change, and what needs to be done to fix the system. Unless we engage in spreading information and changing people’s minds about what being mentally ill means, support for policy changes will be thin on the ground. And unless we come up with some solutions that people understand and support, nothing will change.

Myself, I work mostly in the stigma fighting camp. I don’t have the political acumen, contacts, and energy that real activism takes. I know it is vitally important, but it is not something I can do very much or very well.

What I can do, through my blogs and my books, is help with the information and education, spreading the word about mental health and mental illness, and helping alleviate the stigma that accompanies them. I also intend to start looking for opportunities in my writing to comment on the larger societal issues and proposed solutions and help with education about them as well.

To solve the problems surrounding mental illness, we must all do what we can, and what we do best.

Asking for What You Need

I saw a post on a bipolar Facebook page that asked what coping mechanisms people used. There were the usual responses about self-care, which is certainly a fine coping mechanism. But it’s far from the only one.

I’ve learned any number of coping mechanisms over my years in psychotherapy. There’s “looking at how far I’ve come.” There’s “leaving the room when my anxiety gets too bad.” And there’s always one of my favorites: “petting the cat.”

But the answer I put down was “asking for what I need.”

It’s a good coping mechanism because no one can read minds. No one else knows what I need. And, short of them guessing and hoping to hit on the right thing, the only thing I can really do is ask.

I can ask my therapist whether we can work on my anxiety today. I can ask my friend to check in on me daily for a while. I can ask my husband for a hug, or alone time, or some distraction.

Of course, I don’t always know what it is that I need at any given time. At times like that, I can simply ask for things that might help or have helped in the past, like the aforementioned hug or alone time. My husband has been with me for so long and is so familiar with my bipolar disorder that he knows a number of things that are likely to help, and he can suggest them. If all else fails, he suggests I go to bed, or read, or listen to music, all things which can calm or center me. Sometimes he simply puts on my favorite movie, to help draw me out.

Closely tied to the mechanism of asking for what I need is the technique of negotiation. I may know what I want or need, but the other person may not be capable of providing it, or at least not right then. If a friend can’t take my phone call, I can suggest an alternative: Call me after 10:30 or sometime tomorrow. If I need distraction and my husband has to go to work, he can suggest that we go out to lunch the next day.

We’ve developed a shorthand for such situations. When the only thing I can do is say, “help,” he responds with, “help how?” If I can then come up with a suggestion, I do. A lot of the time he is able to provide what I need. But sometimes he just isn’t. Maybe he isn’t able to get me out of the house for lunch. So instead I say, “I need comfort food.” He usually says, “You can get that.” Or he may respond with what it is that he can do: “There’s cheese and crackers here. Will that do?”

Asking for help isn’t easy, and Lord knows negotiating for what you need isn’t either. Both take lots of practice. And there is always the possibility that another person simply cannot supply what you need. That’s where self-care comes in. I know down deep that a nap, or comfort food, or music may help me, and if no one else can provide them, I can usually do it myself.

Receiving help may not be easy, either. Asking for what you need can make you feel, well, needy. And receiving help from someone else may make you feel guilty or unworthy. But the fact is that you – all of us – need help at times and that learning how to ask for and accept help is a valuable skill. And a totally valid coping mechanism.

Does Immorality Cause Mental Illness?

Aaand…we have a new contender for what causes mental illness.  According to U.S. Attorney General William Barr, it’s a breakdown in Judeo-Christian morality. In fact, he blames a lot of woes on what he calls “secularism”:

Along with the wreckage of the family, we are seeing record levels of depression and mental illness, dispirited young people, soaring suicide rates, increasing numbers of angry and alienated young males, an increase in senseless violence and a deadly drug epidemic.”

Let’s look at that for a minute. Immorality causes wrecked families, depression and mental illness, suicide, violence, and drug epidemics. Lack of religion – or at least the proper Judeo-Christian one – brings on everything but the zombie apocalypse.

Steve Benen, writing for MSNBC, points out the flaws:

For one thing, it’s factually wrong. There are complex factors that contribute to problems such as drug abuse, gun violence, mental illness, and suicide, but to assume these issues would disappear in a more religious society is absurd. There are plenty of Western societies, for example, that are far more secular than the United States, and many of them are in better positions on these same social ills.

http://www.msnbc.com/rachel-maddow-show/ag-barr-blames-moral-upheaval-conspiring-us-secularists

Plus, Barr’s theory would have you believe that in the most religious places in the United States, such ills should not occur. Sadly, we have learned that no community is exempt from these tragedies. And it completely ignores the fact that many mass shooters and bombers cite the Bible as justification for their horrendous crimes.

Ah, but you say, those crimes are attributable to mental illness, which, as Barr tells us, is a product of the breakdown of moral values. It’s a simple equation to him: Immorality leads to mental illness leads to an increase in senseless violence. (As opposed to sensible violence, I suppose.)

And that’s where this slippery slope gets dangerous for those of us who have mental illnesses. Not only are we stigmatized by being blamed for mass violence, we are stigmatized by “ignoring” the cure for our disorders – adherence to the right religious values. (I think it’s fair to assume that Buddhist, Islamic, Baha’i, or Shinto religious values don’t count. In fact, to some religious people, such beliefs are tantamount to mental illness themselves.)

If mental illnesses can be cured by inculcating appropriate religious values, why are we spending so much money on psychologists and psychiatrists, medications, and hospital beds? According to Barr’s theory, that money would be better spent on religious indoctrination, especially for young people. There are many, especially in the halls of power, who agree with him.

You’d think that with the crumbling of the “pray away the gay” philosophy, these people would be hesitant to attempt changing someone’s internal constitution and thought processes simply through the exercise of religion.

Make no mistake, it’s an exercise that is doomed to failure. God does not miraculously grant the right balance of neurotransmitters to the faithful. He does not prevent or cure schizophrenia in those who pray to Him. He does not see to it that tendencies to mental disorders are not handed down through the generations in godly families. Mental illness can strike anyone and does afflict one in four people at some time in their lives. Surely that 25% of people are not all secularists. Just because people with mental disorders are sometimes shunned by faith communities (and that does happen) doesn’t mean that they aren’t religious enough.

Morality is not just for the mentally healthy and mental illness is not just for the immoral. If we let this absurd statement go unchallenged, we are setting ourselves up for more stigma, less funding, less freedom, less choice, and less dignity. If we make sure to oppose this dangerous notion whenever we encounter it, we are doing ourselves, our families and friends, and our nation a service. Educating people about mental illness may begin at home, but it needs to spread to society at large or we will be bombarded by more of these ridiculous, dangerous theories.

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