The AOT gets people out of jail scam

March 4, 2015 by

The argument has been made in some version many times.  It is powerful.  It is emotional.  And it is so very, very wrong.  It distorts the facts and in doing so prevents solutions to a very real problem.

The argument goes something like this:

1.  Treatment works.
2. Jails are filling up with people with mental illness.  The usual figure quoted is 325,000.
3. This crisis is the result of their failure to access treatment. (Because of course treatment works)
4.  The solution is to force people to accept treatment so they will no longer commit crime.

AOT will solve the problem of the mentally ill in jail…

Simple right……


The argument has more holes than it has argument.  Many people might argue that the across the board assumption that criminal behavior is a result of a defiency in mental health care is simplistic nonsense that obscures the real causes of crime and makes dealing with those causes much more difficult.

And then there is AOT itself.  In no state is it meant to be anything other than a very small part of a very big picture.  People who argue for AOT say it is not a big problem because it is not a big anything. 

The previous post talked about Orange County.  They have over 3 million people.  The latest figure I could find was that they had about 7000 people in county jail.  They hope someday to serve 120 people in AOT.  They, it seems, see it as appropriate for very few people in their mental health system.  I wonder if you told them that AOT is the answer to their jail population if they might not question your appropriateness for AOT.

The Murphy hype in no way matches the AOT reality.  The costs are prohibitive.  In Orange County if you combine treatment costs and administrative costs it comes to over $45000 per year per person served.  Not exactly affordable.  Not exactly an answer.  Not exactly anything.

Rep. Murphy tries to have it both ways.  In one breath he touts it as a core of his program for mental health reform.  In another breath he says that people worried about the ethical questions are blowing things out of proportion. (Another long discussion there)  After all it is meant for only a few people.

As a major answer it fails.  It fails the eye test, the money test and most importantly the people test.  And it obscures the search for real solutions.

And if is only a small thing, a very expensive small thing, and an ethically challenged small thing, but still a very small thing Congressman Murphy what exactly are you proposing as a big solution?

I have seen the bun.  Where is the beef?

AOT: a very expensive very little drop in a very big bucket

March 4, 2015 by

The link above describes the initial report from the first four months in Orange County, California.  If you have not yet read it I suggest you do before reading this post.

Here are some of the early numbers.

500 inquiries.  310 were information only calls.

169 referrals
Of these 144 were resolved without heading to court.
18 referred to substance abuse treatment
19 were already enrolled in outpatient treatment
34  voluntarily went into treatment
24 still outstanding

No one committed to AOT.

The numbers suggest lots of questions but that is not the real point I want to make.

Orange County has 3.14 million people in it.  If you believe the statistics of the TAC 157,000 of them have a “serious mental illness.”  If you further accept their ideas about anosognosia 78500 of them do not have awareness of their illness, despite severe and disruptive symptoms.  The goal of Orange County is to perhaps serve 120 people a year.  It would seem 78380 people are missing!

The 120 people would cost 5.7 million dollars, perhaps as much as 6.1 million.  That translates according to the article treatment costs of  $18600 per person.  What that also means is that the non-treatment costs per person is $28900….a total of 47500 per person.  No mention is made of costs for the missing 78380 people.

Nevada County in California hopes to serve 36 people a year at about the same cost per person.  My Tennessee measuring point is peer support centers that serve about 3500 “severely disturbed people” for about $4 million or about $3 a day.

Why the emphasis on numbers?  The mythology of Torrey, Murphy and company is that large numbers of people with “severe mental illness” are resistant to treatment, that that resistance is a symptom of their illness, and that widespread use of coercive intervention is not only justified but a central feature of real mental health reform.

The numbers tell the lie.  120  people.   Regardless of what you think of AOT for any particular person or circumstance it is simply not true that this represents a central need or that there is a widespread justification for coercion as a central figure of the mental health system.  In New York, the promised land of AOT, 1/3 of 1% of the people served by the mental health system are in the AOT program.

It doesn’t mean that some people dont lack insight.  They most certainly do.  What it means is that the narrative that large numbers of “severely mentally ill” people are resistant to treatment and that resistance is a symptom of their illness is simply not true.

The irony of AOT is that a program proposed by die hard “advocates” for the “severely mentally ill” serves basically next to none of the “severely mentally ill” and there is no evidence that it is appropriate to meeting their needs.  It is the loudest small program in the mental health system of many states and like in most things volume is no proof of value or importance.  If you judge it by what it advertises itself as….the salvation of the “severely mentally ill” it fails.

There is no guarentee

March 2, 2015 by

There is no promise, no guarantee that if you speak out and speak on issues important to you that you will ever be heard.  No guarantee not now…not ever.  The only guarantee is that you will never be heard if you don’t.

Sometimes speaking out is not even about what we say as much as becoming the kind of person we want to be.

Make your voice count.  Use it.

Some things….

March 2, 2015 by

Some things just lead to bad things.  Some people lead to bad things.  We all spend too much time way too much time watering the weeds….Take care of what takes care of you.

Watchdog: A look back at Laura’s Law in Orange County, which forced mentally ill people into treatment

February 28, 2015 by

Watchdog: A look back at Laura’s Law in Orange County, which forced mentally ill people into treatment The Orange County Register
【from Next Browser】

Both/And: Dbsa President Allen Doderlain visits Tennessee

February 28, 2015 by


From the archives

Originally posted on Hopeworks Community:

Over the last 3 days DBSA president Allen Doerderlain has visited Tennessee. Linda and I have had the pleasure to be his traveling companions over the much of that time.

More than anything it has been a conversation about community. So much about the conversation is either/or. It is about protecting the rights and ensuring a chance for better life for “consumers” or addressing the concerns of family members who feel hopeless to deal with the suffering of their loved ones and themselves. So much of the debate has been about how to help one at the expense of the other. There is a national debate right now about the Murphy Bill which makes me wonder if any solution that is either/or will really ever solve anything.

Allen met with people in Chattanooga, Maryville, and Nashville. Today he goes on to Jackson and Memphis. Everywhere there have been both family…

View original 349 more words

Perhaps there is more than one Murphy: On the Murphy infomercial

February 28, 2015 by

Fixing America’s Mental Healthcare System | TheHill
【from Next Browser】

The link above is to the recent Murphy commercial on “The Hill”.  It was billed as a serious story but it was closer to infomercial.  A lot of softball questions and a lot of homeruns.  I would have paid a lot of money to see the look on Rep. Murphy’s face if when he started talking about the necessity of treating the “whole person”, addressing both physical and mental health at the same time if the moderator had asked if he believed that so much why he had voted to repeal health care reform that made that possible many, many times.

I would have paid a lot of money to see that.  But alas there were no deviations from the script. 

This was also the first public display of Sen Murphy who says he is going to introduce a bill on mental health reform in the Senate.  He says he is not related to the Representative but after hearing him I wondered.  Mental health consumers I know in Connecticut are confused and alarmed.  They thought he had clearly heard their problems with the Murphy Bill.  They are more than a little nervous right now.

The presentation ended with a second panel.  What caught my eye was on Facebook DJ Jaffe assured people that although the Murphy’s had been great there was absolutely no need to watch the second panel.  Needless to say watch the second panel.

The R word (recovery) was actually used and some good points made.  What stood out for me was when one of the panelists handicapped the Murphy Bill’s chances of success.  He thought 50-50.  The main problems he saw was the cost (big ticket anything was going to face tough sledding) and the White House.  It basically means Obama would have to do a 180 on mental health policy and come out against what he has already supported.

I wonder too about the Senate.  Based on the early returns Republican control of the Senate does not mean the same thing as Republican control of the House. I think Obama problems will happen in the Senate long before it gets to the point of veto.

We will see.  I had hoped to see more than an infomercial but I did find out there was more than one Murphy.  Hopefully first impressions are wrong.

And don’t listen to Mr. Jaffe.  Listen to the second panel.

Grassroots advocacy in Tennessee: a progress report

February 26, 2015 by

The goal of the DBSA is, as part of their ongoing effort to increase the availability of quality and effective mental health care for all, is to find a way through the development of a mechanism for effective grassroots advocacy for the members of their support groups and other involved or interested people to have a real voice in the decisions made about mental health in the public sphere that affect the quality of their lives.  In short, take “nothing about us without us without us” from sentiment to reality.  Make the voice of ordinary people count.

The effort is in its infancy.  The DBSA is concentrating on 6 states right now with hopefully more to follow soon.  As chairman of the effort in Tennessee I will be giving periodic progress reports.  My intention is to both share where we think we have made progress as well as where we think we need to do much better.  We have no secrets and freely share everything in hopes you may learn from our experience and us from you.

This is the first progress report.

We start from the idea that we must build the capacity to advocate.  There is no advocating without advocates and no advocates in a culture that does not see advocacy as a valued choice people can make and try to nurture and empower them in that choice.  For advocacy to flower it must be planted.

With that in mind here is where we have started:

1.  A letter is being written describing what DBSA is doing and particularly how that affects Tennessee.  The sentiment is simple:  “These are challenging and important times for those who daily struggle with mental health issues.  You have a right to be heard in decisions that affect you and our goal is to help you be heard.  We know that advocacy can be a scary and overwhelming idea.  We want to give you the tools and support to make it possible.”  The letter will be sent to chapter leaders to share with members.  Contact information will be provided to get further information.  Also we will be letting them know there will be a state wide advocacy training done by national dbsa in the early summer, late spring that interested people can take part in.  The initial goal is to get contact information on as many people as possible.  They need make no commitments as to any action at this point.
2.  Between now and the next scheduled state meeting on April 11 face to face contact will be made in as many support groups as possible.  Again the main goal is to let people know what is going on, answer questions, and assess and solicit interest in further participation.
3.  In the state meeting on April 11 the grassroot advocacy committee will be presented again.  We will also talk about targeted issues.  The goal will be to build a state wide consensus for the importance of action and momentum towards that action.
4.  The state director and assistant are drafting a letter to legislators both introducing DBSA as someone they will begin to hear from in the future and offering our help and assistance in any way.  This letter will also address our concerns about an initial targeted issue:  the decision by Tenn Care to eliminate level 2 case management in community mental health centers.  Many people in DBSA support groups have been greatly helped by this service and will be horribly impacted by the loss of it.  We want to share over time as many personal stories as possible.
5.  Make that all DBSA members are aware of this issue and encourage them to contact legislators to share their stories and concerns.
6.  Using contacts made and the context of the effort to save case management encourage as many people as possible to attend the state wide advocacy training in May or June.

These are some of our crawl before you walk steps.  We invite any comments or feedback.

A third letter: It works

February 25, 2015 by

Mental Health America on “fruit smoothies”

February 25, 2015 by

In Response to the WSJ Op-Ed: Mentally Ill, Drink a Smoothie | Mental Health America
【from Next Browser】

A second letter: 830 people

February 24, 2015 by

Dear senator ramsey and speaker Harwell

February 24, 2015 by

I know a psychiatrist who has a full time job as a human being

February 24, 2015 by

I have a friend who is a psychiatrist.  But that is really a part time job.  His full time job is being a human being.

I asked him to explain how he does his part time job.  (What follows are my notes on what he said.  If anything sounds confusing it is probably my doing.  He seemed very clear with me.)

1. My job is to help find a way to help them improve the quality of their lives not simply to “manage their symptoms.”  Too many psychiatrists “believe the operation was a success even when the patient died.”
2.  My first question is not about appropriate medication.  It is whether or not medication is even needed.  Simply showing up in my office does not mean the issue is settled.
3. Does medication do something for my client that other interventions are not likely to do?  Is medication needed to make it possible that other interventions will work?
4.  If medication is needed what is the least powerful medicine with the least disruptive and least dangerous side effects that I can prescribe that matches the level of symptoms that I am trying to help manage. 
5.  The patient must know and understand why I prescribe what I prescribe, how long it will take to work, what benefits can be expected, the most likely side effects to be expected, and any long term danger I am aware of.  Most importantly the patient needs to know that while this is my recommendation it is their choice.
6.  I don’t prescribe atypical antipsychotics on a long term basis.  I believe them to have long term bad effects not worth the risk except in perhaps the most extreme of circumstances.  I do prescribe them sometimes on an acute basis when need is high for a quicker response, but I never put someone on an atypical without a clearly spelled out idea how to get them off.
7.  I normally don’t prescribe anti depressants for mildly or moderately depressed people.  I don’t think they work very well.  And I have learned that by and large no one takes medication that interferes with their sex life very long even when they say they will. 
8.  In the end my job is to help.  That means working with people and not on them.  If I don’t take care of the human relationship the doctor/patient relationship is not likely to have much of a lasting impact.

He had more to say, a lot more.  It seemed worth sharing.

Believe it or not life is about more than how well you cope

February 23, 2015 by

Sometimes we get so wound up in survival that we never realize that coping and living are not quite the same thing.  We try so hard to control the negative things in our life that we forget or never even realize that the absence of negative things is not the presence of positive things.

It is the difference between coping and thriving. If you cant cope with the stress of everyday living, if it seems astronomical to get from the beginning of the day to the end without catastrophe then not much else happens. It is hard to make or maintain meaningful relationships and impossible to live the life you want or become the person you want to be. But coping is important because of what it allows us to more easily do. There is a difference between life defined by what is hard and life defined by what is important.

No one “copes” in the absolute sense. The question is “do you cope enough?” Do you cope enough to maintain a focus on the opportunities in life?? Do you cope enough to allow your values, passions and dreams to give direction to your life. Do you cope well enough to be successful in life in ways and in things important to you. Do you cope well enough in live to maintain and develop your connections and relations to others. Do you cope well enough to feel like you are leading a life of meaning and purpose. Do you cope well enough to feel like life can and will get better?

Your “enough” and my “enough” may not be the same thing. It may differ in degree and they may focus on totally different things. The key is what has to happen to what degree to allow you to feel like life is not limited or defined by how bad you feel or how difficult you find the events of daily living. When you have “coped enough” you show resilence. You bounce back and move forward.

The more capable you are, the stronger you are, the more focused on thriving and growing you are the easier it will be for you to “cope enough.” It is two sides of the same coin. The more you cope the better in life you will be able to do. The better in life you do the more you will be able to cope.

I get too wound up in coping. I am guilty as guilty can be. Right now there are so many areas of substantial challenge that promise and opportunity seem quiet and far away. Sometimes just pure fatigue with life leaves us stuck and feeling like better things are just not possible.

Hope tomorrow is a new and better day for both of us. Remember life is so much more than coping with what we are convinced we have to settle for.

The voice of ordinary people: building mental health advocacy in Tennessee

February 23, 2015 by

I believe the voice of ordinary people should matter.  More importantly I believe it can matter.  To often it does not. 

“Nothing about us without us” is a great idea.  It is a value worth making real.  Too often it is not.  With so much in the public debate about involuntary treatment and an almost romanticization of asylums and psychiatric hospitals this is a disheartening time for many people with lived experience.  It is time, long past time for voices to be heard.

I spent this weekend in Chicago with the DBSA talking about a pilot program they are launching to make that happen. Nationwide there are over 50000 people in DBSA support groups.  In Tennessee alone there are over 2000.

  A large portion of them have been diagnosed with bipolar disorder and they are the people who put lie to the notion that recovery is a gimmick or fanciful notion for people with “serious mental illness.”  They are a wide range of people some doing poorly and some doing well.  They are united by a common faith that life can get better and that nothing is closed to them or should be closed to them because of their diagnosis.

The DBSA idea is to develop grass root advocacy organizations that leverage and extend the influence of their support group members on public policy that affects them.

6 states have been identified to test the notion and develop and refine the processes that can make it a nationwide reality.  I am the chairman of the Tennessee grass roots programs.

Many times issues arise on a state, local or national basis that affect mental health and the call goes out to “call your legislator.”  The result of that call is often less than hoped for and advocates are left to wonder why people are so apathetic about something so important.  This illuminates a central insight which is a foundation to what we hope to accomplish in Tennessee.  To many efforts fail not because of the action proposed or what people want to accomplish.  They fail because organizations assume they have the capacity for action rather than realizing that capacity must be developed and grown.  Capacity must be planted and nurtured as if a flower worthy of bloom.  Many great ideas die from the inability to do, from the lack of capacity for effective action.  The development of capacity is one of our prime goals.  One definition of capacity would be to have enough people to act who believe that things can get better if their ask, their cause becomes reality, who believe that what they do makes a difference in service of that goal, who believes they have the ability, knowledge or skill to do what matters, who feel supported in their efforts and who feel like the whole effort has meaning and purpose

By no means are all the ideas in this post mine. Phyllis Foxworth national director of advocacy for DBSA has had decisive impact on many of them. The grassroots organizations of Illinois and New Jersey are helping to already put some of these ideas into real life and polishing them and refining them further. People from Florida, California, Washington DC, and Texas were also represented this weekend. It was and is a communal stew. This post tries to describe what it might look like in Tennessee.

Our plan can be conceptualized on several different dimensions:

1. Principles How do you get people to actually step into action? Many organizations I have been part of assume this is automatic or simply a matter of effort it isn’t. The principles of getting people to act were alluded to earlier in this article and described more fully in another post. Briefly they are: Encourage People must believe that things can get better and that part of things getting better are in what you advocate for. Empower People must believe that they can do something that matters, that makes a difference in making your ideas real. Educate People must believe that if there are things to do they cant do they can learn how and you can teach them. Support People must feel like they will be supported in their efforts. They need to know they are part of a web of connections. Confirm People must believe that this is a meaningful effort and have a sense of purpose. Advocacy must be worth the effort, the pain, the struggle, and the risk. Everything is a matter of degree and to the degree these things are true it is likely you will have a true advocacy community.
2. Leadership Roles There are several key roles in developing this kind of organization. Some of the roles identified for the DBSA organizations include: Recruitment finding people who will be part of the organization. Basically it is advocating for advocating. It is getting the word out, contacting those interested, assessing that interest and getting people to commit to action. Partnerships and coalitions DBSA is not the only advocacy organization in Tennessee. We are not competition for anyone, nor them for us. The role of the coalition person is to reach out to other organizations and identify ways we can connect and work with them. It is foolish to reinvent the wheel when others are driving cars. Policy These are the people responsible for researching facts and helping to identify issues and formulate positions. Actions These are the people who are leading in the formulation of possible actions on issues.

It is possible to identify other roles. In a real sense everyone involved will do all these things. The idea of leadership roles is to help maintain focused effort in each area. Leaders are really more facilitators than anything and hopefully there will be multiple people in each role. Organizations dependent on the personality of one person tend to be very unstable and likely to fail.

3. Levels of involvement It is ok for people to be involved at different levels. For some people an email to a representative is a big step. Others may do more. There is no “real advocacy. ” You must meet people where they are at and by doing that increase the chances that in time they will be able and willing to do more.

4. Issues It is important to know what you are about and what you are for. Issues should be clear and concrete. You should know what you want and what you want should be achievable. You should have an idea of how to get it that is practical. And finally you should have a way to know if you got it that is measurable. If you are confused about where you are going you don’t tend to get there. If you try to go too many places you tend not to ever leave. What starts in confusion doesn’t just end in confusion…it ends.

We are at the crawling stage right now. The obstacles I am sure will be many and strong. We don’t know the answer because we don’t know the questions.

A friend once told me that much mental health advocacy was a circular firing squad. Our goal is to straighten the line and go after targets that make a difference. If you live in Tennessee and would like to be involved we would like to hear from you. You need not be involved with the DBSA. If you are in other states doing similiar things we would love to talk to you and share stories and experience.

Everyone should have access to quality mental health care. And the time to act is now.


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