"For" or "against" AOT—Are we asking the wrong question?

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Over the past year, the Children’s Mental Health Network has convened a series of dialogues in Washington, DC on Assisted Outpatient Treatment (AOT). AOT is one of the cornerstones (though only a small part) of the Helping Families in Mental Health Crisis Act. The bill didn't go anywhere in the last Congress, but any day now we should see the introduction of an updated version of the bill. No doubt, the new bill will once again, be the topic of intense conversation in mental health circles.

Why did the Children's Mental Health Network focus the dialogues on AOT?
Championed by Representative Tim Murphy (R, PA-18), the Helping All Families in Mental Health Crisis Act included two components that have dominated the conversation in mental health circles. Both the inclusion of AOT and a stinging critique of the role of SAMHSA in addressing the needs of the seriously mentally ill have led to divisive splits among advocates. Sadly, the important conversation about mental health reform has been narrowed to one of the appropriateness of a civil commitment process that already exists in 45 states and questions about the leadership and focus of the Substance Abuse and Mental Health Services Administration (SAMHSA).

Mixed in the fray last year was the introduction of the Strengthening Mental Health in Our Communities Act, which was viewed by many as a Democratic response to the Helping All Families in Mental Health Crisis Act. Championed by Rep. Ron Barber (D-Ariz.) the bill moved away from controversial recommendations (such as AOT) and took more of a prevention focus for treating mental illness.

Members of Congress who are drafting legislation this year in both the House and Senate deserve a more robust dialogue between advocates that goes beyond a "for" or "against" argument. If we are unable to address the complexity involved in comprehensive mental health reform, how can we expect members of Congress to do the same, or more important, to ever come to an agreement on something useful?

Start where the tension is greatest and the pain is deepest
We have a simple rule for our dialogues. We start where the tension is greatest, and the pain is deepest, in this case, the AOT debate. The dialogue series and our recent visit to a community that utilizes AOT is the first step in the Children’s Mental Health Networks’ ongoing effort to address this polarization among advocates.

  • Note: We will turn our focus to bill recommendations regarding the role of SAMHSA beginning next week.

Why a visit to observe the AOT process?
After our third dialogue session on AOT, it became evident that the next logical step in the process was to visit a community that utilized the AOT process in a way that Congressman Murphy would likely hold up as an example of excellence. I asked the Treatment Advocacy Center, the group most knowledgeable about how AOT is being utilized across the country, for a recommendation of a community that they would describe as a shining example of the use of AOT. It is important to note that the founder of the Treatment and Advocacy Center, E. Fuller Torrey, has been a vocal proponent of both the Murphy bill and AOT.

The Treatment and Advocacy Center referred me to the court of Judge Randy Rogers, probate judge for Butler County, Ohio, located in the city of Hamilton, Ohio. Judge Rogers, his team and community partners welcomed us to visit, observe their process and engage in dialogue.

  • Note: Focusing on this particular community does not, and should not, imply that they are “perfect” in their approach to meeting the needs of individuals with serious mental illness and their families. The individuals from Butler County, who facilitate the AOT process, would be the first to tell you that their approach is not perfect. But they have been at it for a number of years and have continued to learn from mistakes and make modifications to make the process better.

The focus of the Children’s Mental Health Network on the visit to Butler County
Our purpose was to observe, listen and ask questions so that we could better understand how this one community utilizes AOT. None of the Network team gave advice or tried to promote a personally held position on AOT. We directed our questions toward what they saw as the keys to success in their approach to wrapping services and supports around individuals with serious mental illness who are going through civil commitment proceedings.

Recognizing that AOT is approached differently in communities across the nation, we were hopeful that we might be able to identify a few key elements that would help broaden the national dialogue on AOT beyond “for” or “against.”

  • Note: A list of CMHNetwork site visit members is included at the end of this post.

Structure of the visit
We spent the morning in the courtroom, observing several updates with individuals under civil commitment. After the morning session, we held a roundtable discussion over lunch with representatives of the court, mental health, the local hospital and other community leaders. We then transitioned to a roundtable discussion with community providers, family members and advocates. Finally, we held a wrap-up discussion with Judge Rogers in the late afternoon.

Overall conclusion about AOT as utilized in Butler County, Ohio

  • The “A” (Assisted) in AOT is one component (and critical starting point) of a comprehensive wraparound effort employed by a number of different agencies and providers.
  • The “O” (Outpatient) in AOT provides a mindset for this community of providers that the goal from day one is healthy integration into the community.
  • The “T” (Treatment) in AOT is the element that holds everything together. Confidence on the part of both the judicial system and the mental health community on the availability and robustness of a wide range of services and supports is critical to the successful use of the AOT process.

It was enlightening to hear from the local participants in the dialogue as they reflected on how far they have come in their understanding of how to effectively use the AOT process. The road leading to where they are now was full of mistakes, but also enough success and strong leadership to keep them motivated to continue to improve.

Most striking was they way they talked about AOT. For them, it was very clear that the civil commitment component was the beginning part of a larger process to help individuals along the way to recovery. For this group of providers, family members, court officials and community leaders, the question is not “Are you for or against AOT”. The question is “Do we have sufficient services and supports around this individual to help them recover in the community? The actual civil commitment process and court follow-up is a critical component, but only one of many.

Broadening the understanding of the AOT process is important for readers to understand. If we want mental health reform, true mental health reform, we must get away from asking “for” or “against” questions. Instead of asking if someone is for or against AOT, the better question is “What does a community need to have in place to effectively protect and promote recovery for individuals with serious mental illness?” In Butler County, it requires a combination of services and supports, and for those who are most ill, a compassionate judicial system.

What makes the AOT process work in Butler County?
We spent much of our time on this visit asking participants in the dialogue to share with us what they saw as the key components of their success utilizing the AOT process. Their willingness to be candid about challenges and triumphs over many years of developing a process that seems to be working for them was both humbling and inspiring.

Courtroom leadership is knowledgeable about mental illness, emphasizes humanity and dignity in the courtroom, and exercises authority through love.

Judge Randy Rogers
Judge Rogers is an imposing figure. Six-foot 7 inches tall, a booming voice and a heart as big as Ohio. I am pretty sure that if you looked up the words “charismatic” and “sincerity” you would see a reference to Judge Rogers. The people around him idolize him. And it is not hard to see why. He is intensely focused on wrapping love and support around those who come before him in court, almost to the point of obsession.

Before court began on the morning of our visit, Judge Rogers spoke to us about his view of the responsibility of a probate judge, especially when invoking civil commitment proceedings. Judge Rogers said,  “When you place someone on a civil commitment you are responsible. You have a responsibility to know where they are and know what they are doing. It is not acceptable to not know where they are. When you take some of their civil liberties away from them, you owe them a higher level of care. The goal of civil commitment is for people to recover, get better and get off civil commitment. “

Commitment to humanity and dignity
Everyone we spoke with during the visit commented on how Judge Rogers exudes passion, love and care for the individuals who come into his courtroom. He, himself, referenced changes in his life 20 years ago that had an impact on who he is today and how he views those individuals involved with AOT. Judge Rogers bases his approach on the principle of Parens Patriae, which for him, translates to leading with authority through love. “You have to care for people in order to have the authority over them.”

Here is one example to give you an idea of his level of commitment to those coming before him in court. The judge is about six years away from retirement. In preparation for retirement, he has asked his assistant to go through the more than 1300 cases that have come into his courtroom during his long career on the bench. His assistant is finding these people, taking a picture and writing a brief bio of them. Why? So that when he retires, the next judge will have a folder, with a picture and brief synopsis to help humanize the process for both the judge and the individual appearing in court. They call this the “Red Book”, and Judge Rogers thinks it will take about two years to complete this project.

Magistrate Patricia Hider
On the day of our visit, Magistrate Patricia Hider was presiding over the court. Sitting in the courtroom watching the proceedings was unlike any courtroom experience I have ever witnessed. Magistrate Hider was intently invested in each and every person who stood before her. The magistrate's interviewing skills and respectful question probes were impressive to observe. She gave 100% of her attention and energy to the individual before her, their family members and providers in the room as she worked to understand how the individual was progressing. She was never condescending or abrupt, even with those who might not have been following their treatment plan.

Magistrate Hider told us that she learned her interviewing skills in her previous work as a negotiator in the private sector. After law school, she worked in patent law. From there, she had the fortune to stumble upon Judge Rogers. She had a case involving mental illness and was told to “talk to the judge who handled mental illness cases.” Both she and Judge Rogers had similar personal tragedies in their background, and just like that, she was home. “You go where you need to be, not where you think you will go”, she said.

Personal experience
In the dialogue that took place after the court session, Magistrate Hider said that for her, personal experience with a loved one with mental illness helped her be a better Magistrate. Her personal experience gave her a better sense of the pain the individuals standing before her and their family members were experiencing.

Education
Magistrate Hider told us that another key factor in her development early on in her career was Judge Rogers insistence that she brief all cases related to mental illness and observe the cases he was presiding over. “I wanted to write down personal comments about people so I could remember them”, she said. I didn’t want people ever to feel we had forgotten who they were.” Now that the “Red Book” is online, she has ready access to personalized information about individuals that come before her. One of the most compelling things Magistrate Hider said to us during the visit was, “When I first started doing these hearings I would always whisper to myself before coming into the courtroom -Do no harm.”

Nicholas Schrantz, Butler County Probate Court Monitor
Judge Rogers court has a full-time Probate Monitor dedicated to his courtroom. “Nick” brings to his job both an understanding of public mental health and how the judicial system works. His job is to coordinate care between the respondent, the treating agency, and all the other players (court, mental health board, group home, crisis team, family, payee, etc.). He emphasizes to the individual under civil commitment that their treating agency is the one that provides the care, and they need to focus their attention on that treatment relationship in order to one day be released from court supervision. By doing so, he keeps the focus on the treatment relationship, and this puts the court in the background until it is necessary. As a sign of shared commitment to ensuring the highest care possible for individuals involved with the probate court, Nick’s position is fully funded by the mental health board.

Understanding the responsibilities of the court and treatment providers
There was universal agreement in our dialogue that Nick played a critical role in the process. We repeatedly heard praise for Nick’s ability to navigate the wishes of the client and treatment providers with that of the court. “His ability to talk the language of the courtroom,” as one participant stated, “is invaluable to ensuring strong communication between the court, treatment providers, the individual under civil commitment, and family members.”

Evolution of the probate court in Butler County
In 1988, Ohio Governor Richard Celeste signed into law the Mental Health Act of 1988, in large part, to reduce the number of people in state psychiatric hospitals. The push to develop community-based services and supports was on. Butler County realized if hospital beds were being reduced; they needed to beef up their community-based services.

Over time, the Butler County community mental health board developed a wider array of services and supports to help individuals transition from hospital settings to community-based settings. They developed residential housing options and a mobile crisis team, which included a deputy sheriff as part of the team. They created a crisis hotline, ACT teams, a step-down program, and rehabilitation options, along with other ancillary services designed to wrap support around individuals with serious mental illness.

With a community of health care leaders invested in developing alternatives to hospitalization, Judge Rogers noticed that there was a clear process for addressing individuals with serious mental illness in the criminal justice system (forensic monitor), but nothing on the civil side.

Fourteen years ago, the judge sat down with the psychiatrist representing the mental health board and together, they began to think through how they could adapt the model used in criminal court for civil court.

They quickly realized the harsh reality that if they were to require a treating psychiatrist to attend every outpatient commitment hearing, it would be outrageously expensive and likely just not happen. They knew that whatever system they put in place would have to be based on trust between judicial officers, mental health providers and the individuals and family members involved in the court process.

Ongoing education between the judge and the lead psychiatrist
A critical part of their planning involved educating each other. Judge Rogers reached out to the Mental Health Board psychiatrist, Dr. Kenneth Tepe and said “teach me.” As Dr. Tepe said in our discussion, “I taught him about schizophrenia and he taught me about Parens Patriae.”

The influence of the drug court model
In addition to looking at the forensic model used by the state, Judge Rogers also borrowed heavily from the Drug Court model. Judge Rogers had experience running a drug court, and the principles were similar. “The way we were doing the community docket on civil commitments put me right into my drug court mode.”

Initial efforts were not successful
Former Magistrate not invested in mental illness issues

Participants in the dialogue said that the magistrate who preceded Magistrate Hider did not have a strong interest in individuals with mental illness and that this impacted the process. Magistrate Hider stressed that if a judicial officer is going to do this work it has “got to be something you can relate to. You need a magistrate who has both heart in it and an intellect and understanding of the individuals they are seeing.”

Former Probate Monitor focused only on treatment
Initially, another agency provided the case management role in the courtroom. It became evident that the case management role was perceived to be that of a mental health treatment case manager and as such, they just focused on treatment. There was not a strong emphasis on understanding and navigating the interface between mental health and the court. As one participant told us, “There has to be a level of respect for the situation the person is in. If you allow your client to go awol, you allow them the opportunity to jeopardize even more of their personal freedom than before.“

What changed?
Communication was poor between the court and mental health, and it did not appear that individuals under civil commitment were getting what they needed. Recognizing the problem, the contract for the Probate Monitor was moved from an agency that was 100% focused on mental health services to one that had more experience with the forensic and mental health setting. The ability for the court and the mental health provider to be able to understand each others role was critical to developing a strong working relationship.

With the change in agencies, Nick Schrantz, an individual with experience in both judicial and mental health settings, was hired as Probate Monitor. At the time, there was not a job description for the Probate Monitor, so the Judge and his team created one based heavily on Nick’s input.

The elements were quickly falling into place. A passionate judge; a new magistrate who was knowledgeable about mental illness and equally passionate; and a new probate monitor experienced in both judicial and mental health settings.

Additional critical elements in place today
Participants in the dialogue identified two key elements that were critical to being able to intervene effectively with individuals in crisis. The first was the development of a mobile crisis team that could respond quickly to individuals in need of help. The second important element was the passage of a law that gave authority for health officers to be able to write an “application of emergency admission." Ohio law permits a psychiatrist, licensed clinical psychiatrist, licensed physician, health officer, parole officer, police officer or sheriff to take a person into custody and transport to a hospital as long as they have a reasonable belief that the person is mentally ill subject to hospitalization by court order, and represents a substantial risk of physical harm to self or others.

According to Nick, for the civil commitment process to work, you need a probate monitor, residential placement options, a mobile crisis team, and hospital triage social workers at a minimum. He said, “People in the community who are in trouble must have someone to call and a mobile crisis team who can respond. If they drive themselves to the emergency room, ER staff need to be trained to know how to evaluate and get the individual seen by a physician instead of discharging them without an assessment. Without these options available, most people in mental health crisis would never get into the probate process.”

Fiscal incentives and cost savings
Representatives from the mental health board were clear in our discussion that the incentives offered by the state for community mental health boards who reduced hospital bed stays helped. Early on, they exceeded their use of budgeted hospital bed days and were required to pay back the state over six hundred thousand dollars. That got their attention, and they got serious about their initiative to build community resources. Just last year, representatives from the mental health board estimated that they saved over a million dollars by avoiding the use of hospitalization. According to the probate monitor, 83 % of the individuals under civil commitment don’t end up in a psychiatric hospital. The mental health center utilizes a variety of community-based settings, many which include medication administration with nurses staffed 24 hours a day.

However, the representatives from the mental health board offered a cautionary note. Funding for supporting processes like this and the ancillary supports that help make it work far exceed what Medicaid can provide. With state funds diminishing, the mental health board has to rely on local tax levies to help support the work being done. Currently,  there is not a funding structure in place to recoup savings from Medicaid and reprogram those dollars to be reinvested in efforts like this at the local level. Not all counties have been as fortunate as Butler County with local tax levy funding. Many mental health centers in Ohio do not have the budget to put things like this in place.

Probate process continually evolving
It is important to note that in this community, the probate process appears to be continually evolving. Judge Rogers approaches the civil commitment process used with individuals who have a serious mental illness with pride, humility and an overriding concern for the safety and well-being of the individuals appearing in his court.

During the dialogue, the judge was up front about the mistakes they have made along the way and how they have learned from them. He pointed out that they have spent the last ten years honing the role of the probate monitor, developing trust and clear communication with mental health and other providers. Over the past 10 years they have developed a series of written forms to help them track progress, which has led to increased confidence on the part of community providers that the court/mental health partnership can indeed work and be beneficial to individuals under civil commitment. His hope is that others can study their mistakes, how they overcame them and possibly apply lessons learned to their community.

The AOT process used in Butler County did not happen overnight. It took years of trial and error, led by a passionate judge who would not take no for an answer.

Concluding thoughts
I want to leave you with a few quotes from dialogue participants that inspired us all during our visit:

  • Judge Rogers – "For outpatient commitment to work you have to have an interested judiciary, an array of residential treatment options, coordination of effort (like Nick), and cash to pay for the treatment programs."
  •  Magistrate Hider – “The longer I do this, the more I appreciate family history. Family members are boots on the ground.”
  • Ruth Fox – "For individuals with severe mental illness, if there is not a Judge Rogers around, those folks will be put in hospitals or locked facilities. People like Judge Rogers help the system see the value of least restrictive – but you have to have the services in place.”
  • Maria Silva - “I hope that what we saw today could happen for all families in this situation. If it were me, I would hope to receive the respect that individuals felt in the courtroom today. “

I hope this brief glimpse into one community’s approach to utilizing AOT helps broaden your understanding of the complexities involved in ensuring the protection of individuals with serious mental illness and assisting them to a place of recovery and wellness.

After our visit to Butler County, a reporter asked me, “So now that you have seen AOT, does it change your mind? Are you for or against AOT?” “Neither,” I said. “For or against is the wrong question. The question you should be asking is, ‘Does this community have in place what it needs to protect and promote recovery for individuals with serious mental illness?’ My answer to that question for Butler County, Ohio would be – ‘They are well on their way.’”

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scott

Scott Bryant-Comstock
President & CEO
Children's Mental Health Network

 

The following people made up the Children's Mental Health Network site visit team:
  • - Scott Bryant-Comstock, President & CEO, Children’s Mental Health Network
    - Dennis Embry, President/Senior Scientist, PAXIS Institute, Tucson, AZ
    - Ruth Fox, Executive Director, Allegheny Family Network, Pittsburgh, PA
    - Lee Gutkind, Distinguished Writer in Residence at the Consortium for Science, Policy, and Outcomes, Arizona State University
    - Martin Rafferty, founder and Executive Director, Youth M.O.V.E. Oregon, Eugene, OR
    - Maria Silva, Senior Supervisor, Allegheny Family Network, Pittsburgh, PA

Sandra Spencer and the National Federation of Families begin new chapters

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I like to think of the children's mental health movement that I have been a part of for the last thirty years as a series of chapters in a never ending story. A story of how communities across the nation wrestle with the complexities of building and ensuring family voice as an equal partner with care providers.

Sandra Spencer, Executive Director of the National Federation of Families for Children's Mental Health, is moving on to new opportunities in her professional career. With this move, she closes one chapter and opens a new one for herself, which, knowing Sandra, will be most exciting.

The first chapter of the Federation centered around Barbara Huff, the architect of building a new national voice for families 26 years ago. In those early days, Barbara had to navigate the Federation through the challenges of mobilizing support among providers, researchers and policymakers just to get parents recognized as being valuable partners in treatment planning for their children.

Then, ten years ago, Barbara closed the first chapter of the Federation and transitioned back to Kansas. Sandra was tapped to be the Executive Director of the Federation and began the second chapter of this dynamic organization. Sandra took the helm and steered the organization into uncharted waters during a time of rapid change and growth of family involvement in all sectors of the mental health field.

The last ten years have seen the rise of families as providers, certification programs, and the growing acceptance of family voice as an integral component of policy development. It has been an exciting time in the national dialogue around the role of families in the mental health field, and Sandra has been right in the middle of it.

And now, both Sandra Spencer and the Federation enter new chapters in this never ending story. Sandra - Embrace your next chapter, as I know you will. We at the Children's Mental Health Network wish you well.

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scott

Scott Bryant-Comstock
President & CEO
Children's Mental Health Network 

Prevention science leads to success in school. Let's focus on what is behind the symptoms

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Morning Zen Guest Blog Post ~ Kevin Dwyer

About six years ago I wrote a chapter on mental health promotion and prevention (with a professional colleague Dr. Erica Van Buren) in a book titled “Handbook of Youth Prevention Science” (Dole, B., Pfohl, B. & Yoon, J. Eds. (2010) New York & London: Routledge). Our chapter began with a scenario about an 11-year-old boy we called Jeremy who was being “disruptive, fighting, and calling his teacher a “mf.” He was an angry, lost soul who was academically way behind and had a record-breaking number of suspensions. Everyone in the school knew him including the principal, counselor, social worker, school psychologist, school secretary, cafeteria manager and community liaison police officer. The school labeled him as a “high flyer” who consumed staff time and energy to no avail. He actually spent more time in in-school suspension than in class.

He lived with his grandmother who was willing to do whatever the school recommended including “therapy” and “pills,” as well as “behavior contracts.” She took him to the mental health clinic that “wait-listed him as a priority for services.” So far behind academically, he was retained, making him older and bigger than his classmates. The school had many meetings about Jeremy, did evaluations and wrote and re-wrote an Individualized Education Program (IEP) placing him in special education services diagnosed as “seriously emotionally disturbed.”

The school’s social worker met with Jeremy and his grandmother at school and in his home. He told the social worker he hated school. His grandmother also told the social worker that Jeremy, “couldn’t read.” It took the social worker a little longer to find out from his grandmother that he had nightmares, no friends and “felt bad” about giving her grief.

In looking at his school history in kindergarten, he was described as a more anxious, frightened preschooler, not joining the group, not benefiting from the pre-reading instruction as easily as his peers. Although these problems were noted the social worker and school team could not find any documentation of the school’s interventions to provide him direct instruction or diagnostic instruction in those early years.

He started acting out late in first grade and the school’s focus moved quickly from the academic problems to addressing the disruptive behaviors with interventions such as “time-out,” behavior contracts class removal and, by second grade, in-school suspension.

In that chapter we wrote, “Academic and behavioral problems like those experienced by Jeremy often place students on a road that is paved with school adjustment difficulties, gradual disengagement from school and inevitable school failure and dropout.” (Ibid. page 45).

Good people with multiple sets of knowledge started what they saw as intensive interventions for Jeremy – but too late in this student’s educational history and even those interventions were still provided in a usual sequence of intensity, too little to make a dent in the complex of issues this student and his family faced. It is like doing an X-ray when the injury is muscular and an MRI is needed. It doesn’t show the depth of the injury and, therefore, results in misdiagnosis and therapies that will not work! With human behavior there is no MRI, there is no genuine diagnostic tool that can tell us what the problems are and what might work to address those problems. We only see want is on the surface, the behavior problems, defiance, anger, resistance to our interventions.

In that chapter, we called this pattern the “Domino Effect” of failure in learning that, when un-remediated, makes school so abhorrent to a child that he/she becomes a behavior problem. The fight-flight coping strategy kicks in and time after time the frustrated child says or does offensive things, off-putting things to those who want help him learn and behave.

The school does not understand his anxiety, and his inability to cope with failure. Rather than show he cannot read he fights with defiance and is then removed from toxic embarrassment in front of his peers.

He has so many strikes against him. His mother is in jail; his father is unknown. His caregiving grandmother is his only supportive connection. She can keep him safe from the violence and pain of his neighborhood but not from the frustration and pain of not learning to read.

In that chapter, we talked about the school’s responsibility to seeing that for some, for Jeremy, intensive school mental health services are essential to learning as are social emotional learning skills. And these services must be aligned with equally intense reading support. We cannot continue to let the Jeremy’s in our schools fall off the cliff.

In that chapter, we noted the good news! Schools are doing better for Jeremy. We talked about the tremendous improvement in school communities using best practices to prevent problems and promote academic and social emotional skills. We talked about the successful initiatives, programs and practices that are making a difference in children’s functioning. In fact the theme of that book and our chapter is success, a litany of components of successful mental health promotion, prevention and risk reduction as well as early and intensive interventions, all aligned to reap benefits for our children and families, and yes, even ourselves. Yes, systems are improving services and many more schools are providing successful initiatives that are reaching many more Jeremys before they become defiant lost souls.

Now, several years later a serious problem remains. We do not know how many schools are providing this array of effective best-practices to improve mental wellness and academic success of our children. Is the number 50% or 25% of our schools? Who is monitoring the necessary growth and effectiveness of these critical initiatives? Is this a responsibility of CDC, NIH, SAMSHA, Department of Education, States, universities, professional organizations, and advocacy groups? We have some good data on children’s physical health and our physical health promotion and prevention. We have loads of assessments of their academic progress and some information about its relationship to instruction. We have little data on the nation’s schools provision of the needed array of services that promote social emotional skills, effectively address early interventions and ensure that wraparound services the Jeremys need are provided. Although we have made strides in improving the availability of mental health service to these children we may still be using the least-to-most intensive continuum ineffectively. We may still be doing the too little - too late intervention model because we are focused upon the symptoms rather than the why behind those symptoms. Let’s start effectively measuring our success and how universal that success is for our nation’s children. 

Our children deserve to benefit from what we know works for all grade levels. Pre-school and kindergarten is where to start!     

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dwyerKevin P. Dwyer, M.A., a Nationally Certified School Psychologist, is an education and child mental health consultant.  He recently served as a principal research associate for the American Institutes for Research. For over 30 years he practiced school psychology in public schools and held several local, state and national leadership positions in the fields of mental health and education, being responsible for the design, development, implementation and evaluation of programs and practices, for improving school climate, safety, and wellbeing for the education, and mental health of children.  He has helped school staff in many districts use data to inform decisions on improving caring and connectedness with students and professional peers.  His work, publications, presentations, and practices have influenced public policy and the development of efficient, family-focused collaborative child service systems.  During his 30 years as a public school psychologist, he worked directly with over 10,000 children and their families as well as trained over 6000 educators. He provided psychological services to children, including those with disabilities and those whose anxiety and mental health problems blocked learning and adjustment.  He assisted teachers and staff in supporting a caring, inclusive school climate for all children.  In 2007, the Maryland Coalition of Families awarded Mr. Dwyer and his wife for their work in making schools more family friendly.  He served as president of the National Association of School Psychologist and was given its highest honor, the Life-time Achievement Award.  In 2000, he received the Tipper Gore “Advocacy award for improving the lives and mental health of America’s children” from the National Mental Health Association.

Leaders as clowns, sans nose

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Morning Zen guest blog post ~ Dr. George Patrin, Singing Clown, Advocate, Children's Mental Health Network Advisory Council

george and friendsThose in privileged leadership positions, no matter the organization or occupation, should be clowns, every day. I refer to taking on a social clown persona - a person who remains light-hearted, positive, with no reservations or shyness about being of service to all we meet, doing whatever we can to bring joy and diffuse stress, even if for only a moment, out of genuine concern for others, especially those in our sphere of responsibility and care.

Adopting this attitude change would be a huge service to employees, colleagues, and acquaintances as a truly transformational leader. Does this require a red nose, you may ask? Initially, yes, the artificiality of the red nose breaks down needless barriers, ones we imagine are there, and also barriers those we interact with put in place to protect themselves… from us. With the nose on we can be bold in our interactions as it’s an obvious public statement that this person you are dealing with at the moment isn’t really me, but a ‘clown me.’

georgeguatamala

The nose clearly allows one to “make a fool of oneself” in public, which takes immense courage, actually. Think on it – if the boss is willing to do this, perhaps I can take a few risks to improve the workplace and so our product, too. The ’magic’ of the nose is it transforms our behavior and sends an immediate, unspoken message that this interaction is not to be ‘business as usual,’ but a time of removed barriers, improved communication, personal interaction, and right now. The nose insists on attention and reaction; it demands it… for us, without having to ask for it. And the nose works in every language, not surprisingly. This is only known, unfortunately, by those who have put one on, and gone out in public.  

georgeairportSo go ahead, do it, put one on tomorrow, before you go out the door. Those you meet will certainly know you are “up to something.” Out in public, especially with people you don’t already have a relationship with, the nose will immediately establish a connection, it ‘opens the door,’ gives permission to interact. The nose removes barriers because people want to let their guard down and laugh, smile, and wonder, when a red nose appears. It’s genetic in all of mankind, the emergence of the ever-present inner child. A sincere clown triggers trust between people, even hope, because people want to be loved. Given the power of the nose, the best leaders should clown a good amount of the day, get over themselves, do whatever is necessary to be of service to others bringing joy and hope into the workplace… on arrival. It’s good for morale.

Clowns can do anything; there are no expectations, except maybe, for surprise. Sit unexpectedly still, suddenly laugh, cry, look with amazement into the eyes of another; it’s all good, and right, and true, coming from a clown. Perhaps most importantly, in our culture people aren’t supposed to, are not allowed to, touch. Clowns however, are expected to try to get away with it, give a humble and sincere hug, whenever possible, the longer the better, truth be known.

The beginning and end of every meeting should be a (group) hug, as long as the moment will allow, one of genuine appreciation and humble concern for the hugee(s). Far too often, touch is only for a fleeting moment, through a handshake or placement of the hand on a shoulder or arm. We don’t plan for, allow for, genuine non-sexual touch in our daily encounters, unfortunately. We are too rushed. The nose breaks the routine and allows for lingering, breaking the routine, just for a moment.

friends

We know there is great value in providing momentary comfort, a connection, even if with only the eyes, a release from stress and daily care. If we do this consciously, with genuine concern and unconditional love for another, even though fleeting, moving on to another moment with another person, we leave the former recipient forever changed, to wonder if they'll (hopefully) see that caring clown again, anticipating a longer moment and connection, next time.

Leaders can and should leave behind a trail of wondrous smiles and ‘hopes’ at days end. True, in so doing we leave behind a piece of ourselves… if we do it right. Eventually, in time, we can be brave enough to do all this without the nose, but retain the persona. Leave all we meet with a token of our affection, given without expectation other than to draw out the child within, and an unspoken pledge of continued support for the grown-up caretaker of that child spirit in the future. Yes, leaders should be clowns in public, with or without the nose. The world would be a better place. Don’t bother to send in the clowns…they’re here. Send me. 

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george patrin

COL(Ret) George Patrin, a Children's Mental Health Network Advisor and Morning Zen contributor, has recently returned from a second International Community Clowning Trip with Dr. Patch Adams of the Gesundheit! Foundation. Dr. Patrin's first trip with Patch was to Russia in Nov 2012  to visit orphanages, senior homes, and hospitals. Surrounded by the love, giving, and friendship of new clown soul mates, George had an unexpected improvement in PTSD symptoms and depression resulting from his 23 years of active Army service and two deployments to a combat zone, complicated by the suicide death of his 20 year old son five years ago. While psychotherapy, support groups, and men's grief therapy were helpful, this two week experience so changed him that his wife and family, especially his 1 1/2-year-old grand-daughter, noticed the remarkable difference immediately. 

Gesundheit! Spring Break in Guatemala
The pictures in this Morning Zen post are from the trip March 7-14, 2015, which is the traditional Spring Break trip to Guatemala for Gesundheit!.
 (See The Gesundheit InstituteDr. Patrin went along to clown again and enjoy the experience but also to scope out the location and brainstorm issues that might arise returning with all Veterans as opposed to the usual International mix of attendees on these trips. This group was made up of citizens of the US (TX, CA, WA, VA), Mexico, Bolivia, Panama, and Canada). Guatemala is an ideal clowning location as the country has an established humanitarian clowning program (called Fabricas) and the hotel is a private bed and breakfast where the troupe can decompress each evening and check on how the day's visits are affecting the troupe. Prior clowning is NOT expected nor required to go on any Gesundheit! Humanitarian Community Clowning Trip.

Clowning with veterans
george and patchGeorge spoke with Patch Adams on the trip home resolved to work with Patch's Gesundheit! and George's Serendipity Alliance to conduct a future clown trip with Veterans to determine if this effect was universal. Over the past two years they have written a research protocol with the Chicago VA to arrange for Veterans currently in therapy due to any number of conditions - PTSD, TBI, depression, addictions, anxiety and/or suicidal ideation - to go to Guatemala. The trip is scheduled for October 10-18, 2015. Providers caring for Veterans who might benefit from this groundbreaking Gesundheit! research trip can contact George at patrin.george@gmail.com. This first trip can take only 10 Vets, but they will start a waiting list for future trips, should this prototype trip have the results expected for the first ten selected.

The demise of the mental health system is not the result of SAMSHA

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The following is a response to commentary made on the Morning Zen post - SAMHSA is under attack - and the rank and file are paying the price.

Morning Zen Guest Blog Post ~ Dennis Embry

Thank you, Scott for noticing the bigger problem.

The demise of the mental health system is not the result of SAMSHA, though the demise is a casualty of the broad dismantling of mental health systems of care that has been happening since the bloom and bust of the private psychiatric hospital wars in the late 1980s and early 1990s. Most states have systematically defunded their mental health treatment services that include both medication and all of the ancillary services required to help people with serious mental illnesses. I've watched this in Arizona where I have worked as a clinician with adults and children with very serious mental illnesses. I have witnessed the absolute destruction of such systems in Kansas in a decade where I grew up and was at the epicenter of this destructive dismantling. How big is the defunding by states? At least $5 billion, just in the last few years. If you are ticked about this, vote for new state legislators.

SAMSHA did not cause the decline in funding for the seriously mentally ill, nor did its many fine and dedicated civil servants. SAMSHA’s core funding priorities are decided by Congress, which funds about $1.8 billion for substance abuse treatment and prevention by SAMHSA and only about $450 million for mental illness. The latter is about $9 million per state provided by Congress, which can accurately be described as “budget dust.” How infinitesimal is that by comparison to New York State’s special appropriation to support high-quality services for seriously mentally ill in its Assisted Outpatient Treatment effort?  Well, New York state spent an extra $160 million dollars, which adjusted per capita for the rest of the United States is about $3.9 billion extra dollars for high-quality mental health treatment.

Let’s wave a magic wand. Every single penny of the $450 million Congress appropriates to SAMHSA for mental illness is overnight spent on the most seriously mentally ill. That sounds like a cure for cancer or more, unless you have a 4-function calculator. If you hypothesize that high-quality treatment costs about $15K per year, only 30,000 people could be helped by those federal funds. Now, frame that in context of Dr. Thomas Insel’s blog (the director of the National Institute of Mental Health) who noted that 500,000 people have a first-episode psychosis each year in the U.S.  Let’s say Tim Murphy’s committee has its way and mandates SAMHSA spend its mental health funding on really, really serious mental illness like those 500,000 people with first episode psychosis. What an admirable priority!  Nobody could disagree that such folks with first episode psychosis need treatment, and such folks are responsible for the bad things that happened Tucson (my home), the Aurora Colorado movie theatre, and Sandy Hook Elementary. What a great idea! Each state can spend $900 for their treatment.

Now, most states have voluntary commitment procedures. It’s not pleasant to do, and its agony for us a family members. I had to do this with my parents, and it did not work because the “treatments” were actually iatrogenic. Such coerced treatment in no way guarantees effective results. Please read the Cochrane Review (the august impartial, non-political review of such matters) here: http://bit.ly/compulsoryRx.

As a well-respected scientist, I don’t believe ANY member of Congress regardless of their political leanings about their reports of science nor the witnesses they call. There is just way too much psychotropic money greasing political campaigns, even in state elections. I go read the bloody science myself, which any reader of the Children’s Mental Health Network can and should do. The best source is the National Library of Medicine, www.pubmed.gov, which you may conveniently read for a search on “compulsory treatment.” I urge both the advocates and the doubters to read through these abstracts, and if you believe the political stances and hyperbole on either side of the AOT…well, that is a completely different diagnosis called, “thought gullibility”.

The insistence that mental illnesses—even serious ones have nothing to do with behavior and are purely “brain diseases” is so far off the mark of what we know scientifically. That is a long lecture, and not possible to communicate in sound-bytes. The “brain disease” sound byte creates the false belief that these problems are inevitable genetic, biochemical disease. Perhaps the most cited person for the concept of “brain disease”, Dr. E. Fuller Torrey, is the very guy who proved that some cases of schizophrenia could be the result of an infectious disease passed on by cat poop. Dr. Torrey’s group also funded the first randomized trial in the world to prevent first episode psychosis, using nothing more than 1.3 grams of high-quality omega-3 (fish oil).  More detail can be read at www.pubmed.gov.

But consider an analogy that puts it into a layperson’s experience. Almost everyone reading this post knows that we have an epidemic of diabetes. Clearly diabetes involves elaborate biochemistry with one major organ. So should we now call diabetes just a “pancreas disease?” Hardly. There are many environmental, social, epigenetic, and behavioral predictors and levers to move to help a person afflicted with diabetes live a healthier life than just taking insulin. And, this is just so about mental illnesses from V-codes to major, serious mental illnesses.

The rank and file SAMSHSA employees are pawns in a really bad movie. I know many of them. They have been given a job to prevent, treat and cure the most costly and difficult illness in America on a peanut butter budget. It’s a time for SAMSHA leadership to stop defending an impossible task to stem and epidemic of mental illness in America, and it’s time for us to call out politicians and others for engaging in Kabuki theatre for 10-seconds of fame.

Dear readers, we have an epidemic of mental illnesses that dwarfs the polio epidemic. That requires a wholly different discussion than current posturing, deflection and blaming.

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enbry

Dennis Embry, President/Senior Scientist at PAXIS Institute – Dennis D. Embry is a prominent prevention scientist in the United States and Canada, trained as clinician and developmental and child psychologist. He is president/senior scientist at PAXIS Institute in Tucson and co-investigator at Johns Hopkins University and the Manitoba Centre for Health Policy. His work and that of colleagues cited in 2009 the Institute of Medicine Report on The Prevention of Mental, Emotional, and Behavioral Disorders Among Young People. Clinically his work has focused on children and adults with serious mental illnesses. He was responsible for drafting of the letter signed by  23 scientists, who collectively represent scores of randomized prevention trials of mental illnesses published in leading scientific journals. In March 2014, his work and the work of several signatories was featured in a Prime-TV special on the Canadian Broadcast Corporation on the prevention of mental illnesses among children—which have become epidemic in North America. Dr. Embry serves on the Children's Mental Health Network Advisory Council.  

My perspective: Individuals with behavioral healthcare needs under attack

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Morning Zen Guest Blog Post ~ Richard Chapman

I am a licensed mental health counselor in the state of Florida. Before that, I was an advocate for individuals with both developmental disabilities and behavioral health care needs. I was educated by some of the best individuals on the planet. Some of these individuals have the traditional behavioral health care training. Also, some of these individuals are family members and individuals that have behavioral healthcare needs. What I got most out of my education is the fact that I needed to listen to my clients and the families that we serve. We are not in the age of Sigmund Freud. During that time, the psychotherapist was seen as at the one that has most of the power in the room. As a psychotherapist, I only have power because the client has more power. I have the obligation to listen to the families and the clients that I provide support to.

I understand the movement in the United States Congress to restrict freedoms of children and adults with behavioral healthcare needs. This is coming from a place of fear. They do not want to see another Newtown or Florida State University. They are labeling people with behavioral health care needs that have done nothing wrong. Just because you have a mental illness, does not make you a violent person. As a behavioral healthcare practitioner, I believe that we need to take the lead from the client and their families.

If I don’t have buy-in from the client or their families, I am not going to get anywhere in the treatment. What I find most disturbing is the reliance on mandated treatment or so-called assisted outpatient treatment programs. We cannot mandate treatment just because we don’t understand, or we have a misconception about what a person with a mental illness is. We must do everything we can to protect the rights of persons with mental illness and their families.

So what needs to be done? We need to begin with dialogue. This dialogue must happen with both consumers and professionals at the table. I am encouraged by the Children’s Mental Health Networks continued call for dialogue and education. I hope to continue to be able to provide my perspective on this very important issue. 

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richardRichard Chapman is a mental health counselor in the state of Florida. He has his license and is the president of Tampa Bay community counseling. As a mental health counselor, his primary specialty is working with individual that have trauma-related disorder, as well as individuals and families with disabilities.

Richard is involved in disability advocacy efforts local and state. He is a consultant to disability rights groups and other organizations working towards using for individuals with all disabilities. He is a member of the Board of Directors of disability rights Florida, Florida's protection and advocacy system for persons with disabilities. Richard has been involved with the Federation of Families for Children’s Mental Health. Richard is active in several professional organizations related to mental health counseling.

Let's get rid of the "bad bench" and focus on positive interventions for pre-K and kindergarten

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Morning Zen Guest Blog Post ~ Kevin Dwyer

A kindergartener is sitting on what he calls the bad bench in front of the principal’s office. I ask him why he is there, and he says he didn’t put his back-pack in his cubby. He sits there fidgeting for hours. As I leave my meeting with the principal, he whispers to me, “I can read!” That is how he wants me remembering him. He was not learning to improve his reading all morning of that school day. Nor was he learning how to behave. 

We know that pre-kindergarten and kindergarten children can be taught foundational readiness skills for reading and calculating. Their spoken and understanding of language can be further developed and reinforced in these pre-primary grades. Equally and critically we know they also can be taught effective social and emotional skills and behaviors. They can be taught to stop-and-think, to deal with frustration, to be empathic, to work with others and to problem solve. 

We also know that these very young children can be scarred by being socially isolated or ridiculed for misbehavior. We know that removing them from the classroom to sit on the bad-bench in front of the principal’s office does not result in improving behavior nor does suspension or expulsion. Dunce caps, standing in the corner and corporal punishment are also failed and damaging discipline interventions long gone from most schools, although Texas and other states still allow corporal punishment. 

Like reading, appropriate and inappropriate behaviors are learned and most frequently they have been reinforced in some way in the past by reducing stress or gaining approval. The critical concept is that most behaviors are learned, and, therefore, the skills necessary for appropriate behaviors can and should be taught. And, yes, like reading, there are proven instructional practices that teachers and others can use to teach children effective behaviors and social-emotional skills. 

And like reading and language development, some children (as many as 20%) will need more individualized instruction to master those age-appropriate social skills.   

We know what works in helping almost all children demonstrate effective social emotional skills including those skill outcomes Dr. Maurice Elias of Rutgers University defines as “habits of mind and patterns of thinking that include curiosity, explaining their reasoning, feedback process, asking questions, and defining and solving problems, and striving to communicate clearly and proudly.” 

We also know that starting the school day with structured class meetings that help children get ready to listen and learn and help teachers connect to their preschoolers increases a positive climate in those classrooms. There is greater connection and caring reported by children.    

We also know that some children will need individualized instruction and proven interventions to master these positive social and behavioral skills. We know that helping children learn alternatives to their inappropriate behaviors works as a replacement for the harmful bad-bench or in-school or out-of-school suspension. School systems like Cleveland Ohio public schools, have found that combining social skill instruction with class meetings helps all when planning centers are in place where children can go to talk with a trained staff member to help those children who need individualized supports develop alternatives to their problem behaviors and master social skills. This combination has improved school climate and classroom behaviors. With fewer behavioral disruptions, instructional time actually increases as does teacher satisfaction. 

No one is left behind in this development of social skill mastery including those needing intensive interventions. Clinical mental health supports for the child and family are provided in every school. So each school and pre-school program has an agency mental health clinician assigned to work with the school’s student support team that is structured to address and monitor progress of students receiving these interagency services.    

All of these proven programs that positively change behavior and provide the foundation for life-long social skills require resources, staff training, and the revision of policies beyond just outlawing suspension for toddlers and kindergartners. Effective interventions require: an agreed upon strategic plan supported by top administrators; teacher and staff training; an adherence to the fidelity of the proven universal and targeted strategies; multi-year action steps and; accountability measures of annual yearly progress. Poorly or partially implemented they will fail.  

Our children deserve to benefit from what we know works for all grade levels. Pre-school and kindergarten is where to start!     

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dwyerKevin P. Dwyer, M.A., a Nationally Certified School Psychologist, is an education and child mental health consultant.  He recently served as a principal research associate for the American Institutes for Research. For over 30 years he practiced school psychology in public schools and held several local, state and national leadership positions in the fields of mental health and education, being responsible for the design, development, implementation and evaluation of programs and practices, for improving school climate, safety, and wellbeing for the education, and mental health of children.  He has helped school staff in many districts use data to inform decisions on improving caring and connectedness with students and professional peers.  His work, publications, presentations, and practices have influenced public policy and the development of efficient, family-focused collaborative child service systems.  During his 30 years as a public school psychologist, he worked directly with over 10,000 children and their families as well as trained over 6000 educators. He provided psychological services to children, including those with disabilities and those whose anxiety and mental health problems blocked learning and adjustment.  He assisted teachers and staff in supporting a caring, inclusive school climate for all children.  In 2007, the Maryland Coalition of Families awarded Mr. Dwyer and his wife for their work in making schools more family friendly.  He served as president of the National Association of School Psychologist and was given its highest honor, the Life-time Achievement Award.  In 2000, he received the Tipper Gore “Advocacy award for improving the lives and mental health of America’s children” from the National Mental Health Association.

SAMHSA is under attack - and the rank and file are paying the price

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It was joyous and sobering for me, standing on stage looking out at the audience filled with bright, passionate and dedicated researchers, policymakers and providers. Everyone attending the 28th Annual Research and Policy Conference for Child, Adolescent, and Young Adult Behavioral Health this past week, has in some way been touched by involvement in a SAMHSA-funded grant or initiative.

If my close to 30 years being involved in this work has shown me anything, it is that innovation and creativity always find a way to rise to the top. And this room was full of creative innovators.

How ironic that of the close to 700 people in attendance at the conference, easily two-thirds of them have had direct involvement with a SAMHSA-funded initiative. In that capacity, these bright researchers have been able to extend our knowledge about the science of prevention and treatment strategies that make a difference for youth with mental health challenges and their families. I can only hope that the small slice of SAMHSA that I am most familiar with, the Child Mental Health Initiative, is representative of the other initiatives that SAMHSA funds. If this is the case, then I am inspired and hopeful for the continued development of innovative treatment strategies based on the realities of today, not 30 and 40 years ago.

However, it seems that for each innovative step forward, we tend to cycle through regressive periods when we take three steps back. You know we are in a regressive cycle when you realize that we seem to have forgotten the lessons learned from the evolving science of effective prevention, treatment and support for individuals with mental health challenges. That forgetfulness is evidenced by a tendency to embrace the safety and comfort of antiquated and simplistic notions of effective treatment. We are in such a cycle right now. 

SAMHSA is under attack – rank and file are paying the price
SAMHSA, and specifically Administrator Pam Hyde, is under scrutiny by the House Energy and Commerce Committee Oversight and Investigations Subcommittee as part of their ongoing discussion of mental health reform. In the last two years we have seen pronouncements of simple, quick fix answers to some our most complex mental health challenges; the proliferation of six-word sound bytes denigrating SAMHSA (e.g., SAMSHA doesn’t care about mental illness), smug commentaries in leading newspapers across the nation that reward and encourage the constant attack on SAMHSA, and a barrage of questions and probes which focus on individual examples from agency-funded grants that show complete disregard for the overall context in which they exist. I fear that the tug of war between the Oversight and Investigations Subcommittee and Administrator Hyde is a harmful distraction to the overall functioning of the agency.

And yet, the rank and file who work within SAMHSA continue to do the work that needs doing, following orders from above and remaining loyal to the mission of the agency.

  • Can you imagine what it must be like to be an employee of SAMHSA, knowing that in the media, the agency you work for is being denigrated daily? 
  • Can you imagine how hard it must be for the employees of SAMHSA to not take this public barrage as a personal attack? 
  • Can you imagine the inherent conflict in working late, coming in early and caring deeply about the initiatives that you are a part of, only to have that dedication lumped into sound bytes that suggest incompetence at best, and negligence at worst? 
  • Can you imagine what it must be like to work for an agency that is rapidly becoming defined by the purchase of a painting or the cost of an early intervention website? 
  • Can you imagine day in and day out being equated with something that is clueless, out of touch, inexperienced, and wasting taxpayer dollars?

I cannot come close to imagining what that must be like or how it must feel.

SAMHSA employees don’t need to imagine. They live it day in and day out.

Low morale 
The strain on SAMHSA employees is obvious to me and my fellow colleagues. It is also painfully clear in polling data. In a recent poll by the Partnership for Public Service on the best places to work in federal government, SAMHSA ranks 298th out of 315. SAMHSA ranks lowest in morale in all of HHS. There are only 17 agencies in federal government who rank lower.

Brain drain
The deterioration of knowledge within SAMHSA is further evidenced by the increasing number of seasoned professionals leaving SAMHSA for other endeavors. This institutional knowledge cannot be replaced. There has got to be a solid effort to stem the tide of knowledgeable innovators leaving the agency for other pursuits.

Recommendation to Congress 
It is no secret that the House Energy and Commerce Committee Oversight and Investigations Subcommittee has had SAMHSA squarely in its sites for some time now. I have written about the childish behavior exhibited by some members of Congress in hearings with SAMHSA Administrator Pamela Hyde, as well as the contentious responses from Administrator Hyde to subcommittee questions. While that behavior on both sides may continue, the staff of SAMHSA do not deserve to be drawn into the fray.

Here is my respectfully submitted recommendation to members of Congress:

  • Thank you for your service 
    One of the most important changes in the public perception of the military of today as to the military in the Vietnam era is the almost universal respect for the soldier. No matter how much for or against military involvement in conflicts around the world, the American public seems united in honoring active duty military and veterans with the common refrain of “Thank you for your service.”  The generals and other high-level decision-makers get paid to take the barbs and the hits regarding their decisions. But the soldier is honored for his or her loyalty and commitment to doing the best job possible.

    Whenever a member of Congress decides to lay into Administrator Hyde, it would be a good start if he or she would preface the shellacking with acknowledgment of the foot soldiers working within the walls of SAMHSA. If members of Congress don’t begin doing this, then they are part and parcel in contributing to the low morale of agency staff and the alarming brain drain that is taking place. 

Recommendation to Administrator Hyde 
Yes, some of the barbs thrown your way have, for the most part, been out of context. But the field needs you to rise above and broaden your leadership approach. Viewing your leadership approach from afar feels a bit like “my way or the highway.” That may not be your intent or what you are doing in practice, but that is how it looks and feels to many in the field. I fear that if you stay on this course, SAMHSA ultimately loses. And the loss most significantly will be in the brain trust that is the staff that make up the organization.

Here are my respectfully submitted recommendations to Administrator Hyde:

  • Address low morale 
    Assign a task to the SAMHSA National Advisory Council to review the “Best Places to Work in Federal Government” poll and make recommendations for improving staff morale. Addressing the systemic low morale across the agency needs to be a high priority.
  • Revisit the GAO report recommendations 
    Revisit the GAO report and consider revising your response. At a minimum, identify strategies for addressing the spirit of the GAO recommendations around higher visibility of interagency collaboration efforts. 
  • More transparency regarding funding decision-making 
    Consider modeling the approach NIMH Director Tom Insel is taking with the development of a white paper outlining how funding decisions are made at NIMH and the approach being taken in developing their strategic plan.

Folks, SAMHSA is in crisis, and we cannot sit by and watch it both self-destruct and be torn down by political forces outside. There is too much good being done by too many good people to let this happen. Show your support for the dedicated employees who work for SAMHSA and send a clear message to Congress and Administrator Hyde that they have got to figure out how to work together.

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scott

Scott Bryant-Comstock
President & CEO
Children's Mental Health Network 

Remembering Virginia "Ginny" Wood

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ginny2The children’s mental health field has lost a pioneer and an extraordinary advocate with the passing of Virginia (Ginny) Wood. The founding executive director of the statewide family-run organization, Families Together of New York State, Ginny was loved and highly respected. Her perspective, expertise, and consultation were highly valued. Her smile was quick and steady, her voice strong and unwavering. She thought carefully about the issues at hand and always told the truth.

Ginny Wood gave so much to so many and asked only that we keep our vision squarely focused on meeting the needs of children, youth and families.

Our thanks to Mary Armstrong for organizing a letter of remembrances to be shared with Ginny's family and our collective national family. Read the remembrances below and feel free to add your own. 

Dear Family and Friends of Ginny,

Many members of Ginny’s national network of friends and colleagues are saddened by her passing. We would like to share with you our thoughts about Ginny’s contributions in the field of children’s mental health and what she has meant to so many of us personally. Some of our colleagues offered the following thoughts about Ginny as a mother, advocate, researcher, student, and above all, a friend.

Jan McCarthy, Georgetown University National Technical Assistance Center for Children’s Mental Health

  • Ginny was our partner for more than five years on a health care reform tracking project.  She contributed her own family’s experience in trying to access mental health services to each of our site visits, to every discussion and analysis, and to every publication. She kept the project grounded in reality and never let us forget how families often see the system differently from administrators and providers. During site visits she ably facilitated the family meetings and helped the team learn what really worked or didn't work for families and kids. Her knowledge, her honesty, her sense of humor, and her kindness made her a trusted and effective facilitator.

    In addition to the professional expertise Ginny brought to the project, she also brought her wonderful personality. We had many meals and late evening chats together. Ginny loved to gossip (in the good sense of the word) and wanted to know everything about everyone. She was interested in our lives and in sharing hers. She told us of meeting Bob for the first time, what a gentleman he was, and how happy he made her. I so remember her beautiful dimples and wonderful smile. She will be sorely missed by all who knew her. 

Gloria Logsdon, Former Associate Commissioner for Children and Families, NYSOMH

  • I remember all that Ginny did for the Office of Mental Health and for the children and families of New York State when she was our parent advocate on the federal grant when I first came to the central office. She was an incredibly effective advocate in those days as she worked throughout the state to rally and empower families of children with serious emotional disturbances. Since that time I've had the privilege of continuing our friendship when she was in Tampa for the children’s conference and I was in Arizona on business or vacation over the years. I'm just glad that I was able to spend time with her last spring when we got together for dinner here in Tampa and for lunch in St Pete while she was staying with relatives there.

    Our other link of course is that we both have a child with a disability, and although their diagnoses are different, the toll that that takes on our kids and on us as parents strengthened our relationship and brought us closer together.

    I'll miss my friend Ginny, but feel very privileged for the times that we shared over the last 20 years, and hope that the fact that Ginny had such a profound impact on New York's children's mental health system, and in other areas of the country, will be a source of both pride and comfort to Ginny's family as they and we mourn her passing.

Trina Osher, Huff-Osher Consulting

  • I had the privilege and joy of collaborating with Ginny on several training and technical assistance activities. The most notable was “It’s a Great IDEA!” which enabled hundreds of families across the country become more effective advocates for their children who needed special education. It was always a pleasure to work with her, not only because she was skillful and knowledgeable but because she was passionate and dedicated. Ginny was courageous – even fearless – when it came to advocating for policies and practices that would improve the lives of children, youth, and families. I honor her life and will miss her dearly.

Barbara Huff, Federation of Families for Children’s Mental Health, Huff-Osher Consulting

  • I remember about two months after we opened up the National Federation office in 1992, I received a call from the director of policy at the National Mental Health Association. Critical system of care legislation was in front of a congressional committee with a New York congressman who needed a serious nudge to support it. I called Ginny, and she had a least 20 families contact that congressman in record time. Of course, he did, in fact, change his mind!

Sheila Pires, Human Service Collaborative

  • Ginny was a wonderful colleague and friend. I was so happy to work with her on the Health Reform Tracking Project, to which she brought her wisdom, patience, inquisitiveness, and good humor. The project was immeasurably enriched by her involvement. I also called on Ginny many times to get her insights into system changes in Arizona, or to brainstorm ideas to advance partnerships with families, and she was always so generous with her time and thoughts. I will miss her. My heart goes out to her family; please know that she was admired and cherished by so many of us.

Sybil Goldman, Georgetown University National Technical Assistance Center for Children’s Mental Health

  • I am very sad about Ginny. She and I traded emails since I heard about her cancer. I’m currently going through cancer treatment, and we talked about how shocked we each were to get the diagnosis, how difficult the treatments are, how important it is to be positive, and mostly how important it is to have the love and support of friends and family. Ginny was so loved because she was truly a wonderful person – funny, filled with optimism, hard working, a great partner on any project because she always wanted to be helpful and constructive. She was a tremendous advocate for families. I valued and respected her as a colleague in this work devoted to the mental health of children and young people and as a friend. I will miss her.

Mary Evans, University of South Florida

  • She taught many of us just what it is like to be a mother of a young person with significant mental health challenges. I also respected her for working so hard as an adult on her bachelor's degree.

Beth Stroul, Management & Training Innovations

  • I saw one of Ginny’s last emails in which she said that she was looking through her papers accumulated over 30 years and remembering both working and “funning” with her many colleagues. I am fortunate enough to count myself among those colleagues. Along with Mary, Sheila, and Jan, Ginny and I were part of a team that analyzed state financing for children’s mental health over a five+ year period. Sure we worked diligently, but our work was interspersed with regular doses of funning…..laughter, irreverence, and wine… which only improved the quality of our work. Site visits were involved, and Ginny and I both fought the others mightily for the chance to do the one in Hawaii and triumphed. The couple of extra days we took to enjoy the sun and the beach allowed us to connect in a way that we hadn’t been able to before, and she so generously spent much of the time helping me through a difficult time in my own life. I could talk about her pioneering work in the family movement, her impact at the state and national levels, the depth of her knowledge, and her passion. I will remember all of those things, but I will remember best the “funning” and will treasure the memory of Ginny not only as a colleague, but as a friend. Only 10 days ago, Ginny emailed me that I owe her a martini. I’m so very sad that she can’t join me, but I will raise my glass and toast her for all the lives she touched, including mine.

Mary Armstrong, Dept. of Child and Family Studies, University of South Florida

  • What a privilege it has been for me to assemble this letter! I feel so gifted because Ginny has been a friend and colleague for over 25 years. For me, first of all, Ginny was Jim’s Mom. Her courage and persistence in “never giving up” in efforts to get Jim the appropriate services and supports was such a witness for what advocacy is. Second, she was a friend. We shared so many things: a common background growing up in upstate New York, an absolute love of politics wherever we lived. And she was a colleague in many venues: partners in Albany working to improve the system of care, partners on the national level on several research projects. Ginny was also both savvy and smart and presented many unanswered research questions for us to address. I am so grateful that I spoke with her very recently and am so saddened by her loss.

    Her memory will be cherished by us all.

Children's Mental Health Network readers are invited to share their remembrances of Ginny in the comment box below. 

A mother responds to childhood trauma; a family begins to heal

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Morning Zen Guest Blog Post ~ Deborah Sheffield

Last week we featured a Morning Zen post from Daun Kauffman where he appealed to Pennsylvania Governor Tom Wolf, to seriously address the issue of childhood trauma. A reader sent in a heartfelt response from the perspective of a mother with mental health challenges. She gave us permission to share her letter but wanted to make sure it was okay with her daughter first. You can read her daughters' response at the end of the post.

Dear Daun Kauffman and Zen,

I recently read an article in a post of Zen. My beloved, determined, and successful teaching daughter could have helped you write this article! But I cried because as I read, knowing that although, as an educator she helps students-- many like those mentioned in the article…I am certain that she also would feel a sense of recognition for herself as a child with ACE, according to your definition. I recently found one of her notebooks from middle school.  It read, “I hate my mom! None of my friends can understand why because she is so nice. But I never have anything I want or need.  I hate her!”

I’m tired…and I have been so very tired for a long time now, tired of mental illness associated with those who commit horrible violence or hurtful cruelty against children. I am a mother, was a single mother…and yes, I have a mental illness diagnosis. But I was never a cruel mother to my two children, although I have many heartbreaking regrets.

When my first was born, I had spent eight months in the preparation and, in knowing that she was a girl, prepared her bedding in white and pink dotted-swiss. She had nice quality clothes waiting for her, a pink and lace-clad Ms. Noah bunny and Italian leather baby shoes. I breast-fed on demand and could recite from Your Child’s Self Esteem by the time she was 1. Her dad, she, and I lived in a 1-bedroom apartment, but she had lots of attention, as I was a stay at home mom. There were many colorful and stimulating baby toys, lots of books that were read to him by both her father and me. And there are countless photographs depicting our little lives during those early years.

Our lives were a little more stressful when my son was born in the bitter Kansas winter of l990. Our little family had just endured a layoff of my husband and relocated from the Nashville, TN area. Everything I had read supported breastfeeding as the best way to protect a baby from illnesses, so once again I nursed my child until he was one year old. He had books, toys, and songs too. He was so bright-eyed from the day of his birth! I continued my college education, even though our family had just one car. My children and I would meet my husband after work, and they waited on campus for me to attend my night class 1 evening each week.

Yes, it was difficult and not the most desirable situation, but one night a week they waited for me and then on Saturday, I spent the morning in class again. These were the early days of my children’s lives. This, along with Sesame Street, Minnie Mouse, homemade bed linens and posters of all the Disney Princesses. Little trucks, Little Tikes, and sandboxes--these were the days of books read each night before bed, and the “3 Little Kittens” who nightly lost their mittens! My daughter’s nighttime song was “Brahms Lullaby” and for my son, it was “Swing Low Sweet Chariot”…lullabies sung to them by a mother who loved them both dearly. Their dad sang to them too, “Muffin Man”. Our Thanksgiving as a little family alone in the Midwest was something like this: the four of us colored pilgrim hats, and Native American headbands to wear at the Thanksgiving table where we told the story of the Pilgrims and the Native Americans celebrating a harvest and harmony together in peace. 

That Thanksgiving, I was told by a college friend that my children were “overindulged” because of this interesting way of celebrating.

Then slowly, everything began to change. I met some friends at school who were young, unmarried, and who liked that I could buy the appetizers and drinks on my husband’s American Express card. I was naïve and lonely for friendship. As the mother of 2 young children, I needed to be at home when not at school or the library. But with new-found friendships and attention that accompanied a major weight loss, I began spending more and more time with my new school friends. This wasn’t the right thing at that time in my children’s lives… they needed the stability that had been and a structure for their young emerging selves.

But things worsened. In the spring of l992, the stress of school and a deteriorating marriage broke me; I had a breakdown that landed me in the Psych ward of a local hospital for 2 weeks and in a psychiatrists’ office in Topeka, Ks for the next 4 years; which has turned into most of my adulthood! Then, the  meds were debilitating…they made me so drowsy during the day that I could barely function; when they created a terrifying restlessness that confused me all the more, hives happened and another medicine was ordered to counter the effect of the medicine creating the restlessness and hives! These were the days when meds were given, and no information nor warnings allowed. I sincerely believed that the restlessness and hives were just further indications of being increasingly crazy, of descending further and further into madness.

My life after my breakdown was bleak and heartbreaking, but worse than anything I suffered… My children lost the attentive mother they had grown accustomed to and known since their births.

These two children have been in the forefront of my mind despite 23 years of living with Bipolar Depression… precisely 23 years next month. As a former educator, (yes, I managed my own classroom in middle school in 95-96), my heart goes out to children who are abused both physically/sexually and emotionally. As I think back on the years my children grew up… there was indeed some neglect for which I can never forgive myself. But it was not a neglect from callous uncaring; I quit helping with homework when my son came home from Elementary school and said his math teacher was “tired of his math homework always being wrong.” 

There was a divorce when my daughter was 10 and my son only six years old. As a woman trying to be “Normal” but knowing that I carried a diagnosis most people feared, I was shy and a wallflower at Brownie functions and could feel the silent judgment of the other mothers. Because of that heavy silence, I never attended a PTA meeting at their Elementary school. They played soccer with the other middle-class kids, but I never knew if the child support check would arrive timely or 3 days, one week, or 2 weeks late. Curiously, accounting glitches were the norm. Needless to say, my credit suffered and worrying about where the next loaf of bread would come from or pleading with the electric company to leave the lights on 3 more days was taxing, stressful, and something not hidden well. My children never saw me crying in the night and despite all my sadness and depression, I tried my best to be “up” when they were home and around.

The neglect that my children suffered was not some deliberate aberration, some scary threatening aspect of mental illness so often depicted in the media. We were poor; and we had a tiny or old car, always a used car. We lived in a 2-bedroom apartment/duplex but they had their own rooms because I so believed in children having their own spaces to call their own. My bed was a day bed in the living room, and I dressed in the 1 bathroom. But at night, my night meds created deep sleep… slumber that kept me from reminding them to brush their teeth or demanding lights out. When they argued, I didn’t have the energy or confident courage to stand my ground—I often gave in and was a push-over mom.

Finally, I discovered donating plasma, for 2 years I made 45.00 a week selling the fluid from my blood twice weekly. It bought after school snacks, put gas in the car, and also gave my youngest son allowance each week after my daughter moved in which her dad and his new wife. I now have Rheumatoid Arthritis and Lupus….I don’t know if there is a connection, but certainly donating plasma isn’t the most healthy way to earn 45.00 a week!

I write this to you as a mother who was a single mom with a mental illness. Never in my life would I deliberately hurt my children! I would give my life for them gladly if needed and never was any of the neglect deliberate, but sadly they endured neglect nonetheless.  What I needed was help…not judgments and rumors; assistance with stabilizing my home… not deliberate efforts to destabilize. And what I needed was knowledge, structure, and a demonstration of caring for me as a mother of my two wonderful children from my community—not further searing isolation. I had some wonderful doctors and therapists over the years, but the community seemed so unenlightened about mental illness and supporting single moms.

My children have memories of lack. Although their father and I were increasingly incompatible and hurtful to one another in differing ways, I would give anything if I could go back to those Thanksgivings with homemade head-dresses and black pilgrim hats so that the years of their feeling lack could be undone.

I’m glad there are astute teachers, like you and my daughter, to help the children with ACE… holistic helping, with true caring, empathy, and kindness-- rather than indifferent judgment, is key to helping those children...helping those families.

Sincerely,

Mom

Daughters response to Deborah's request for permission to post in Morning Zen

  • "No, I think it is great to read that because that is what I have wanted you to understand for a long time. My ACE is really high compared to people I associate with, but lower than the kids I teach. I have worked hard to overcome the things that could have so easily brought me to a lower standard of living, but I always say that if the worst that has come from my childhood is being a young mom and cursing like a sailor, I turned out alright. I'm not embarrassed in any way. I tell people about my childhood all the time. It has given me a lot of insight and empathy. Publish away."
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