Dedication in the Socialization of Mental Health Care

With the new administration in the White House, many issues and debates have seeped through the porcelain walls of this presidency that have left us biting our nails down to the bloody nubs our fingers have become. But none have kept millions of Americans up at night so much as the repeated attempts to repeal the Affordable Care Act. ObamaCare, which was passed in 2010 and increased reasonable access to health care for lower income individuals and their families stirred baseless fears of socialism, prompting the GOP to act once in power. Stemming from Trump's "America First" campaign promises, what his healthcare proposals have demonstrated is that it's really "rich, white, male, heterosexuals first" and everyone else can fend for themselves. Commitments to help everyday working class citizens have dissipated beneath the avarice of the 1% and the other self-serving Americans who have adopted the every man for himself approach to life. And while we await the unveiling of Trump's dreaded budget tomorrow, we expect that Medicaid and likely Medi-Cal will be affected as well.

Socialized medical care is an approach adopted by numerous countries around the world, and while no system is perfect, no system of healthcare should be based on how much you make, and no one should have to die because they're too poor to pay the hospital bill. In a country where so many things are socialized such as public schools, parks and beaches, libraries and museums, police and fire department protection, it's incredible that we buck and bite at the mere prospect of having to pay for someone's life saving surgery or cancer treatments. I'll pay for children that aren't mine to go to school, I'll pay for the library I never use, I'll pay for the fire department to put out the fire on your house, but I won't pay for you to live a few more years with your loved ones. Makes sense. But in spite of the general population's pettiness, we do have some small saving grace in my lovely sunshine state.

Medi-Cal is a form of government provided healthcare in California. Most people who don't make enough money to qualify for ObamaCare are left with Medi-Cal as a last resort. Provided by everyday tax payers, low income individuals and their families are given access to at least some semblance of healthcare, though it's not always glamorous and at times far below quality. But I am not qualified to speak of the medical component of Medi-Cal; I can only speak to the amazing work we do in community mental health services, and how it compares to the greed of private insurance companies.

I am a mental health therapist and a clinical supervisor for a non-profit, county contracted agency in Los Angeles county. We are funded by Medi-Cal and the Department of Mental Health. We work solely with low income families who either have Medi-Cal or do not have access to health insurance at all; we turn no one away. After completing a full and quite lengthy assessment, we begin services. We see our clients at least once a week but if more sessions are needed due to severity, we will see our clients perhaps two times per week. If even more care is required, the client is referred to a more intensive program where they will receive the adequate care they need. Services are unlimited and we don't stop treatment until therapy goals are met. If our clients cannot come to the office due to transportation issues (many don't have cars or money for the bus, some parents work long hours for meager wages and can't afford to take time off), we will go to them. We provide services in our kids' schools, we go to the client's home, we'll meet them at McDonald's if needed to ensure they get the services they need. We adjust our work schedules and extend our days well past working hours to squeeze in a client who is too severe to go another day without us checking on them. We're always available if they need us. The clients may call in between sessions for information or additional support, and we have a 24 hour call center where clients in crisis can reach a supervisor in the middle of the night if they need to (just please don't call when it's my turn to be on duty, I'm really unpleasant when I don't sleep). 

We provide care outside of therapy. Since our program mainly deals with youth, we often go to the clients' schools to provide support during meetings such as IEPs and 504 plans. We advocate for the client to receive additional resources and services and battle with the schools who don't want to pay the extra cash out of pocket to ensure our clients succeed academically. I've gone with my at-risk youth to probation court dates to provide emotional support while they face the judge. I've gone to family court with my DCFS clients to hear and process the good or bad news about whether they will be returning home to their biological families. We've gotten cauliflower ear living on the phone to consult with social workers, probation officers, school psychologists, teachers, and principals to advocate for our clients' needs and coordinate care with everyone who comes into contact with our kids. Because we genuinely care about these people. And that's just individual therapy.

We also provide psychiatrists and nurse practitioners onsite to conduct psychiatric consultations and provide medications as needed. We have incredible psychiatric nurses who work closely with the doctors and frequently check in with clients, medical doctors, and pharmacies to coordinate mental health with medical care. We have case managers, who provide linkage to resources such as food banks, clothing banks, job training, educational programs, additional healthcare programs such as Planned Parenthood, substance abuse programs, and other financial assistance programs. They help kids and young adults complete their high school diplomas, apply for college, and apply for jobs. They also provide additional behavioral services to supplement the therapy services they already receive with individual rehabilitation. We have a housing department to help families obtain affordable housing so they can move their children out of hotels and get back on their feet. We also have heavy involvement with Head Start programs, which are early education programs for low income families that can't afford preschool. We offer parenting classes and a client-run center that works closely with clients trying to stay sober and developmentally disabled adults; they teach these clients job skills, social skills, and provide a sanctuary to keep themselves out of trouble. Needless to say we work our butts off for these people. But for all their profits and budgets, can big private insurance say the same?

Most insurance companies are not designed for high quality out-patient mental healthcare, though the premiums you pay indicate otherwise. When referred to your insurance therapist, you are pre-approved for a set amount of sessions, depending on your reason for referral and the severity of your symptoms. Most patients get 8-10 sessions. If you get a provider who works directly for your insurance, these sessions are typically conducted once a month for approximately 45 minutes. If you get a contracted therapist, you may have weekly sessions, but they will run out much more quickly. Once you complete your authorized amount of therapy sessions, if your therapist determines that you require more care, they have to formally request additional sessions from your insurance provider and await approval. Again, depending on your severity, this may or may not happen. During the course of your treatment, you are required to travel to each session, your therapist will not come to you. You have a very specific amount of time allotted for your issues, and if you require additional time outside of this session, such as going past the session time or calling on the weekend, you will be charged for it. Your therapist will not go to your child's school, will not sit with you at important court dates (unless you subpoena them), and will not advocate for you or your child beyond writing a brief letter of concern, for which you will be charged. It is difficult to develop a sincere, trusting relationship with an individual you may only see once monthly, and truth be told, in some insurance companies, your therapist likely will not remember you very well, as you are one in the 150-200 clients on their caseload. 

Now please don't misunderstand me in assuming that all providers under insurance companies are heartless bastards. I had an insurance contracted therapist as a wee lass. She was amazing and she saved my life, and I'm sure there are many in the field like her; however, based on what I hear nowadays, with this conglomerate of private insurance raking in billions of dollars every year, compared to the minuscule budget we're granted, they can and should be doing a lot more. But then again, they're a business. We're not.

The work we do is not done without sacrifice. We jump through hoops to appease our contract holders and there are mountains of paperwork to complete above and beyond the direct care services we provide to our clients that drives us up the wall. As previously mentioned, our offices at times tend to be noisy fast food restaurants, a dirty bench at an inner city school, or in my own unfortunate experience, a living room where I subtly flicked roaches off my bare legs so to not embarrass my young client in their poor living conditions (but I try to look on the bright side, I wasn't the therapist who got scabies). There's never enough time in the day, there's never enough chocolate in the office or tissues to cry out the stress, and if for once there is enough wine in the fridge when you get home, because you're a therapist, you refuse to drink it because you'll psychoanalyze yourself into an alcohol problem. For the additional care and support, the added stress, long hours, and intense caseloads, we are quite underpaid for our contributions to society, and if rumors are true, the small financial relief we got under Obama's Student Loan Forgiveness Program will soon be dismantled. Ironically, though sometimes we need them, we don't make enough to pay for our own private therapy sessions every week and we make too much to qualify for the same level of care we provide. We're stuck with our own private insurances as well.

The funny thing is that if we wanted to, we could go to work for a private insurance company. The work is supposedly easier: they have far less paperwork, they don't have to worry about the county breathing down their necks, and they start their therapists at anywhere from $20-30,000 more a year (yeah, that freakin' much). But the care won't be there. The connections may not be there. The support we know our clients need won't be there. We do what we do because we know that it works. Because we're not a business. 

Healthcare, in any capacity, should not be a business. It should not be about profits or maximum charges for minimum care. The services provided by John Q. Taxpayer in this socialized hell I've painted for you are what every American deserves and is entitled to. And I will take the stress and the pay cuts, the bald spots and the premature graying (I have hair trauma from this line of work), to continue to provide what I believe in to my clients. And I'm proud that my agency and my staff are doing the same. May is Mental Health Awareness month, but we do this all year long, and I can only hope it doesn't stop here.

The Marijuana Mentality

People have been puffing the magic dragon for decades, but only recently has it been thrust into the spotlight as it gained acceptance as a medicinal treatment in 1996 and a legalized recreational drug in Washington and Colorado in 2014. It has become so commonplace in the world that many police officers don't even find it worth the paperwork to prosecute cheeky teens caught with the grass and the DEA doesn't really bother the dispensaries around the country, even though it is still technically federally illegal. Probation departments are eliminating marijuana from their scores of drug testing and some companies are not even screening their new hires for it anymore. But mental health services are falling behind and slipping back into the dark ages in terms of how we approach marijuana use with our clients. Are we benefiting our clients by demonizing their vices and making a federal case out of their nearly-legal behaviors? Is it hurting them as much as we believe it is? Can we even utilize marijuana to help alleviate their symptoms?

More and more clients are flooding our facilities with regular marijuana use, demanding that secondary diagnosis of substance use/abuse/dependence, along with that lovely 30xMJ coding for our DMH Dual Diagnosis requirements. Once mentioned, eyes roll, heavy sighs fill the air, judgment clouds the room, and the client is cast in the same group as meth-heads and heroin addicts when their use is revealed in supervision. An admission of bong possession automatically elicits referrals to substance abuse programs, unsolicited psychoeducation, and numerous nagging sessions about how the client needs to stop smoking out. In essence, we waste a lot of resources on drug treatment and drug discussions on clients who don't want it and may not need it. Though they smoke are we genuinely and accurately assessing the impact marijuana has on their disorder and whether it contributes to a functional impairment? And in the long run, the constant chiding can damage the therapeutic relationship when the client gets tired of you acting like their mothers.

Let me note now that I have never smoked/ingested marijuana in my life, and I don't plan to, but I appreciate a good glass of wine/beer and the occasional bit of liquor. This is hardly a concern for my doctor, and no one in my life circle has approached me out of fears for my well-being because I enjoy a drink once in awhile after a hard week at work. Like alcohol, many individuals smoke marijuana socially, to relax, to have fun, to unwind after a tough day without any presenting functional impairment. But for some reason, they get twice the judgment. Ironically, they may suffer half the consequences. Naysayers for marijuana screech about the effects on the lungs, the heart, the brain, but the effects of alcohol on the liver and brain and carries with it a significantly higher risk of death. Marijuana does not have definitive research on the long term health effects, but it has been shown that marijuana does not impact lungs the same way that cigarettes does, and there is virtually no risk of overdose. And beyond the scope of recreational purposes, medical marijuana has been soothing the ill for years.

Much research has been done on the effects of THC on various physical ailments, such as reactions to chemotherapy, glaucoma, pain management, Multiple Sclerosis, and seizures, just to name a few. Unfortunately research into the effects of marijuana on mental illnesses is much more limited, likely in part because there are still so many stigmas they're fighting (organizations like NAMI continue to battle marijuana use, citing increased symptomology, the inevitable opening of the drug gateway, and criminal behaviors). Because of this limited research, many articles and agencies discuss the known side effects of marijuana on emotionally healthy individuals while disregarding the effects of marijuana on the mentally ill and the possibility that it may reduce symptoms of significant emotional disorders.

How many times have we heard about our clients' marijuana use as self-medication? "It helps me sleep," "it calms me down when I'm anxious or stressed," "the voices aren't as loud after I smoke." Many mental health professionals have balked at this because of the research they know about the bud. I vividly remember my client telling her psychiatrist the weed helped reduce her voices and calmed her manic episodes, and he vehemently spat back "No, it doesn't! It does not help you!" as if he had recently taken up residence in her chaotic mind and could dictate to her her own feelings. Here's what these doctors actually know: it has been shown over time that mentally healthy people can, at times, suffer from reactions to marijuana which increase anxiety and paranoia. Mentally healthy people may experience hallucinations and delusions when under the influence. Mentally healthy people may show signs of depression when high. All of which is true. But another fact is certain strains of marijuana are depressants (not 'boo-hoo I'm sad' depressants, but 'chemicals that slow the cognitive processes of the brain' depressants). Depressants can be used to calm the sympathetic nervous system, slow the synaptic firings of the axons, reduce the heart rate, and relax tension in the body (all physiological symptoms of anxiety and mania). One small study at Harvard found that marijuana calmed the brains of bipolar individuals considerably. Adversely, there are strains of marijuana that are stimulants, which activate the brain, increase energy, alertness, and motivation, which could in turn assist with symptoms of depression and ADHD. And considering that we give kids with ADHD amphetamines like it's candy, would it hurt to invest in researching a less harmful and more natural drug?

The reality is there are still side effects to marijuana, and while the research is lagging, some studies have definitely found a link to cognitive difficulties in children and young teens who smoke, mainly because their brains are still developing (these effects were not found in young adults who began smoking after the age of 18). But the harsh truth is also what was briefly alluded to before, that our prescription medications are just as if not more dangerous. The synthetic chemicals we pump into each pressure molded tablet have several concerning side effects that can impact our children for years to come (ask the young males who developed breasts after taking Risperdol). With many popular drugs, we still do not know what long term effects will impact a young child's brain and many of these medications were developed for young adults and older adults before they were haphazardly doled out to our youth. So if we're going to scream about dangerous drugs, let's talk about your medicine cabinet. That is, if your rebellious teenager hasn't sold everything in them to the junkies on the street yet.

But if we let our kids have marijuana, can't that lead to other more intense and dangerous drugs? Here's the thing about the gateway myth: if the drugs are being used recreationally, clients have no greater risk of graduating to crack or heroin than you have of becoming an alcoholic because you had a glass of wine watching Game of Thrones last Sunday. The ironic thing is the risk becomes greater when individuals abuse marijuana as a form of a coping skill or self-medication, to numb themselves. So why the hell am I advocating for marijuana in mental illness, you ask? Because prescribed and controlled, it is no longer self-medicating; you are under the care of a physician, which is no more dangerous than taking Zoloft or Adderall as prescribed. And if you teach your clients appropriate coping skills in addition to their new medication and assist them in processing their illness, as we do with therapy and psychotropic treatments, the illness should gradually become manageable as it would any other way. Thus, eliminating the need to bury or numb the suffocating emotions and devastating poisonous thoughts.

So with all this talk of Mary Jane tolerance, what is our role as a mental health provider when our client says they smoke weed? Well, the first step would be to determine if the weed is impacting their mental stability or contributing to their diagnosis (this is hard to do because again, there's no research on it). More importantly, assess for functional impairment, much like you would when you're determining if the client is a social drinker or an alcoholic. If they smoke weed on the weekends but their grades are good or they're going to work on time every day, I'd say the weed's not a big issue at the moment. If they are flunking school because they'd rather stay home and hot box the day away or if they smoke then go drag racing, it's time to grab the drug brochures and write down that 800 number.

In regards to medicinal use, aside from the abundance of studies we still need to wait on, it is crucial to acknowledge that while marijuana may someday be an alternative to prescriptions, many factors need to be considered and reviewed before the client could be advised to keep smoking. The doctor would have to take into consideration the client's diagnosis, mental health history, physical health, and family history. For example, if the client does not have schizophrenia, but there is a strong family history for it, you're not going to want to provide a drug that could trigger their first psychotic break. But with research comes information and precautions: knowing the right type of marijuana strain for which disorder, knowing what the recommended dosage should be, ensuring that the client is getting pure medicinal marijuana and nothing laced or synthetic that they may pick up on the streets, and providing education for safe use and risk reduction.

There are so many unanswered questions, but just because we are unsure of the unknown doesn't mean that we should demonize our clients for doing generally the same thing we do with our drinks, or that we should disregard the potential for a drug that is already helping many people with medical illnesses. As we know, science is a living breathing creature that is always growing and changing. Years ago they said marijuana caused cancer, now they not only use it in cancer treatment, but developing research is showing marijuana can kill certain types of cancer cells. So who knows what we will find in the future. For now, chill. Legalization is coming, and with it will require a whole new approach to drug assessment and treatment, and we should be ready.

The Love Song of the Depressed

Today is World Poetry Day, a day celebrating the penned works of many artists throughout the centuries around the globe, many of whom struggled with their own mental illnesses, emotional disturbances, and deep, personal demons. Much like those who created them, the characters in many of these proses mirror their own existential chaos and provide a fictional window into the minds of our clients and their daily struggles. In The Love Song of J. Alfred Prufrock, by T.S. Eliot, the eternally downtrodden J. Alfred is reflecting back on his somber journey through this world and making a self-appraisal of what he has become today. But in the daily depression and devastation his life had become, Prufrock found comfort in the monotony of it all. In spite of living in misery, it was unvarying, unwavering consistency; though things never got better, they could never get worse. This doesn't mean, however, that he never dared to dream of what could have been. In a moment he asks himself "Do I dare disturb the universe?" Do I dare to break through this carefully arranged mortality of gloom and despair and try to seek out some light, some happiness? Do I dare risk the disappointment and heartache I may find if I am unsuccessful? Do I dare to change my life?

This is a question many of our clients face before they decide to seek mental health services, and some are still grappling with it well into the middle phase of treatment. We typically refer to this as resistance. But the term resistance indicates some underlying tone of opposition or defiance, and can be a very superficial perception of what our clients are truly struggling with. Sometimes it can be frustrating when our "resistant" clients refuse to follow through with our recommendations. Sometimes we want to pull our hair out when they just come to session to vent on a repetitive cycle of grievances rather than to try and work with you to find solutions that can end these daily tribulations. I once had a client who, after two years of treatment with little to no progress, openly admitted that she didn't want help, she did not want to get better, she did not want solutions, she only wanted "someone to complain to." Unfortunately, after verifying once more that she would not willingly work towards her treatment goals and personal betterment, we closed the case and I left her in her dark void.

But this is not often the outcome for clients of county-contracted agencies. In a private practice, if a therapist determines that the individual is not truly ready for treatment, they can recommend that services stop at that time. In fact, it's unethical for a therapist to continue seeing a client and taking their payments knowing that they are not in a frame of mind to benefit from treatment. But in our agencies, we are rarely permitted to close a case simply because they are not ready. We fight and sweat and scream and cry trying to get our clients to that place where they might be ready. And it's rarely an easy task.

Much like our dear Mr. Prufrock, I had a client just last week who is struggling to find her own motivation to disturb her universe. Having been in a depressed state for the better part of 15 years, she was at least insightful enough to recognize that she prefers being on rock bottom. "If I'm at my bottom, there's nowhere to fall. It's steady, it's stable, and I'm okay here. I'm unhappy, but it's safe." She continued "if I get up, if I start climbing that ladder out of my hole, soon I will be above the ground, and then if I slip, I'm going to fall farther down again, and I'm too scared of that. I'd rather just stay here." Another colleague of mine discussed a similar situation with her own client today, finding herself struggling with his refusal to utilize any of the interventions or tools that she provided. And again, this is not outright defiance, this is not him yelling in her face "I don't want your help and I'm not going to use your stupid mind tricks!" This is simply him staring blankly at her with resounding "I don't knows" whenever she asked him questions about how to help himself. They've gone over this multiple times. He knows. He is simply too scared to take the help. You're drowning, but relaxing and sinking to the bottom of the sea is easier than kicking and fighting to keep your head above the surface. Depression is just easier. Not better, but easier.

This is a battle I'm all too familiar with after recovering from a 12 year bout of depression myself. Especially given that I was diagnosed when I was 9 and probably had symptoms much earlier than that, I didn't much recall what it was like to be happy. As I meandered through my teens, as my demons grew larger and my world became darker, it was hard to see any light that may have been shining through that darkness. But this was my life, the only existence I have ever really known, how could I leave it behind? I remember thinking the same thing my client did: at rock bottom, there's nowhere else to fall. When I was 19, after one too many days in Hell, I finally made the choice to disturb my own universe; I finally realized no matter how scary that risk might be, it couldn't have been worse than the fate that awaited me if I stayed in that eternal night. I was 21 by the time I was fully recovered, and even since then I've had a few slips here and there and I've fallen down a few rungs on my own ladder, but one must tighten their grip and climb back up the best they can. As part of the depression game, sometimes the lack of motivation and the hopelessness our clients are enveloped in make it damn near impossible to get them to jump over that abyss and start moving forward in their lives. Sometimes you have to be their tireless cheerleader, sometimes you just have to sit with it, meet them where they're at, and wait until they reach their own awakening, which only they can do alone. Sometimes, they need a little friendly therapeutic push. As I've told my clients, you may fall, but if you try you have a 50% chance at succeeding and finding happiness. If you don't try, you have a 100% chance of failing and feeling this way forever. So let me know when you're finally sick and tired of being sick and tired.

I had been in therapy off and on for a few years in my teens, but with a therapist who never challenged me and me not yet ready to challenge myself, I stayed stuck far longer than I should have or needed to. I will never get that childhood back, but I want to save my clients from the same fate of wasted time. Some clients need that reality check and some clients need a little more empathy and unconditional positive regard to guide them to this final realization. Sometimes we as therapists need to recognize that resistance for what it really is, comfort in familiarity and fear of the unknown; we need to understand it, and we need to address it appropriately. Sometimes I share with my clients this solemn love song and Prufrock's tale of woe. For me, this poem has become my mantra, and I have the famous line tattooed on my shoulder, just in case I need to glance in the mirror and give myself a little reminder to never stay stuck for long, wherever I may find myself. Just because it's comfortable, does not mean it's where I'm meant to be.

Deadly Force & DSM Death Sentences

In the wake of the Black Lives Matter movement, the catalyst of mounting frustrations and rage regarding the excessive force police officers use with black individuals, another targeted population is emerging in the light as well. For decades it has been widely known that blacks are singled out, mistreated, mistrusted, and grossly mishandled whenever police become involved in any given situation. But sometimes the color of your skin is insignificant, even completely forgotten when one crucial factor is introduced into the equation: mental illness. For years mentally disturbed individuals have been killed at the hands of police, some violent, some not so violent, some wielding weapons, some just seeking help. But in a situation that requires, nay, begs for patience and compassion, the police find little time for anything more than pulling a trigger.

On July 6^th in Lakewood California, a man named John Berry was disturbed and required psychiatric intervention. He had previously been diagnosed with Schizophrenia, a condition which had been managed by medication, but his brother, Chris, stated he may have gone off his medication prior to or when he was terminated from his job. With his car parked on the front lawn, appearing disheveled and sleep deprived, Chris recognized his brother needed help. A federal police officer who works with psychiatric facilities, Chris immediately contacted the PET, or the Psychiatric Evaluation Team, in hopes that they would respond, evaluate his brother, and get him the care he desperately needed. However, the emergency response team allegedly reported that the sheriff’s department needed to go first and assess the situation to ensure it was safe for them to come and complete the evaluation.  Bear in mind, John never threatened himself or anyone else in the exchanges he had with others on this day.

The sheriff’s department arrived as John was attempting to leave the house. Chris walked alongside his brother’s car as he slowly rolled down the road, trying to coax him out of the driver’s seat. One officer pulled in front of John’s car and blocked him with his cruiser. Many other officers arrived and within a short time frame of approximately 5 minutes, the situation escalated out of control. With several police officers shouting orders and demands, John looked about bewildered, his hands locked on the steering wheel, petrified of the circus that suddenly enveloped him. He repeatedly asked “what did I do? What’s wrong? What did I do wrong?”

Having no luck in the few moments the officers attempted to verbally draw him from his vehicle, they began beating him with their batons. John was then tasered four times, and one officer leaned in through the passenger’s seat window and pepper-sprayed him. In the confusion of it all, somehow the car was placed in reverse, and shot backwards. Chris, who witnessed the entire incident, maintains he saw his brother with his hands gripping the steering wheel, never moving. He believes that in the struggle where the officer sprayed him, the officer may have bumped the car’s shift into reverse himself, and John’s foot may have struck the gas pedal.

What happens next is contradicted between the parties involved. The sheriff’s department stated that in reversing the vehicle, a police officer standing behind the car was pinned between that vehicle and another police cruiser, crushing his legs. Chris reported that he saw an officer bumped by the car, then fall back on his rear end, before rising quickly to his feet and walking away. Whatever occurred, the officers took this sudden movement as a threat and immediately opened fire, shooting John multiple times through the windshield of his car.

Where to begin with all the things that went wrong in this scenario? First off, I will admit some ignorance when it comes to PET policy; in the times I’ve called out the PET, they have never requested that law enforcement must respond first. Then again, I’ve never called for someone potentially having a psychotic break; most of my clients were suicidal. However, whatever policy may be, I can’t imagine why a clinician could not accompany a law enforcement officer to the scene to ensure safety and continue with the evaluation, or, in this circumstance, provide some much needed guidance to the department in handling mentally ill individuals.

Secondly, where in any handbook of worldly common sense would someone get the idea that screaming at a mentally disturbed individual is going to result in the desired outcome? In the brief training I received working in group homes with mentally ill teenagers, even we were exposed to the most basic approaches of crisis intervention and de-escalation. The rules are simple: speak slowly in a calm voice, give short clear directions, have only one person designated to speak, allowing the speaker to build rapport with that individual and avoiding overwhelming them with multiple people talking at once, and remain a short distance away from the individual so they do not feel threatened. The approach shown by these officers was pretty much the exact opposite of the aforementioned guidelines: initially, Chris had asked officers to allow him to talk to his brother, and calm him, in hopes that he might get him to cooperate, but they refused, ordering Chris to stay back. They surrounded John and multiple officers collectively barked orders at him, causing confusion and panic; they immediately encroached upon his space, getting in his face, yelling, grabbing him, beating on him, and spraying him, which may have frustrated him, clearly frightened him, and resulted in the car accelerating backwards, however it may have ended up in reverse.

Third, I’ve personally dealt with restraints of mentally ill individuals in complicated situations and surroundings, and yet for the life of me, in the short video of the incident provided by a witness, I could not comprehend why five officers could not pull this man out of his vehicle after he has been weakened by four tasers, batons, and blinded by pepper spray. John was a 31 year old man who judging by photos could not have weighed more than 180 pounds. Officers could have easily ejected him from the car by pulling his arms and legs before reaching for their weapons. And yet, no effort was ever made to grab him, to remove him, to immobilize him, it was simply to beat him, blind him, and electrocute him before shooting him to death.

Lastly, the incident of the officer supposedly getting pinned between the two vehicles. While reports are conflicting, let’s just say for the sake of argument that the officer was pinned. Chris had pointed out that John was in a newer model BMW which is adorned with the fancy Start/Stop button rather than a key ignition you have to turn. Why, if the officers were concerned about John driving off, didn’t they just push the damn button when they were leaning into the car to pepper spray him? And why was that officer standing behind a vehicle with a running engine and a mentally ill man at the wheel? Why hadn’t someone pinned the back of the car with a cruiser like they did the front of the car to avoid any movement at all? But, in spite of the sake of argument, I don’t truly believe this man, writhing with a face full of pepper-spray, backed up his car intentionally, and if he did, it was not to harm a police officer.

The officers in this situation reacted as though they were apprehending a wanted serial killer rather than a sick man who needed their assistance and protection. Not once was he afforded a kind word, a reassuring gesture, or any genuine offer of help. John never reacted violently, never swung at officers or tried to attack them; terrified, he simply clutched the steering wheel and refused to let go, and what started as a call for help ended with a call to the coroner. To watch the video, click here. Warning, the video is disturbing.

But sadly John is not the first in this situation. In Denver, a mother contacted police when her mentally ill son was having an episode. Suffering from Schizophrenia as well, Paul Castaway was waving a knife around, threatening to harm himself and at one point holding a knife to his mother’s throat. Though his mother sustained a small cut, she stated he was only trying to scare her, and she believed he never truly intended to harm her. He immediately turned the weapon on himself. His mother called the authorities and reported that she needed help with her son. She had called police on Paul many times before, and she maintains they were well informed of his history. The police arrived and found Paul with a knife to his throat. Minutes later he was dead. The police report reads that he was violent, he had “stabbed his mother in the throat” and came “dangerously close” to police with the knife, which resulted in them shooting him to death. Surveillance video of the incident shows he never approached police with the weapon and never lowered it from his own neck before being killed. Not once did a police officer with any crisis intervention training attempt to talk Paul down and de-escalate him. Again, barked orders, noncompliance, and guns.

In another tragic incident where an individual sought police help, 17 year old Kristiana Coignard entered a Texas police station with a knife, asking to speak to an officer. One officer arrived in the lobby, and spent a total of 19 seconds attempting to “de-escalate” her before lunging at her to grab the weapon from her. Prior to this, she did not make any threatening gesture to the police officer or gave any indication that she intended to harm him. They struggled off and on for approximately 3 more minutes as he held her in various restraints, pinned in the crevice of a bench seat, throwing her to the floor and jumping on top of her, multiple times appearing to have the situation under control. Finally he rose to his feet without having obtained the knife, and drew his weapon on her. She did not move, but he did not try to take the weapon from her. He held her at gun point as two other officers joined him. Kristiana climbed to her feet, agitated and distressed, and moments later rushed toward the officer who had fought with her as he shot her multiple times, killing her. Granted she posed a threat to his safety at this point, however if he had initially responded more appropriately, utilizing the alleged 40 hours of crisis intervention training he had reportedly received at his precinct, perhaps he could have safely retrieved the knife and she would still be alive, getting psychiatric treatment. Or, if he had taken the knife from her during any one of those moments during the restraint, he probably would've been okay there too. See the video here.

What is most concerning currently is police dealing with the autistic population, individuals who, if low functioning enough, can appear to be under the influence, rocking themselves back and forth, defiant, unable to process directions being given, disturbed, avoiding eye contact, flapping their hands, hitting themselves, and can act out erratically if frightened, stressed, over-stimulated, or simply confronted by someone they don’t know. They may not respond to verbal commands, they may repeat commands given instead of following them, they may recoil at being touched and may even strike the person invading their personal space. Their unusual behaviors can elicit an aggressive response from an officer, which can in turn become a violent situation for both. Some departments have taken the initiative in training their officers, but as I told my brother-in-law, an officer with the Orange County police department, each person with autism is different, each responds to directives and commands in a different way. While training can be helpful, working with autism requires an individualized approach, an exorbitant amount of patience, and understanding to learn how to effectively communicate with each of them and ultimately help them.

So police all over America are getting trigger happy in many situations that never need to become violent if they not only receive appropriate training, but utilize it. In the case of John Berry, a talk show host stated that this needed to be an example to follow, a lesson for police officers to learn from, but what she got wrong is that this is not the first, and likely will not be the last. The mentally ill are not criminals. Though one mental health trainer was confronted with comments such as “I’m a cop, not a social worker” and people mockingly calling this delicate approach to individuals with mental disorders “hug-a-thug”, the reality is these officers were vested with the power and the trust of the community to protect all who needed it, including those who need protection from themselves. If you can’t handle that, give me a badge. I’ve worked with, provided crisis intervention, de-escalated, and physically restrained aggressively autistic individuals and psychologically disturbed teens, both of whom physically assaulted me on numerous occasions, and I’ve worked in the seething cesspool of mental illness that is the Los Angeles ghetto. I have not injured or killed one person yet. Take note, officers.

The Mask of Mork

The genie has been set free; the nanny has retired; Peter Pan has slipped beyond the second star to the right; the good doctor has checked out; the radio waves of Vietnam have gone silent. Today we lost an icon, an artist, a genius, and a cornerstone of our own happy cinematic memories and childhoods. Robin Williams has spanned several genres of films, TV shows and stages, creating characters and commanding audiences with his vocal talents for decades. He was one of the few actors who mastered both comedy and tragedy with a physical presence of body language and facial contortions that made us laugh and an intensity in his brow with a softness in his blue eyes that touched our hearts. But like the dark side of the moon, he had another side of him few knew or saw, and today his lost his long battle with depression.

Robin has had a few clashes with fate in the past forty years, admitting to a cocaine addiction back in the 70s and 80s, which he finally beat. Unfortunately years later in 2006, he entered rehab for alcoholism. Earlier this year, he checked into rehab again for maintenance, reporting that he was “fine-tuning” himself though he had not slipped off any metaphorical wagon. Numerous reports have lamented that he was suffering from severe depression as of late, but none have expanded as to the duration of this depressive bout or potential triggers.

I think the most shocking component of this tragic ending was the stark contrast of Robin’s life compared to the nature of his death. Robin was not known for being deep and brooding; while achieving great depth in some of the characters he created, some stories suggested he could barely manage to stay in the darkness required to breathe life into them. Filming one particularly heavy scene in a movie whose name escapes me at the moment, it was reported that once the director yelled “cut!” he would immediately burst out of the solemn state of his character with spontaneous comedic relief. It was almost as though his typical light heartedness and energy could not be confined to the suffocating devastation of his alter egos. Looking back I think he couldn’t bear to be crammed back into the storm cloud that he probably held much more familiarity with than he cared to admit.

Robin was hands down my favorite actor. I loved him. I loved his laughter and the way his eyes squinted up when he smiled. I loved that he was extra fuzzy and usually made light of this in many of his films. I loved that he seemed like a soft hearted teddy bear and I never once heard a negative story about him in the press, ever. So I think I struggle more with the realization that his resounding personality of boundless joy and happiness was a cloak that covered his shattered spirit, that the man we all fell in love with was wearing a mask which exuded rays of light to blind us to his inner demons; a mask that is standard equipment when dealing with depression.

Until today I had never cried over the loss of a celebrity. I have always met such news with chirps of “that’s too bad,” “wow he/she was so young, so unfortunate,” or “I never thought it would happen to  him/her.” I think this was due in part to my love for his work and who he was, but also a subconscious reaction to the fear and awareness of recurrent depression. For some, depression is a single snapshot in a difficult moment of life that they eventually overcome and move on. For others, depression is a lifelong battle that can never fully be won. You have to constantly put yourself in check, know your baseline, know when it’s the normal blues and when it’s more severe, get those therapy “booster shots”, and take time for yourself. There’s always a lingering fear that it could come back, there’s always that little shadow in the corner of your being, aching to creep up into your core and take over again, and sometimes it takes an army to beat it back down into submission. Never elimination, just submission. Robin tried, god love him he did, but it was too little too late.

Suicide by asphyxiation. A simple, brief explanation of this tragedy but a superficial scratch to the glossed over surface that is the complexity of depression. It doesn’t sound the trumpets to the relentless antagonists that were his demons; it doesn’t pay tribute to the resilience of a man who battled darkness for years before emotional exhaustion left him with no more fight.  Like the eerie quiet that falls over the trenches in the early morn following a brutal battle, we sit in stunned silence with the overwhelming sense of absence in our hearts. Soon the grief will pass and we will be left with the warmth he poured into every character on his filmography, we will remember the better times, but for now, we pray for his peace of mind, to finally be blessed with peace. “For in that sleep of death what dreams may come.” Be at rest, My Captain.

Exorcise the Gay Away!

June is LGBT pride month, which essentially means there will be a month long drought of rainbow décor and glitter in craft stores everywhere that will make the California water shortage look like Waterworld. And they certainly have something to celebrate: gaybugs have made immense amounts of progress in the last year, really within the last few months, given that the majority of states that had bans on gay marriage were challenged and the bans were overturned. It would appear that the scales have finally tipped in favor of the human rights movement, though the progress treads dangerously close to the borderline, and the percentages of proponents and opponents are sometimes varied by a few points. Public opinion obviously shifts depending on where you stand in the hemispheres of America, as seen in this unpleasant video on ABC's WhatWould You Do. There are still those who think it’s a sin, there are still those who think it’s disgusting. Most importantly, there are still those who think it’s a choice with a cure.

Conversion Therapy, once known as Gay Aversion Therapy, has lost popularity in mainstream mental health services gradually since homosexuality was eliminated as a mental disorder in the DSM in 1973. Prior to that, aversion therapies ranged from talk therapy and prayer to catatonia-inducing medications, shock treatment, and even lobotomies. Being gay was viewed as an unnatural diversion from the evolutionary, biological, spiritual, and moral norm; a disease that must be treated and cured alongside polio and leprosy. But even as early as the 1920s, individuals were starting to recognize the folly in this belief. One being Sigmund Freud, who was never really a particular favorite of mine, but scored bonus points with me when I uncovered this quote about conversion: “’in general to undertake to convert a fully developed homosexual into a heterosexual does not offer much more prospect of success than the reverse.’ Success meant making heterosexual feeling possible, not eliminating homosexual feelings.” And so many of these therapies focused on the latter; shock that was administered in pairings with “inappropriate visual stimuli”, if successful, only created a negative association to homosexual feelings. Heterosexual feelings were never fostered, and most “cured” gays were expected to live the life of a celibate or fake orgasms with their heterosexual partners. Documentaries focusing on these so-called ex-gays usually depicted men with plastered smiles on their faces, perched on a couch next to their wife, holding a bouncing baby, and seething with self-hatred and distaste for life. Some of these men eventually “regressed” back to their homosexual lifestyles once they found self-acceptance.

But these issues were from decades and even centuries ago, right? We’re no longer plagued with such ignorance. The American Psychological Association, American Psychiatric Association, American Association of Marriage and Family Therapists, the American Medical Association have all unanimously spoken out against the practice of gay conversion therapies citing the damage that it can create and the principal of the Hippocratic Oath: Do No Harm. Conversion therapy feeds into guilt and shame, which causes depression and suicidal ideations. So why is it that only recently some states are beginning to adopt bans against this harmful treatment?

Just one year ago in 2013, Governor Jerry Brown determined that it was illegal for mental health providers to administer conversion therapy to minors identifying as LGBT given that many of them were being forced into treatment by overzealous parents. New Jersey has a similar law, which means no more straightening camps, no more trivial therapy sessions, and no more private lashings (sadly, this does not apply to religious organizations such as pastors or priests, who are not licensed mental health professionals and always seem to think they can do whatever the hell they want anyways). Illinois is on its way to passing a conversion ban, as was New York, but unfortunately, ongoing passage of these protective legislations has hit obstacles.

As New York prepared passage, they were stalled because these so called ex-gays ventured out to a few meet and greets with law makers, trying to perpetuate the image that there is nothing wrong with degrading and denying your true self. Though I can’t call it a surprise, Texas has also jumped on the bandwagon as earlier this week the Republic party unveiled its anti-gay platform. In addition to claims of gays being the devil and “tearing at the fabric of society,” they argued that they “recognize the legitimacy and value of counseling which offers reparative therapy and treatment to patients who are seeking escape from the homosexual lifestyle. No laws or executive orders shall be imposed to limit or restrict access to this type of therapy.” Likewise, in spite of the excess of medical and mental health associations noted above who are against conversion, and being one of the first states to ban conversion therapy for minors, the California Association of Marriage Therapists took a subtle stance against bans as well. While acknowledging that there is nothing wrong with being gay, CAMFT refused to go so far as to speak out against conversion therapy, stating, “CAMFT acknowledges that current cultural prejudice about same-sex sexual orientation compels some clients to seek out sexual orientation change due to personal, family, or religious conflicts, or to better fit into some cultural and religious norms[…] CAMFT advises mental health professionals that do provide assistance to those who seek sexual orientation change, to do so by utilizing affirmative multi-culturally competent and client-centered approaches that recognize the negative impact of social stigma on sexual minorities and balance ethical principles of beneficence and non-maleficence (sic), justice, and respect for people’s rights and dignity.”

So yes, we know that being gay causes distress in homosexual individuals. They are constantly faced with adversity, discrimination, bullying, humiliation, and weekly if not daily reminders that their lifestyle is not moral, that they are Hell-bound, that they are dirty and second-class citizens. They are not afforded the same protections and rights as heterosexuals. They have been beaten, they have been shamed, they have been spit on and knocked down. But in what other circumstance would a mental health professional tell someone to change themselves to reduce stress from an outside source? “So your husband berates and beats you? Well let’s teach you how to stop being annoying and getting in his way.” “Oh your mom’s an alcoholic and it bothers you? Well, we’ll teach you to be a better child so she will stop drinking.” “Someone called you the N-word and burned a cross in your front yard? Well let’s start painting your skin white, and then no one will bother you.” “Oh it’s hard to be gay in today’s society? Well then, let’s straighten you out!” The responsibility of change needs to shift away from the client and out into the world.

The cornerstones of therapy are self-efficacy, self-esteem, and self-acceptance. When a gay child is distressed or depressed, it is not reflective of some innate internal struggle. It is the crushing dissonance this world has implanted in their small minds. And it grows with them; it consumes them. It is the mental health professional’s responsibility to challenge and destroy these distortions, to strengthen the client, to stand against social stigmas. As a lesbian, I can tell you, being gay is not a walk in paradise, and yes, life got hard, but I got stronger to survive it. I can’t and won’t be fixed; I’m not broken. As a mental health professional, I can tell you it’s not my job to fix anyone else who’s not broken either. 

The Therapist Formerly Known as Crazy

As mental health providers, we not only work to dissipate mental illness in our clients, to restore some semblance of normalcy to their lives, to give them a sense of calm in the storms of their minds, but nowadays we work harder than ever to destroy the social stigma that comes with mental illness. Our clients are surrounded by clouds of shame, and often refuse therapy or medication because they’re afraid of being crazy, looking crazy, or being labeled as crazy. What would our clients do, however, if they found out that we had once been crazy* too?

For any therapist who has sat through a loosely structured psychology class, you know it gradually shifts from being a period of lectured instruction to a group therapy session. For some reason, even the psych class provides a sense of safety and security to students that clients feel in a counseling office, and before you know it, it’s sharing time, and people are divulging their darkest secrets and sordid histories. Most have been through some harrowing experience at some point and time in their lives which undoubtedly drove them to such a profession to help others in their same plight. Unfortunately, depending on where you go to school and the level of progressiveness your professors may have, self-disclosure to your clients could be considered taboo; don’t share with your clients, redirect the conversation back to them.

Well, I don’t follow the old doctrine of self-disclosure (of course this once cost me a job interview). I believe that if you have processed your issues and you recognize that sharing something about your own experiences helps your client, then you should open up to them and foster a stronger therapeutic relationship. And I have been open about my own experiences with my kids. I have been through the ringer. There isn’t much that a kid can come through my office with that I haven’t experienced: verbal abuse, physical abuse, sexual abuse, sexual assault, bullying, body image problems, issues with sexuality, divorce, cutting, depression, suicidal ideations, concerns about psychotropic medications, the list goes on. I have seen my clients respond in completely different ways when they realize I’ve lived it and I’m not talking out of my ass or pretending I understand their problems because I read about it in a textbook. But, why, when I see the benefit of self-disclosing to clients, am I so fearful of letting my colleagues know about the same things?

A few weeks ago I attended a lecture given by a social worker at our agency who struggled with her own major depressive episode, suicidal ideations and attempts, and ultimately her hospitalization. I marveled at her ability to be open about her experiences, even at her own place of work. I always feared the stigmatization if people were to find out about me. When I wrote blogs or created videos on YouTube talking about my issues, my family warned that I should take them down because potential employers could see them and would refuse to hire me. Or current employers would see it, deem me a risk, and fire me. As this woman stood before me I couldn’t wrap my head around the fact that it may be okay to be a recovered head case and be successful in this field. I think of course, that some of this stems from a clinical supervisor who was not stable and forced me to feel as though I was not okay. Long after I disclosed to her my history and my ongoing difficulties with social anxiety, when things went sour with this particular supervisor, she had written in my employee file that I was a risk because I had at one point been depressed and suicidal (this was 13 years prior to my employment) and I was unstable because I suffered from anxiety, which made me unfit for licensure (it doesn’t). So, fearful, I locked my experiences away, but I can’t keep my mouth shut as well as I’d like. As bits and pieces slipped out in the workplace, in clinical supervisions, I panicked and wondered if I would be under close watch, if they would be assessing me for stability knowing that I had struggled in the past. I panicked at this lecture, which I attended with my current supervisor, because I knew I could not provide some feedback about it without giving more information than I should. But I think some of my anxiety came from wanting to share, wanting to stop hiding myself, wanting to shed the stigma.

One point that was echoed at this lecture was the one noted earlier here: you can empathize with your clients and connect with them on a whole different level because you have been through that same dark valley and you can join with them in ways someone who is ignorant of these experiences can’t. And why shouldn’t we self-disclose? Most, if not all drug and alcohol counselors and therapists are required to be recovered addicts and they share this freely to join with their clients. It demonstrates that there is hope; we can be the shining beacons for our clients by proving yes, we fought what you’re fighting and we survived, and you will too. And in spite of your history, you can still move forward in the world and get a job doing whatever you want because there’s nothing wrong with being crazy for a moment, and you can overcome and move on.

I reflect on my crazy. I was so lost, for 12 years I fought depression, hopelessness, my fears of the world, and the black-hearted people in it. It was a long and harrowing battle, and even after recovery, there is a constant fear of relapse. I have slipped on the precipice a few times and clawed my way back to the light before the darkness took hold again. I watch myself like a hawk. I gauge my serotonin and stress, my activity levels, my socialization, my sense of hope, my sleep, my eating habits, and my drinking habits. I watch the instruments of my functionality like a pilot flying a plane, working to maintain altitude. I have my markers; I know when the cabin pressure begins to fall and when it’s time to go back to therapy. But I have not and will not go back to where I was before. Read more about my journey here.

I want to help my clients. I want to stand at the top of the hill, guiding them through the treacherous path of their own struggles, lighting the way and holding their hand when they need it, because I know where the pitfalls are: I know where the ditch on the side of the road is, I know where the rabid dog hides behind the brush and where the ogre beneath the bridge lays, waiting to grab you by the ankle and drag you back to the depths of your own despair. I want to help the client who won’t take her medication because her family tells her only crazy people need that; I want to help the client who is afraid to come to therapy because someone might see them walking into the office; I want to help the one whose mother is so fearful of the stigma that she told her daughter to hide her treatment from the world and keep it a secret. But how can I help them fight the stigma if I’m afraid to face it myself? I can write it on a blog, I can film it on a YouTube clip behind the anonymous safety of my computer screen, so I should be able to say it face to face with people in the hub of mental health services. Besides, why should a counseling agency fear recovered crazies working for them? This therapy stuff is supposed to work, right? Otherwise, what the hell are we doing here?

*Please note that if this blog indicates in any way that I’m the unorthodox therapist, I am. And I’m not politically correct either. I truly believe that you can take a powerful word and disarm it by using it comfortably and often. I have no problem with using the word “crazy” to describe my experience and my state of mind when I was, well crazy, and I think if we can take back the power of the word, this too, will reduce the stigma of mental illness. Crazy just means chaotic, and that’s what life usually is for people who are struggling emotionally and psychologically. Embrace your crazy. It will make you stronger, it will make you a fighter, and it will make you a survivor. No one can take that away from you.