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Mon Dec 17, 2012, 10:51 PM

Wanna see what some mental health providers are thinking right now?

This is a lightly edited (mostly to remove personal identifiers) piece that appeared a few minutes ago on a professional therapists board. I provide it here without additional comment of my own.

I'm very wary of the remarks I am seeing and hearing advocating for better mental health services. If your experience is like mine, you have come to feel that publicly funded mentally ill patients are among the most needy, and the most demanding; poorly compliant with treatment; protected from being required to reimburse clinicians for their failure to arrive at appointments; needing substantial amounts of unpaid collateral contact; at high risk for treatment failure; I could go on. If we provide service to these clients outside a clinic, we can expect to spend a fair amount of time advocating for ourselves to be reimbursed what we are promised, which is less than any private pay patient or any other insured patient, even with Medicare having recently cut all of our pay by nearly 10%. People are implying that if only Nancy Lanza had shepherded her son toward a therapist, all would be well. I have become vociferous in pointing out that we are not as omnipotent as the public and the press would like to believe.

We are quite vulnerable treating high risk patients. I fear that as we sit poised on the edge of the fiscal cliff with demands for reduced entitlements, behavioral health providers will be subjected to a double whammy of increased and unrealistic expectations combined with diminishing resources for ourselves and our most vulnerable clientele.

If you treat a person and that person becomes a killer, you're going to have a rough time ahead of you. You may well be seen as inept, malpracticing, failing to warn, failing to properly dx., failing to provide a proper standard of care. Treating borderlines is sometimes regarded as a dangerous profession. Treating people who feel homicidal can be a nightmare, though I admit that we need to do it.

As a practitioner, I feel ill-equipped to work with violent or potentially violent, anti-social and borderliney clients - as soon as I sense that that is what I am dealing with I am in dread... "What is this person going to do to me? to my family? to my fellow building mates? to my practice? to themselves? to others? to my ability to earn a living? to my free time? How dangerous are they? S**t!" I am frightened of them - how can I help them? I know what they are capable of. Because I do not have any other practitioners working with me, because I have no office staff - I am not inclined to work with dangerous types. Nor do I feel I have been properly trained or prepared to do so despite what most would consider a top notch counselor education program, having 2 licenses and always at least doubling my CEUs each year, participating in 2 local professional organizations and multiple forums.

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Reply Wanna see what some mental health providers are thinking right now? (Original post)
Jackpine Radical Dec 2012 OP
libdem4life Dec 2012 #1
JohnnyLib2 Dec 2012 #2
mzteris Dec 2012 #3
ThoughtCriminal Dec 2012 #4
X_Digger Dec 2012 #6
enlightenment Dec 2012 #11
Skidmore Dec 2012 #27
politicat Dec 2012 #22
coalition_unwilling Dec 2012 #24
Skidmore Dec 2012 #28
easttexaslefty Dec 2012 #32
politicat Dec 2012 #69
Starry Messenger Dec 2012 #35
yardwork Dec 2012 #40
Jamastiene Dec 2012 #41
riderinthestorm Dec 2012 #45
Egalitarian Thug Dec 2012 #53
The empressof all Dec 2012 #57
politicat Dec 2012 #70
duhneece Dec 2012 #63
Comrade_McKenzie Dec 2012 #36
snooper2 Dec 2012 #42
blueamy66 Dec 2012 #49
blueamy66 Dec 2012 #50
99Forever Dec 2012 #54
lapislzi Dec 2012 #56
KT2000 Dec 2012 #5
napoleon_in_rags Dec 2012 #30
ComplimentarySwine Dec 2012 #33
jeff47 Dec 2012 #7
treestar Dec 2012 #8
Raine1967 Dec 2012 #9
Cetacea Dec 2012 #21
RedCappedBandit Dec 2012 #10
socialindependocrat Dec 2012 #12
politicat Dec 2012 #25
socialindependocrat Dec 2012 #43
politicat Dec 2012 #67
socialindependocrat Dec 2012 #71
TwilightGardener Dec 2012 #48
femrap Dec 2012 #13
pacalo Dec 2012 #15
Michigan Alum Dec 2012 #20
pacalo Dec 2012 #26
Fumesucker Dec 2012 #19
pacalo Dec 2012 #14
Michigan Alum Dec 2012 #16
napoleon_in_rags Dec 2012 #31
socialindependocrat Dec 2012 #44
napoleon_in_rags Dec 2012 #64
dkf Dec 2012 #52
The empressof all Dec 2012 #62
napoleon_in_rags Dec 2012 #66
nadinbrzezinski Dec 2012 #17
Lone_Star_Dem Dec 2012 #18
XemaSab Dec 2012 #23
Jackpine Radical Dec 2012 #37
Cetacea Dec 2012 #29
blueamy66 Dec 2012 #51
Cetacea Dec 2012 #68
blueamy66 Dec 2012 #72
Happyhippychick Dec 2012 #34
Jamastiene Dec 2012 #38
Happyhippychick Dec 2012 #46
slackmaster Dec 2012 #39
LineLineReply .
Happyhippychick Dec 2012 #47
Turbineguy Dec 2012 #55
Denninmi Dec 2012 #58
cbdo2007 Dec 2012 #59
The empressof all Dec 2012 #60
lpbk2713 Dec 2012 #61
JackRiddler Dec 2012 #65

Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 10:55 PM

1. K & R

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Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 10:59 PM

2. Vivid reality check.


Thanks.

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Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 11:12 PM

3. Selfish jerk...

Maybe he should find another line of work. Say, a bank, since he obviously cares more about money than actually helping people.

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Response to mzteris (Reply #3)

Mon Dec 17, 2012, 11:21 PM

4. -1


This post reminds me of the Alabama state legislator who argued that teachers should accept low pay because it is "A calling".

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Response to mzteris (Reply #3)

Mon Dec 17, 2012, 11:23 PM

6. Please tell me you didn't say that.

Did you actually read the whole thing, or did you just stop when you found a sentence you didn't like?

Guess what- many of them do donate a HELL of a lot of time that goes unpaid. But if they don't have the funds to keep the lights on, how many patients can they serve?

And here I thought I'd seen it all.

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Response to X_Digger (Reply #6)

Mon Dec 17, 2012, 11:48 PM

11. My first thought when I read that reply.

Yes, the beginning of that post sounded as if money were the primary issue - the remainder made it very clear that the issue is an admission that outpatient counseling is not always the answer - for the patient and for the practitioner.

It is unfortunate that some can't read more than a paragraph before firing off a response. Sometimes the point is a bit further down the page.

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Response to X_Digger (Reply #6)

Tue Dec 18, 2012, 04:53 AM

27. Perhaps instead of stopping to

look at reimbursement issues and denying treatment because of money, this would be an opportunity to restore services and train additional care providers. Mental health budgets have been slashed. When the legislators start screaming "big gub'ment" the first thing they cut are services to the most vulnerable. We have yet to hear of one oil company subsidy on the chopping block. Why is this person not out lobbying for expanded training for services in his field? I see the mindset I've heard from dental care providers who are resistant to providing services as part of public health and then complain because people end up with nasty teeth problems because they can't afford the care.

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Response to mzteris (Reply #3)

Tue Dec 18, 2012, 03:50 AM

22. Just burnt out...

I used to be a clinical psychologist in public mental health. Burn out is the brontosaurus in the living room. Here's a snapshot of the trenches. The average public mental health clinician has been in the job for less than five years, and has been licensed for about the same amount of time. They're mostly young and new. 65% leave public service for either private practice or get out of the field entirely. I was lucky -- I had excellent scholarships and fellowships through grad school, but some of my peers self-financed and left grad school with debt they will be paying until they hit Social Security age. Starting salary at the county level (which is the majority of public mental health clinicians) averages less than the average first year public school teacher. (A psychologist, by the way, usually has 7 years of post-secondary education; a K-12 teacher has 5-6.) We don't have a union. In some counties, we're not even employees -- we're contractors, so no benefits. We don't go into psych for the money -- we're there because we want to help others. And it kills us -- we're 3 times more likely to commit suicide than our peers. We're 6 times more likely to be on anxiolytics than the general population.

In my last year before going back into research, 95% of my clients were court-ordered. The few who were there voluntarily were as compliant as their circumstances allowed, but a court order drops compliance by at least half. A therapist can't help a client who doesn't want help, and often clients work against court-ordered therapy. For the court-ordered client, the therapist is the avatar of a power structure where the client is entirely disempowered. The therapist seems to have the power to send a parolee back to prison for a beer or mouthing off, to place zir children in foster care, to force them to abandon anyone we determine to be a "bad influence" -- which in a lot of cases, means most of the client's social network. In most counties, the client is forced to pay for this. In most places, public mental health services are set up to fail comprehensively. I worked in a red county, and believe me, the county board of supervisors wanted us to fail. If we failed, they could stop paying us liberal commie bleeding hearts and just send all that human garbage to rot in prison (and that prison made a lot of the local power structure a lot of money...)

Our clients' median household income was less than half of the local median household income. Poverty makes compliance harder. Pop quiz: go to therapy or go to work -- when skipping either violates parole? Buy court-ordered meds or buy food? Use one's 9th grade literacy skills to write in one's therapy journal or get an extra half-hour of sleep after a triple shift? Pick two: rent, therapy, or kid's root canal? Clients have a lot of dreadful algebra every day. For a lot of my clients, poverty was both the cause and effect of their dx. Public mental health made me a socialist -- fix the social safety net and half of the client load vanishes because half of the client load is situational. If every kid has enough to eat, safe and comfortable housing and an effective school, if every adult has safe shelter, valued, meaningful work and sufficient leisure, depression and anxiety plummet. It's not a panacea, but our deficits in the safety net magnify our problems.

I spent most of my time in the trenches deeply worried about my clients -- I took it home with me every night. If a client was non-compliant and I reported it, my client could have gone to prison (or gone back for parole violation), which ends any hope of effective treatment. Non-compliance can mean anything from skipping appointments to not doing the work to skipping meds to self-medicating. I was supposed to report every beer, even with clients who had no addiction problems. Do I report someone because zie blew a long-bald tire or got a chance to work extra hours so zer kids actually got new shoes, but can't call to reschedule because zer boss doesn't allow personal calls (or maybe doesn't know zie's in therapy -- people still get fired for mental illness, especially in right to work states)? If I didn't report it, that's my license... And possibly a suicide, or domestic violence, or a relapse. Believe me, that stress eats therapists alive.

Without a license, my master's degree won't get me a job at a call center or flipping burgers. But pissing off a client by reporting non-compliance earned one of my colleagues a severe beating. I had my tires slashed (which were bald, but I couldn't afford to replace them.) I was salaried, scheduled for 30 one-on-one appointments a week, plus 10 hours of group, plus 75 welfare calls (6-12 hours), plus on call for 24 hours a week. Yes, 70-80 hour weeks, for which the county paid us $27K a year plus medical and dental (but I couldn't take the time off to actually see my doctor or dentist...) Unlike teachers, we don't even get summers off. The year I left, the county I worked for cut 3 of the 27 positions and the county judges ordered 21% more therapy. Which meant worse service, worse outcomes, more recidivism, which gave the county board of supervisors more incentive to cut the budget.

This country doesn't care about public mental health, either the clients or the therapists. We're first responders -- and the first rule of first response is don't be a casualty. I was terrified I was going to kill myself, or screw up so badly that a client or someone else got hurt. I cried every night for three years. I am in research now so I have the energy and time to fight for better conditions for clients and colleagues. I still have 80 hour work weeks, but half of that time is lobbying on their behalf. It's the only way we'll ever change it. Public mental health is like juggling burning napalm.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 04:33 AM

24. This really deserves an OP of its own. I honestly had very

 

little idea before reading your post (and the OP) about these types of issues but, as soon as I read your post and the OP, the lightbulbs went on and I went "Duh!" to myself.

It is so sad that this country doe not care about public mental health (or about mental health in general). That is yet one more sign that our society is well and truly fucked in the head (npi).

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 04:57 AM

28. I hear you.

Public health is sorely understaffed in its professions. I did the same thing and went from direct care to research for a while because my physical and mental health was being damaged by my job.

If there is ever something to lobby for it is better mental health care services and more trained personnel.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 07:06 AM

32. Yes. This, exactly.

My son is in the same boat as you were. In Texas.

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Response to easttexaslefty (Reply #32)

Tue Dec 18, 2012, 10:01 PM

69. Oh, lawdie.

I've heard about Texas from grad school mates and been there for conferences. That is the stuff of my nightmares.

I did my internship in Phoenix, then moved to Colorado Springs. Those were some circle of hell, but oi...

Best wishes to him, and thank him from me for his time in the trenches.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 08:43 AM

35. This tallies with everything I've heard.

Thank you for taking the time with your detailed response.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 10:34 AM

40. Thank you for posting this.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 10:35 AM

41. This really does deserve an OP of its own.

Even if you don't have time to respond, it needs to be more visible. If you decide to do it, I'll certainly K&R it.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 10:58 AM

45. +100000000. I really hope you make this its own OP.

My sister's the director of a large county mental health department in CA. I've heard all of this and more from her. Well done for laying it out for people on DU.



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Response to politicat (Reply #22)

Tue Dec 18, 2012, 12:08 PM

53. Another request for an OP with a link to this one, please. People have no idea.

 

Maybe a few will care if they learn.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 12:53 PM

57. I spent twenty five years in those trenches

I pretty much held every position in community mental health from day treatment, residential, case management up to Directing Programs. I left shortly after I saw one of my staff get spit upon. She was a gentle woman in her fifties who was doing nothing more than encouraging this man to put on shoes. The day prior, we had tried to have him detained on a 48 hour hold as he would publically masturbate, urinate in corners of our building, and would verbally threaten others. He was released within 8 hours as he had the privilege of being assigned to a residential bed so was considered to not be a danger to himself or others. The facility he lived in was paid by the state $38 per day to provide him with round the clock staffing, three meals and a semi private room. Now this was ten years ago...I hope they are getting a bit more for those services today.

Your post hit me to the core...... I still have nightmares and lingering rage as a result of my years of "service". Precious little of it has to do with the clients we served. They were sick, and I know we did the best we could with limited resources.

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Response to The empressof all (Reply #57)

Tue Dec 18, 2012, 10:22 PM

70. On the money, not really.

Our juvenile center is $47 a day, last I saw, and juvenile centers are somewhat better funded (federal requirements for higher staff to patient ratios). Of course, there's insurance -- the Child Health system has helped quite a lot. Which doesn't help the adult system as much as it could, but seriously, VA hospitals aren't the only ones that "Article 99".

Residential drives me to beat my head on walls -- it could be so functional, even with such limited funding, but we've broken it. (Personal history: I'm descended from a long line of Quakers. The ones who stayed in England operated what was then called an asylum in the early 19th century. Looking at their records, they treated a lot of PTSD from the Napoleonic Wars, plus bipolar, severe depression and schizophrenia. Before William James, before Sigmund Freud, they were using methods I envy, and getting decent results given the state of medicine. And they did it on a shoe-string. We're reinventing some of their tools, but not fast enough.) I understand why we have the system we had, and why it failed, and how it failed, but there are days I wish for a TARDIS so I could go kick Reagan. (and ya' know, non-theist Quaker, so that's saying something.)

Thank you for staying as long as you did.

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Response to politicat (Reply #22)

Tue Dec 18, 2012, 04:44 PM

63. Loved "...so I have the energy and time to fight for better conditions for clients and colleagues...

I work very part-time as Administrative Coordinator for our Behavioral Health Local Collaborative and I admire all you do & have done. I didn't come from a Behavioral Health background (I'm 62 & was an accountant in small town), but my son was in prison for drugs, my late ex-husband lost both legs in Vietnam, became addicted to pain pills, committed suicide in 1998, so my whole life has been affected by behavioral health 'issues', including the lack of resources, especially in small communities and especially in the past 5 years.

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Response to mzteris (Reply #3)

Tue Dec 18, 2012, 08:49 AM

36. Self-preservation is very selfish and people should be proud of that...

 

We didn't make it this far as a species by putting ourselves in danger.

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Response to mzteris (Reply #3)

Tue Dec 18, 2012, 10:37 AM

42. maybe a professional Internet message board typey person?

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Response to mzteris (Reply #3)


Response to mzteris (Reply #3)

Tue Dec 18, 2012, 11:41 AM

50. My first thoughts as well.

 

find another line of work ASAP

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Response to mzteris (Reply #3)

Tue Dec 18, 2012, 12:13 PM

54. So you wouldn't...

... have a problem working for free? Very generous of you.

Wow, must be wonderful to not need to eat or pay rent.

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Response to mzteris (Reply #3)

Tue Dec 18, 2012, 12:36 PM

56. Physician, heal thyself.

The mirror can be a scary thing to look in.

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Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 11:22 PM

5. that's what I call an advocate

for his/her bank account. A true professional.
Think I'm going to be sick.

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Response to KT2000 (Reply #5)

Tue Dec 18, 2012, 06:11 AM

30. THANK YOU. Amen to that.

Outrageous. I've been in the field for years, on the font line and I know this type: Sitting behind a desk as a mental health practitioner, terrified when anybody with a real mental illness walks in. The people I admire are those working in the institutions or the outpatient programs on the front lines. I remember one guy I admire, big African American dude, showed me his wrist where one patient had bitten into his flesh and ripped it out, but never had a disrespectful moment for the people going through these intense episodes - he understood it as a disease that twists behavior, nothing more. I've seen cops trained in mental health interventions, walk up and smile and trade a guy a cookie for his knife, while the other cops stood back with guns drawn.

If this guy has fear of mentally ill he has no business in the field.

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Response to KT2000 (Reply #5)

Tue Dec 18, 2012, 07:18 AM

33. I don't want to work for free either

 

For that matter, I don't even really want to work for much less than someone is willing to pay me.

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Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 11:27 PM

7. I'm sorry, where was the requirement that all mental health professionals treat all clients?

If this particular person can't deal with these patients, they shouldn't try to treat them. Their "dread" means they would do a lousy job.

So refer the "bad" patients to someone who is competent, and they can go back to the rich people wanting to discuss what their last dream meant.

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Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 11:28 PM

8. that particular individual seems more worried about himself

And he does not sound like he thinks he is competent to deal with the hard case.

Though had Adam Lanza seen a counselor, he still might have done what he did, and it is true the counselor might be blamed for it. People have trouble seeing the limitations of what professionals of any kind can do.

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Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 11:31 PM

9. I'd like to see the responses.

Are we to assume this is a private board?

I'm just not willing to take this as truth or distruth without a link or seeing how others respond.

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Response to Raine1967 (Reply #9)

Tue Dec 18, 2012, 02:47 AM

21. I'd like to see the responses from their clients

I guess any jerk can become a mental health provider.

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Response to Jackpine Radical (Original post)

Mon Dec 17, 2012, 11:44 PM

10. Pfffffffft

I work with the populations of which he speaks, for pennies compared to what he is making. Sounds like he's more concerned with his bank account and afraid to work with 'scary' people. Highlights the fact that we do need more funding, and we do need to attract more empathetic people into the field.

Also as another poster already mentioned, who has proposed that any therapist be forced to treat populations they're uncomfortable with? Makes no sense.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 12:11 AM

12. I would like to hear from more professionals - what should be done with these patients?

Are the easy to identify?
I would think so if the therapist is scared - he knows what the person is capable of.

What is the treatment?
Meds? and if they don't stay on the meds?

How many are cured to the point of not needing to continue on meds?
Do some outgrow the condition? What success rate?

Do these people just wander around until they do something and are incarcerated?
Do they usually become career criminals?

Is there something we could do that would be a better path forward for these people?

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Response to socialindependocrat (Reply #12)

Tue Dec 18, 2012, 04:34 AM

25. Short answers...

Ease of identifying :

Sometimes. A client who is NOT coming from the legal system is harder to ID as a potential threat because they haven't been caught. Paper trails help. Sometimes they self-report destructive ideation, sometimes not. It really depends if they're in therapy voluntarily. The hardest to ID are those in therapy against their will, but under non-legal pressure to be there. (Family pressure, sometimes job.) Non-voluntary means minimal cooperation.

Treatment plans:
Varies. The courts can order medication; but for anybody else, compliance is voluntary.

Cures:
Depends on Dx and client compliance. Non-voluntary usually means low compliance.

Do they wander until incarcerated?:
They who? The fact that the largest providers of mental health care in the US are the county jails, state prisons and federal prisons should help you answer that question. Just behind the penal system is our patchwork social welfare network, most specifically the parts that serve the homeless.

Better help:
Ensure a minimum standard of living for everyone. That removes about half the client load because poverty coincides with enormous situational despair, anxiety and rage. That frees up therapist hours. Extend emergency intake from 72 hours to 7 days, and pay for it. Re-establish residential mental health facilities, especially for brittle disorders where meds compliance is critical. More research funding for better, safer drugs with fewer side effects. (side effects cause most non-compliance.) Add mental health evals to school physicals for kids between 13 and 18 (without parents in the room -- kids will self-report, but not to parents or with them in the room -- it's the same embarrassment as talking about masturbation, but several magnitudes greater). Make mental health evals free for all adults, and uncouple mental health care from employer based insurance. (People still get fired for using their mental health benefits, though employers hide behind right to work and severability clauses.)

All of the out-patient stuff can be done pretty cheaply. The inpatient stuff we're doing poorly, by outsourcing it to the prison-industrial complex.

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Response to politicat (Reply #25)

Tue Dec 18, 2012, 10:48 AM

43. Thank you - You offer some very good information

My original thought was that there are people who are on the streets and
I could tell who they were when I was 14-16 years old. I'm talking about
kids that are aggressive, drop out, have low intelligence an just get into
trouble all the time. At least we should be able to get some of these people
off the streets before they do something like rob a bank and shoot people
(and especially, shoot people for the thrill of it)

Reorganizing so there is more time for professionals to dedicate to real problems is great.

I used to work at Boston State Hosp. - I found it was closed
I thought - What happened to all the people?
even when the hospital was open you could still walk around Boston and see people
talking to themselves smoking non-filter cigarettes with orange stained fingertips.

Mental health evaluations in schools - great.
They could have specialists to assess potentially problem cases.
Although - if some kids get pulled from school ad it gets around that they failed a psych. eval.
it may be harder to get kids to admit to problems.

Thank you very, very much for your time and effort. The information was very helpful.
I see that professionals in so many fields have such great ideas about improving
our society and finances I can't figure out why congress doesn't listen to the
experts and then try to continuously improve in an evolutionary manner.

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Response to socialindependocrat (Reply #43)

Tue Dec 18, 2012, 08:46 PM

67. So...

I'm taking about kids that are aggressive, drop out, have low intelligence an just get into trouble all the time.


Here's the thing with "aggressive, trouble-making dropouts." By the time they're 15 or 16 and have their reputation, they've usually spent a decade in crappy schools with inexperienced or burnt out teachers who have flattened their ability to invest and care out of self-defense. (Note that I'm talking urban-suburban; rural aggressive, trouble-making dropouts have their own set of issues.) It's not the teachers' fault -- teachers have it no better than we head-shrinkers. Those kids are generally not low-intelligence -- the most effective trouble-makers are often of high-normal intelligence. They ARE ignorant because learning is a skill they've never been taught. They often have underlying heavy metals toxicity (which affects impulsivity and long-term planning ability) from living in sub-standard housing. They often experienced early childhood malnutrition, which also contributes to impulsivity. Why should they care when nobody around them does? (If you haven't read it yet, please read Sudhir Venkatesh's Gang Leader for a Day. JT was brilliant and an example of how we waste young, agile minds.)

These kids live in a truly dysfunctional power structure -- they know that their parents/elders are exploited by a system that takes their labor and gives as little as possible in return, or without even the hope of being exploited. They see no reason to believe they'll have anything different, and few reasons to invest in a system that doesn't invest in them. They can't articulate it, but they know they're being screwed.

When people are powerless, they will assert any power possible. If that means causing trouble, that's the scrap they can take. Causing trouble doesn't HELP, but it's a solace for a little while. They feel better, at least temporarily. Intoxicants and sex follow the same pattern -- intoxication is insulation from the insults the world is hurling; sex is a temporary connection. In a world with little solace, you take what you can get.

The Boston State Hospital example (and most of the state hospitals) are an excellent example of what we shouldn't do -- and the smoking is a strong indicator of exactly what population we screwed over. About 80% of schizophrenics smoke heavily, because nicotine and the MAOIs in tobacco smoke work as neuro-regulators. They're medicating when they smoke. Tobacco is a somewhat better drug than the anti-psychotics in our medicine cabinet -- fewer immediate side effects, easier to obtain. (Cancer and emphysema are not concerns when the voices are loud.) Schizophrenia is brittle -- without meds, a schizophrenic has about a 1 in 10 chance of navigating the world. Out-patient care can work, but only with high-touch, regular and consistent assistance and advocacy. A social worker with a 500 client case load can't provide that.

As far as Congress goes... they're the other end of the power spectrum, and just as much at the mercy of money as my teen-age dropouts. Experts don't make campaign contributions. We've got a broken system in need of far more bribery and far less corruption.

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Response to politicat (Reply #67)

Wed Dec 19, 2012, 01:41 AM

71. So, even if we could better the treatment, all it takes is one a month and we've lost the game.

Meaning - If one person goes on a rampage (and I think we've been seeing this more and more - increased frequency)
and we take care of guns, then they go to knives and then baseball bats and then rocks.

How do we stop the killing?

Again, your information is very eye-opening! All the contributing factors.

This part really struck me:
"These kids live in a truly dysfunctional power structure -- they know that their parents/elders are exploited by a system that takes their labor and gives as little as possible in return, or without even the hope of being exploited. They see no reason to believe they'll have anything different, and few reasons to invest in a system that doesn't invest in them. They can't articulate it, but they know they're being screwed. "

Now, we have the need for jobs and the college graduates who are in debt up to their eyeballs.
The frustration these kids must feel will probably lead to people acting out.
My education cost $5K/year (back then). My nephew just graduated at $38K/year (and no job).

I just retired after 35 years. I am lucky to be retired. Still I know I worked very hard and contributed quite a bit
to a company who's focus was and is to find any reason to keep salaries depressed. We would say that 100 at-a-boys
was equal to one oh-shit. you push all year long and put in 10-12 your days and if you slip up once in the year
you won't make the cut of the top 1 or 2 who will get a descent raise or be recognized for promotion.

Add that frustration to a republican congress who will openly say that they will cut waste in government spending
and then give it to the top 2% who will invest it and take money out of the economy - what can I say.

We really need a congress that works toward bettering the lives of all Americans.

Thanks again for your information - fascinating!!

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Response to politicat (Reply #25)

Tue Dec 18, 2012, 11:29 AM

48. I am a fan of your idea of mental health evals for high school kids.

Had that happened, I might have known my son was suffering from depression years earlier. We screen for lice and scoliosis, why not do a quick mental health assessment (also including questions about abuse at home, substance use, etc.)?

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 12:30 AM

13. I wonder

 

who treated Adam Lanza. And if he could get decent care. So far everyone seems to want to blame the mother....while she seems to be the only one in the family to care for him.

But in the last few weeks, she said she was 'losing him.' Could be schizophrenia....Adam was at the prime age for it to strike him. And if he heard voice telling him to kill, he would.

This happened to my cousin at the same age. But he used his fists.

I guess it's best that Adam's mother is dead. I doubt if she could stand the blame....yet his brother hadn't spoke to him since 2010. And no one knows about dad since the divorce was final in 9/2009....when Adam stopped attending college at the age of 16.

A tragedy beyond words. Heartbreaking for all. Can we address PEACE now? Or are we going to begin WW3 in the ME?

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Response to femrap (Reply #13)

Tue Dec 18, 2012, 12:44 AM

15. I suspect it was schizophrenia, too.

If it was, her overbearing personality as I've read it could have made their situation worse in handling him. I wonder how much pressure she put on him.

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Response to pacalo (Reply #15)

Tue Dec 18, 2012, 02:38 AM

20. There have been no hallucinations or delusions reported. But he might have some of the other criteri

Here is the DSM-IV criteria for it:


A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g., frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition


By most accounts, it has been reported that he had criteria #5.

People with this disorder (who are not properly medicated) usually have some very bizarre behavior, do not care well for themselves. I would say that if he does have it, it would be of the paranoid type - they would have more of the propensity for violence than then the other types of schizophrenia.

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Response to Michigan Alum (Reply #20)

Tue Dec 18, 2012, 04:49 AM

26. If he had heard voices in his head it will likely be made public.

Someone, particularly his father & brother, surely must have been made aware of it if he did.

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Response to femrap (Reply #13)

Tue Dec 18, 2012, 01:23 AM

19. Evidently Adam stopped talking to his father in 2010 from what I read a while ago

He was angry because the father met another woman and married after the divorce.

Allegedly of course.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 12:33 AM

14. Very eye-opening.

This nervous, do-nothing person should choose another profession. I see no interest there in helping those who need it most, no empathy or compassion.

Psychiatrists do send their patients to therapists for certain problems. Shouldn't therapists be trained to handle difficult cases?

Nor do I feel I have been properly trained or prepared to do so despite what most would consider a top notch counselor education program, having 2 licenses and always at least doubling my CEUs each year, participating in 2 local professional organizations and multiple forums.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 12:55 AM

16. Big freaking baby! They should not work in mental health. I say this as a mental health professional

It is part of our job. This is obviously someone who works in a private practice where they do not see anyone but the "worried well." Most of us in social services work with all types of clients.

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Response to Michigan Alum (Reply #16)

Tue Dec 18, 2012, 06:34 AM

31. +100

Exactly, mental health professional here too. I've put my personal safety on the line many times (in terms of getting punched) with intervention techniques and never been let down since I really learned what I was doing. Mental illness is scary to look at when you aren't used to it, but generally the tools of listening, caring, and supporting, in a smart environment, are all it really takes. And when its not, there's CPI restraint techniques... But nothing justifies the terror expressed by the OP when things are done right.

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Response to napoleon_in_rags (Reply #31)

Tue Dec 18, 2012, 10:56 AM

44. Would you please define a "smart" environment. n/t

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Response to socialindependocrat (Reply #44)

Tue Dec 18, 2012, 05:10 PM

64. Access to weapons, drugs, and vulnerable members of society restricted. nt

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Response to napoleon_in_rags (Reply #31)

Tue Dec 18, 2012, 12:00 PM

52. So you think you could have prevented every one of these shooters given the opportunity?

 

What do you perceive as your probability of success?

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Response to napoleon_in_rags (Reply #31)

Tue Dec 18, 2012, 04:27 PM

62. I assume you work in residential or in patient care

The kinds of interventions you describe are just not available to those who work frequently alone in community based mental health. I agree, training goes a very long way but in my state even if we had five staff we would never be legally permitted to do a safe take down of a highly agitated client in the community....

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Response to The empressof all (Reply #62)

Tue Dec 18, 2012, 05:33 PM

66. Sometimes that's a good thing.

The laws against restraints and all that, it prevents abuses of clients. Of course there are other cases where it doesn't make sense. If I saw a client about to walk in front of a truck, or a big fat one trip and fall onto a stroller in the store, I would physically involve myself quick for safety's sake.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 01:06 AM

17. I am not surprised Jack

Thanks though.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 01:16 AM

18. Society is always looking for someone to blame after some a horrific event.

"Where was his doctor? Why weren't they on top of this situation before it came to this? Why did they give them that dose of that drug?" Are common memes after a risky patient does the unthinkable.

I get where this mental health provider is coming from, but I don't know what the solution is.

Edited for clarity.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 04:11 AM

23. Re: the CYA tone here

There was a case a few years ago where a young boy was raped and murdered, and someone my mom knew was like "Oh shit... my client did it." The client had had fantasies about raping and murdering little boys, and the shrink actually saw her client in a news clip at the boy's funeral.

What was she supposed to do? She had doctor/patient confidentiality, so if she called the cops she ran a real risk of losing her license and her livelihood.

The shrink wound up doing a bit of a sleazy runaround, where the cops found independent evidence against the guy so she didn't get dragged into it, but she could have been in really deep shit for ratting out a pedophile and child murderer.

Basically if a client makes a specific threat against a specific target, then the shrink is obligated to warn the target that there may be a problem, but if the client just speaks in generalities, then the shrink can't say anything.

Who would sign up to be put in that position?

Not I.

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Response to XemaSab (Reply #23)

Tue Dec 18, 2012, 10:20 AM

37. You're talking about a strict "Tarasoff" Duty To Warn standard.

Some states use that standard, but others use "Duty to Protect," which may involve telling the cops, not the threatened victim (for example).

In the case you cite, the Tarasoff duty to warn/protect would override confidentiality if you think there's a reasonable chance the guy would do it again. In that case you would have to tell abut your suspicions in order to add proper weight to your warning.

I recall a case in a clinic I supervised where a patient disclosed to his therapist that he had molested children in another state while working with a church youth group. The patient was now working with another church youth group, so the therapist disclosed the information to the church & cops. The patient sued the therapist & clinic for violation of privilege. He lost. I would normally have been named in the suit too, but the therapist, feeling a sense of urgency, had acted without consulting me. I would have advised him to do exactly what he did.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 05:07 AM

29. I wonder what people who treat cancer victims are saying? They are just as violent n/t

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Response to Cetacea (Reply #29)

Tue Dec 18, 2012, 11:45 AM

51. And those burnt out ER docs and nurses.

 

Please don't treat me, my family members or friends.

Thank you.

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Response to blueamy66 (Reply #51)

Tue Dec 18, 2012, 08:55 PM

68. Yes. I have seen what that does to healers and caregivers.

Even joking about the patients becomes an "acceptable" way to relieve the stress of burn-out and patient overload.

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Response to Cetacea (Reply #68)

Wed Dec 19, 2012, 09:22 AM

72. I totally agree.

 

I only noticed 2 crabby nurses during the last 6 day stay....I took down their names and even had a few nice words with one nurse. I was polite but told her what was on my mind.

I realize that they are stressed out, but so is a person who was just told that their loved one is terminal.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 08:33 AM

34. I'm a therapist, here's my take

I do not work with a very unstable population for many reasons, first because I don't do meds and they need to be medicated. Second because I'm not very big and strong so I would have no way to defend myself if they became agitated. Third because of shootings just like this, where they will now try to figure out who to blame, who to sue, who to scapegoat for this terrible tragedy.

I work with homeless women, battered women, divorcing women, and some men as well. I cannot work with a population that intimidates me, that doesn't make me unqualified for my field, it just makes me realistic and smart. Not every surgeon can operate on the brain, not every therapist can work with the criminally insane. That doesn't make me unqualified, it makes me realistic and smart.

I agree with the OP. I make precious little money and spend my days and nights doing my best to help others. I don't complain about it but please don't tell me that I am required to treat anyone who needs it, I am ethically and legally required to train those that I am competent to train. I don't treat war veterans because I am not trained in PTSD and it would be unethical for me to do so. I don't work with kids because I'm not trained in play therapy. I work with the population that I feel competent to work with. Sorry if I'm not superwoman, I'm doing my best just like the rest of you.

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Response to Happyhippychick (Reply #34)

Tue Dec 18, 2012, 10:29 AM

38. Not to mention that those of us who are mentally ill but not dangerous

would prefer not to have to be exposed to violence just to get into our appointments. They need specialists and special accommodations for the violent patients. Reagan turned them all out in the streets and they've had no real help since. The best thing to do for the violent patients would be to undo what Reagan did AND provide every community with the facilities AND specialists who can handle those patients.

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Response to Jamastiene (Reply #38)

Tue Dec 18, 2012, 11:08 AM

46. Yes, that's another thing you said that makes me furious. 99.9999999999999999999% of "mentally ill"

(and I hate that term) are NOT VIOLENT. NOT VIOLENT. NOT DANGEROUS. Why should people who suffer with anxiety and depression and personality disorders be lumped in with the likes of this deranged man?

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 10:31 AM

39. I wish I could give that 100 recs

 

Treating borderlines is sometimes regarded as a dangerous profession.

Try living with one.

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Response to slackmaster (Reply #39)

Tue Dec 18, 2012, 11:09 AM

47. .

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 12:32 PM

55. There was a case in Washington State a number of years ago.

The husband, unemployed (quite possibly unemployable), in anger management counseling beat his 5 year old son to death. Yeah, you go in for counseling, talk to somebody, feel better, then get back into you junker car, hope it starts, go back to your little dumpy apartment with the scared wife, the TV on, the dirty dishes in the sink and the disobedient child.

The nature of mental health is that it's with you the whole time. Not just when you are in the clinic. Republicans don't like funding this stuff. And if they do, they set it up to ensure a failed outcome.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 01:03 PM

58. So, I'd like to interject from the perspective of a patient.

Bipolar II, dx in August, did 3 weeks in a PHP in September. Currently on generic lamictal 300 mgs.

Ok, here's the scoop. I have never had a violent bone in my body. I went through this extremely traumatic experience over the summer that left me feeling that had no future except for the gutter or the locked cell of some facility. The psychiatrist I found through a hospital referral site proved to be a nightmare, left me feeling like some kind of criminal because I admitted suicidal thoughts at times, and "sentenced" me against my will, basically threatened me, into this hospital program. I only asked to be treated on an outpatient basis in a manner that would preserve my dignity and privacy, but was completely ignored with zero consideration for my wishes or personal circumstances. It was the most degrading, dehumanizing, humiliting experience of my life. Even the little things, like being asked if I took a shower regularly to bigger things, like being asked if I wanted to hurt or kill someone. Standard questions but utterly degrading.

Then, I saw and experienced things in there in the psych ward that were rough, seeing patients trapped in this hopeless spiral downward. I vowed then and there I would never be this vulnerable again.

I have done evernything in my power to "fix" this mess. Family relationships are strained, money bs a big problem, lost an entire month of pay and getting enormous bills, job was strained and came back to a mess, no one really filled in for me. So, it was rough.

Despite all this, I am doing well, applying the things I learned in the day program, making a lot of positive life changes, actually picking up the pieces well. Starting to think, hey, things will be ok.

So, Friday, some sick kid 800 miles away slaughters a bunch of innocents. And all Hell breaks loose on DU. I get told I should be registered on some law enforcement database, or locked away, or put out of my home, etc.

For what? What exactly is my crime? Bad genes and a very bad childhood of extreme emotional abuse that left me with poor coping skills don't exactly justify "lock him up and throw away the key" IMHO.

Now, it seems like even some mental health professionals are willing to throw at least some patients under the bus. Yes, probably severely disturbed, violent ones first. But what if it gets down to my level, someone who has never been in any kind of trouble and who just wants to live a peaceful, happy life? Do I deserve to be treated like a criminal just because I'm bipolar?

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Response to Denninmi (Reply #58)

Tue Dec 18, 2012, 01:45 PM

59. Don't take it personally. "Mental illness" is just another ridiculous fall back excuse

when these things happen and they don't know what else to blame it on.

I'm in the behavioral health industry and know that most people aren't violent, even remotely violent. Mental illness doesn't cause someone to commit murder, though many people who commit murder do have mental illness.

Thank you for sharing your experience and hang in there

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Response to Denninmi (Reply #58)

Tue Dec 18, 2012, 04:20 PM

60. I think the vast majority of mental health professionals would agree with you 100%

The system that is suppose to help does frequently traumatize even further. What people fail to realize here with this case is -that public mental health care as it exists now and even perhaps in a perfect world may not have prevented this very disturbed individual from committing these acts.

If all the money in the world were thrown at "treating" this guy we just have no way of preventing these acts of violence from people. Hind site is always 20 - 20. Perhaps intensive residential care may have helped but would he have agreed?

We clearly need to address problems with our mental health system in this country...but the reality is that most people who commit violence aren't suffering from a diagnosed mental illness.

I am so sad to hear about your recent foray with the exacerbation of your brain condition. (I prefer that term btw to mental illness) I am however happy to hear you are getting relief from the medication. That is a good thing. In some ways you are very lucky in that Bi Polar conditions are most frequently easiest of the psychiatric disorders to relieve with medication and psycho-educational treatment. Sending healing light to you .....

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 04:23 PM

61. Interesting how they use the RW buzz word "entitlements"




Interesting but not so surprising.

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Response to Jackpine Radical (Original post)

Tue Dec 18, 2012, 05:29 PM

65. Thanks, fellow JR, and never mind the kneebiting.

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