Eight advocates defy critics and come together for honest dialogue about Assisted Outpatient Treatment

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Members of Congress and their staff invited to observe...
When: August 25, 2014
Where: Washington, DC 

There have been plenty of naysayers who have made their feelings known about our plan to hold a dialogue with advocates across the spectrum of opinion on the question of Assisted Outpatient Treatment. Assisted Outpatient Treatment is one of the lightning rod issues in HR 3717 Helping Families in Mental Health Crisis Act that has drawn heated debate among members of Congress and the mental health advocacy community. Not only are we holding a dialogue, we are sending invitations to members of the U.S. House of Representatives Energy and Commerce Committee and their staff to observe our dialogue.

Here is a sampling of some of the fear-based comments that have come from Network readers:

  • "You're consorting with the enemy," "How could you give them more ammunition to make their case?" "What a waste of time." "This will go nowhere." "This is not the way we do things." "How dare you!" 

My answer to the last statement, which sums up the answer to all the others, is, "How dare we not?" 

Why are we holding this dialogue? 
Faithful readers know that the Children's Mental Health Network has been actively fostering dialogue among those with differing opinions on Assisted Outpatient Treatment over the past several months. Assisted Outpatient Treatment is one of the lightning rod issues in HR 3717 Helping Families in Mental Health Crisis Act that has drawn heated debate among members of Congress and the mental health advocacy community. The goal of the CMHNetwork has been to model a rational approach to dialogue on this issue that honors individual experience, but leaves room for finding common ground. To say "we are not going to budge on our stance" does no one any good. Drawing a line in the sand serves only to perpetuate the muddy landscape that is the mental health delivery system, leaving families without answers or direction to help guide them through the turbulent waters of having a child or young adult with serious mental health challenges.

A glimmer of hope 
We were excited when we read a news story in June that a bipartisan group of House lawmakers were looking for compromise mental health legislation. Rep. Tim Murphy (R-Pa.) expressed hope that common ground could be found on his Helping Families in Mental Health Crisis Act, which he introduced late last year. And Rep. Ron Barber (D-Ariz.) expressed similar optimism for his bill, which was introduced six months after Murphy’s. According to news reports, the negotiations would begin during the July recess.

The glimmer becomes a faint ember
It is now close to the end of August, and we haven’t heard a peep about progress with this bipartisan effort. Making matters worse, when Congress reconvenes, the opportunity to get anything meaningful accomplished is doubtful, with as little as a two-week window according to some of our sources in DC.

Time to take charge of the pace 
It seems we have two options. We can criticize Congress for not doing their job and wring our hands. Or, we can take charge of the pace of discussion and model effective collaborative problem-solving. Doing the latter has multiple benefits. First, it gets advocacy leaders with differing perspectives in the same room listening to each other, and second, it signals congressional staff that the populace, the voters, the constituents, (whatever noun suits your fancy) are formulating a strategy to move forward. Instead of the current soundbites of "This is what Murphy is saying," or "This is what Barber is saying," maybe, just maybe we can move forward the conversation to "This is what the people are saying, and it's complicated, and controversial, but the people are determined to figure it out."

Enough with the perpetual arm wrestling, folks.

Big time props to the brave eight who have made a commitment to stick their necks out, take a page out of the humility handbook, and participate. Take a look at the list below (in alphabetical order) and if you have the time, send them a note of encouragement for putting themselves on the line:

Our strategy for conducting a dialogue among advocates on Assisted Outpatient Treatment

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The Advocates Dialogue on Assisted Outpatient Treatment (AOT) is being conducted to achieve two primary objectives: 

  • For advocates 
    Bring together advocates on both sides of the AOT discussion to listen to differing perspectives and share ideas for how to move the national conversation about AOT forward. Key to this effort is a focus on strategies that facilitate collaboration, civility, and improvement of services and supports for individuals with mental health challenges, their families and the communities in which they live. 
  • For congressional representatives and staff 
    Provide an opportunity for congressional representatives and staff to observe the dialogue and gain deeper insight into the perspectives and the different advocacy positions. Since legislative staff are critical to the writing of language in any proposed bill that addresses this topic, it will be beneficial for them to have a broader understanding of perspective and utilize that broadened perspective in working on compromise language.

    We will capture key points and suggestions for moving the dialogue forward in the discussion and will prepare a written report for dissemination to members of the House Committee on Energy and Commerce for their consideration as they work toward compromise language to pass meaningful mental health legislation.

Note: For background context on the creation of the Advocates Dialogue on Assisted Outpatient Treatment, please click here

Overall purpose of the dialogue 
The goal for this meeting is not to pit "for" and "against" head to head. Quite the opposite. The purpose of the discussion is to provide an opportunity for the sharing of personal experience around the challenge of addressing this issue and the emotion it brings – precisely why this discussion will not focus on research, data or other props to support a position one way or the other. Everyone in the discussion is quite astute and could argue a position either for or against with plenty of supported data to back them up. 

What happens the night before the dialogue?
The dialogue experience will begin with dinner on Sunday, August 24th. The only rule for this dinner is that there will be no discussion of the dialogue to take place the following day. Our hope is that by breaking bread together we will be able to get a richer sense of the gifts each of us bring to the conversation to take place on the following day. 

How will the dialogue be structured? 

  • Scott Bryant-Comstock will facilitate the discussion. Discussants will be seated in a circle in the center of the room. Congressional members and staff will be invited to observe the discussion. 
    Note: There will be plenty of opportunity in the coming months to widen the circle of discussants. We consider this dialogue a beginning of many dialogues. 
  • No charts, graphs, research studies, or speeches allowed! There have been presentations of research on both sides of the issue in many different forums. And it seems to us that neither side is listening to the other, so we are gonna leave the PowerPoints behind!
  • At the end of the dialogue, observers are welcome to interact with discussants in an informal "after the meeting" environment. We are not asking for any commitment or public statement from any of the observers. 
  • The goal of the discussion is not to “solve” anything – just to broaden understanding of the unique perspective each brings to the topic. Quite bluntly, our goal in this meeting is not to convince members in Congress of what the “right decision” is, but more to encourage continued and more frequent dialogue between proponents of both bills. Knowledge is power. Ignorance is bliss, which is always short lived. 

Why hold an invitation only event? 
With the well-documented rancor and ill will regarding this topic expressed publically over the past year, we knew we needed to create an environment of safety for constructive, honest dialogue. As well, a room full of supporters and detractors tends to encourage the delivery of platform speeches instead of honest, personal reflection, which is what we are looking for in this dialogue.

We are purposely inviting only members of Congress and their staff to observe. There will be no press or additional advocacy group representation during the dialogue. Once the dialogue is complete, doors will be opened, and anyone is welcome to talk with anyone. Observers can choose to either engage or not once the official dialogue is over.

Moving forward
Members of Congress rely on well-informed information from the citizenry. Our observation is that over the past year, the numerous expert panels, research findings, etc. have only polarized positions. We have not seen evidence of true collaboration on the tough issues. That has to change, and we in the advocacy community have to lead that change. This dialogue is only the first step. There will be much to follow.  


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

CMHNetwork is bringing both sides of the AOT discussion together for conversation with congressional staff

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Last week, Martin Rafferty, CMHNetwork Advisory Council member and Executive Director, Youth M.O.V.E. Oregon, joined me in meetings with staff from the offices of Representative Murphy (PA) and Representative Barber (AZ). The purpose of our visit was to continue our ongoing discussion about the efforts of members of Congress who are looking for areas of compromise between two mental health bills (HR 3717 and HR 4574) currently in committee.

  • Right up front I want to give a hearty thank you to the staff from both offices for their willingness to continue to meet with representatives from the Children’s Mental Health Network. We know your schedules are incredibly busy, and we value not only the time you continue to give us, but your willingness to listen.
  • The back of the business card message from us during our visit was “Don’t give up and don’t shy away from the hard stuff!”

We stressed the importance of dealing with some of the most contentious issues in both bills and not just settling for moving forward the non-controversial ones. There has been so much discussion this past year about the state of the mental health delivery system in America; it would be a shame to take the easy way out and put forward a bill with no teeth in it to address the growing perception of a broken mental health delivery system.

The area of focus for this particular visit was primarily on the provision in HR 3717 that requires states to authorize assisted outpatient treatment (AOT) in order to receive Community Mental Health Service Block Grant funds. The Network has posted several articles from Network faithful both for and against the Assisted Outpatient Treatment provision in the Murphy bill. Like so many things in life, the issue is much more complicated than just a yes or no answer, especially for young adult children who may be living at home with their parents.

In a recent Morning Zen post, I spoke of the "inconvenient truth" that some families face when their adult children are in a dangerous place, and they are struggling with how or if to be involved in treatment decisions. The issue is real, and passions are high for and against. Since the Network has faithful followers and contributors to Morning Zen representing both sides of the discussion, it is incumbent upon us to look for areas of agreement and compromise to help move the discussion forward.

To further drive home how serious we are about modeling rational discussion and expanded understanding of differing positions, we invited both Representatives and their staff to observe a conversation between a small group of dedicated advocates from differing perspectives on the use of Assisted Outpatient Treatment. The purpose of the meeting is not to come up with an “answer” or decision on which approach is better, but simply to create an environment of civil discussion and maybe a bit more insight among participants about the perspective of others.

When we described the structure of the meeting to both offices, each were equally encouraging of such a dialogue, and while no firm commitments were made on who from each office would attend, we were encouraged enough that we are moving forward with the meeting. Representative Barber’s office has agreed to help us secure space for the meeting, and we are looking at dates in August.

We have identified a small group of individuals representing a variety of perspectives on the issue of Assisted Outpatient Treatment. All have written Morning Zen posts for the Children’s Mental Health Network or are Advisory Council members actively involved in the discussion of the issue. Participant names are hyperlinked to their Morning Zen posts.

So far, we have the following commitments to travel to Washington, DC for this meeting:

As always with the Network, everyone pays their own way, and we appreciate the commitment and sacrifice these wonderful advocates are willing to make for this effort.

Here is the structure of the meeting, which is actually quite simple. Just the way we like it!

  • The small group will convene to discuss perspective and experience with Assisted Outpatient Treatment.
  • No charts, graphs, research studies allowed! There have been presentations of research on both sides of the issue presented in many different forums. And it seems to us that neither side is listening to the other, so we are gonna leave the PowerPoints behind!
  • Legislators and legislative staff will be invited to observe the discussion.
  • At the end of the discussion, we will open it up to questions or comments from legislators and legislative staff. We are not asking for any commitment or public statement from legislators and their staff at this meeting. Square one folks. It’s time advocates model the practice that they preach. 
  • The goal of the discussion is not to “solve” anything – just to broaden understanding of the unique perspective each brings to the topic. Quite bluntly, our goal in this meeting is not to convince members in Congress of what the “right decision” is, but more to encourage continued and more frequent dialogue between proponents of both bills. Knowledge is power. Ignorance is bliss, which is always short lived. 

Pretty darned simple and basic. This meeting is not designed to move the earth. It is simply designed to get people with different perspectives in the same room for a calm and rational discussion – something that we have not seen evidence of to date.

We will keep Network faithful posted as the meeting takes shape. To borrow a phrase from the Moral Monday movement in North Carolina, “One step forward, not one step back.”


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


An inconvenient truth that needs to be addressed in a Murphy/Barber compromise: Assisted Outpatient Treatment versus individual choice

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We were pleased to learn that a bipartisan group in the House of Representatives has been meeting to look for some common ground on two mental health bills introduced this Congress – HR 3717 (Rep. Murphy, PA) and HR 4574 (Rep Barber, AZ). While there are similarities in the two bills, one of the lightning rods that distinguishes the bills from each other, and is dividing the advocacy community, is the issue of self-determination and individual choice in treatment decisions for those with a serious mental illness.

A bipartisan meeting focused on compromise is a positive development and gives us hope that some useful steps toward mental health reform can come of this instead of two competing bills both dying in committee.

However, in the spirit of compromise, we hope our elected officials will not shy away from one of the most contentious elements of the Murphy bill that is not in the Barber bill – Assisted Outpatient Treatment (currently, forty-five states permit the use of assisted outpatient treatment). The concept of “forced treatment” raises a host of concerns and has put the mental health advocacy community in opposition to each other, which is the last thing we need if we are serious about improving mental health services in America.

In an interesting critique of the Murphy bill by John Grohol of PsychCentral, he states:

  • “So here are the major problems with this bill, and why it stinks for everyone — especially patients. You can kind of tell this isn’t a bill directed at patients and helping patients in the mental health system simply by its name, “The Helping Families In Mental Health Crisis Act.” You see that there —families. Not people with mental illness. This is about helping families deal with a family member who has an apparent mental illness — not about helping the actual people with a mental illness.”

And there, likely unintentionally stated, is the inconvenient truth of this debate. Yes, there are families with young adult children who are in crisis – today. And we are hearing from these families that they can’t wait for the promise of prevention programs that may provide great things, but not today. What happens today? What is their recourse today? How do they deal with the gut-wrenching worry of not being able to keep their young adult children safe from harming themselves or others today? How do parents who are ardent advocates for self-determination and individual choice resolve the internal conflict of knowing inside that their child needs help, but not being able to provide it? How do they resolve the conflict of doubt – second-guessing their internal intuitive compass that tells them there is trouble afoot?

There are no easy answers to these questions, but to deny the existence of these struggles is as wrong as it is to say that everyone has the right to choose, and that is that. Unfortunately, overlooked in much of the debate about the Murphy bill in particular, is an inconvenient truth – there are families with young adult children who need help now, today, not sometime in the future.

Strip away the personalities of members of Congress involved in this debate, national advocacy group position statements either for or against, and the research data that both sides of the issue present to provide viability to their positions. Strip away the inevitable stigma promoted in the press that individuals with serious mental illness are violent. Strip away the raging debate on the effectiveness and appropriateness of the use of medication. Strip all of that away and you still have an inconvenient truth that is festering like a burr under the saddle:

  • I am fearful for my son’s life because his brother is hearing voices telling him to kill his brother. 
  • I am fearful that if my child doesn’t take his medication he will get in trouble and end up in jail.

There are families with children in deep crisis who need help now.

The Children's Mental Health Network is a huge proponent of the recovery movement and has written about numerous examples of successful strategies for helping individuals take a self-directed approach to getting better. But what does that mean for those families and youth who are in a different, more dangerous place? How should we respond to parents who are frightened by their child when he or she is in a psychotic state, scared for the safety of siblings, others, or themselves? Where is their voice being heard? I am increasingly hearing from parents that national advocacy groups are muting the discussion of this inconvenient truth.

We need to embrace the voices of families of young adults in serious crisis just as fervently as we do those families who have young adults with less serious challenges or just as we do with young adults who are doing amazing, self-directed things on the path to recovery.

Is one perspective more valid than the other? Should we discount the clarion call for individual determination that so many against the Murphy bill have spoken about? Of course not. Should we discount the pleas from family members to have more options in front of them when dealing with concerns about a loved one? Of course not – but in many respects, during this debate we have.

The unfortunate irony in all of this is that there is a plethora of smart, knowledgeable people on both sides of the issue. What we need is for these smart and knowledgeable people to be reasonable and come together in a calm and coherent manner to truly address this inconvenient truth. Whether that looks like a designated commission or committee, I don’t know, but the members of Congress working on compromise solutions between these two bills are in a great position to make it happen.

Representative Murphy, Representative Barber, you were elected to represent the interests of the people in your respective districts and to model collaborative efforts for the nation on how to address difficult issues. We expect you to do just that. We are thrilled to see a dialogue beginning about what parts of each of your bills can be crafted to result in meaningful legislation, but please do not shy away from this issue. It is real; it is uncomfortable, it is not politically correct, but it may be the most important area of focus you could embark on.  


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

Social justice is on the move in education research and practice!

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There is a social justice priority in education and mental health research, in strategic plans and in application that has reached that level of penetration where positive results are happening for children!

Social justice involves not only protecting the rights and opportunities of children and families, but also promoting what works in policies and practices that enable these and all children to thrive, to achieve academically and socially. These solution-focused approaches to quality instruction and interventions are paying off in improving the academic and social-emotional outcomes for children in poverty as well as for racial and ethnic groups who frequently have been blocked from learning through de-facto segregation and poor instructional experiences.

The signs are clear: The impact of poverty on education is being looked-at and addressed head-on in many communities. This proactive focus can become more universal if we deploy the resources and best practices to children and communities that are traditionally “left behind.”

For example, many educators, including school psychologists are more actively examining the effectiveness of early childhood in-home visits to improve the vocabulary of Latino toddlers. Vocabulary development is a critical reading readiness skill. Rachel Eisenberg and her Lehigh University team have shown that parent in-home support increases toddler’s language development, replicating the best-practice construct of structured in-home pre-school support for children.

At the NASP 2014 convention in Washington DC earlier this year it was impressive to see so many sessions and poster presentations following a social justice theme. Hundreds of presentations examined and compared actual interventions including ones supporting safe community facilities for exercise, preparing school staff for social skill instruction, finding positive alternatives to address behavior issues and to address the prejudice use of discipline policies. Gone was the traditional focus on deficits or diagnosis. School mental health professionals are playing an active role in developing strength-building systems of service for economically disadvantaged children and others experiencing institutional barriers to learning and wellbeing. One set of studies used the Special Education Elementary Longitudinal Study (SEELS) database to examine the disproportionate use of punitive and isolating school discipline practices and policies between Black and White male students (who all qualify for special education services). Additionally, this study examined how punitive and isolating practices and policies may help to explain differences in students’ self-reported levels of academic self-efficacy. This presentation by Gregory Young, Ph.D (Kennedy-Krieger Institute, Johns Hopkins) reconfirms decades of research and data on disproportionality regarding harsh discipline use for Black males. Although this study did not directly look at alternative practices and policies, results support the use of alternative evidence-based strategies for behavioral managing within schools.

Many school systems are now implementing alternatives to suspension and expulsion including restorative justice programs where problem solving replaces punishment (see previous Morning Zen post on the use of “Planning Centers” to replace in-school suspension). These are promising practices that show positive results in reducing behavior problems, increasing attendance and better connecting students to school. 

The NASP convention included a host of energized and dedicated school psychologists, trainers and graduate students providing documentation of studies on interventions, policies and practices directed at addressing the neediest children’s academic and social-emotional learning. The measured impact of prekindergarten was presented with an academic focus. In less than a decade, many more educators and school mental health professionals are focusing on strengths as the tools for teaching and interventions. Click here for more information.

Early interventions, promoting language development in parenting skills and resources can help overcome some of the barriers to learning poverty presents. Rather than seeing these children as “learning disabled,” researchers and practitioners alike are refocusing on prevention as the intervention. Examples abound. The spring symposium of the National Joint Committee on Learning Disabilities focused on the barriers that poverty place on learning and the critical interventions that may remove such barriers. Again the stress was in-home support and early childhood education. Similarly, in a briefing held at the U.S. Capitol on April 30th using the same concept of family and home support, parental coaching and engagement were shown to teach social/emotional and problem solving skills in toddlers. This congressional briefing sponsored by Rep. Susan Davis highlighted the success of social skills education at all levels of child development. This shows that public policymakers recognize both the need for social skill development and the critical value that these skills present to address barriers of poverty. Grant programs and national policies based on best practices can positively change practices, integrating social skills into instruction. 

To quote the Collaborative for Academic, Social, and Emotional Learning (CASEL), “Two bills that support social and emotional learning have been introduced in the U.S. House of Representatives during the 113th congressional session. HR 1875 was introduced on May 8, 2013 by Rep. Tim Ryan (D-Ohio) and has garnered bipartisan co-sponsorship. HR 4509 was introduced on April 29, 2014 by Rep. Susan Davis (D-Calif.) with Rep. Tim Ryan as a co-sponsor. Both bills provide strong support for social and emotional learning.” CASEL is following this legislation closely so visit their website to stay informed.

The barriers poverty presents will also require targeted interventions for children and youth who are already falling behind. Robert Balfanz of the Johns Hopkins University School of Education pushes strongly for a focus on 9th grade. In his op-ed titled: Stop Holding Us Back, (NY Times, June 8, 2014) Balfanz found that there are 660 high schools in 15 states that teach only “poor kids of color” and that account for more than half of the Black males who do not graduate. Targeting resources to effectively address the academic and social/emotional learning needs of these youths when in 9th grade has been shown to increase their graduation rate. Implemented with fidelity and properly resourced these 9th grade academies for all those who we know are “at risk” are successful when compared to failed and costly retention. As Balfanz cautions, “These young men are waving their hands early [by sixth grade] and often to say they need help, but our educational and student support systems aren’t organized to recognize and respond to their distress signals.” Most school systems intervene by retaining those who fail and giving them the same inadequate instructional experience over again. Balfanz acknowledges that early childhood preventive interventions are critical as the research supports but that positive preschool experience must be followed by consistent sound instruction and high expectations. He says that for those who are still falling behind more intensive interventions will succeed. What Balfanz found is that the schools for poor children are not equipped or resourced to meet the challenge. He notes the success of some high schools in 14 urban districts where he has joined with two other non-profits in forming Diplomas Now for addressing the needs of middle school and 9th grade youth, improving attendance and academic learning.

Social justice is blossoming across the nation among professionals, policymakers and community stakeholders. Let’s keep this trend going for the sake of our childen!

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.

The trouble with third culture kids

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Due to a great deal of interest we are re-running this Morning Zen post by Nina Sichel, who is co-editor of the collections "Writing Out of Limbo: International Childhoods, Global Nomads and Third Culture Kids (2011)."

3rd cultureYou may not notice her.  At first glance, she may appear perfectly comfortable -- these kids are chameleons, adept at taking on the colors of each new environment they are plunged into.  She looks and sounds like the other kids in her class; she wears the same kind of clothes, has the same gadgetry, carries the same backpack.

Perhaps she comes to your attention because she is having adjustment problems, like any other new kid on the block.  She isn’t making friends easily, doesn’t join group activities.  She is withdrawn, uncooperative, angry or disruptive.  Or maybe she’s been diagnosed and labeled, but it doesn’t seem to explain everything.

She doesn’t want to talk about it.  She doesn’t know where to begin.

What you don’t know and can’t see is that she is a Third Culture Kid (TCK) -- a child who has moved in and out of foreign countries as her parents have transferred around the world.  Born into one culture, raised among others, her identity is most closely aligned with others raised like her, moving internationally.  She is not “from” anywhere.  Although she was born here, for her this country is another foreign assignment.   Feeling out of place is only the tip of the iceberg.  She is struggling through yet another adaptation, another culture shock, another freefall.

kid2TCKs are the children of international business people, global educators, diplomats, missionaries, the military  -- anyone whose family has relocated overseas because of a job placement.  The children attend international or host-country schools, or are sent to boarding schools, or are home-schooled.  They are supposed to be coming home -- even if they’ve never lived here, even if they’ve only been back on furlough.  Often, this is their most difficult relocation.  There are nearly a million in international schools around the world; others in Department of Defense schools on international military bases; countless numbers returned to their passport countries of origin.

Rebecca Grappo, an educational consultant who specializes in the placement of these children, says there are three basic things all children need:  belonging, recognition and connection.  For TCKs, these basic needs are ripped away with each move.  Powerless in the decision to relocate, their many losses are often not acknowledged even by their own parents, and the main problem is unspoken, unrecognized, shunted aside.

It looks like depression, but it’s not.  This is the face of TCK grief.

And, according to Ruth Van Reken, unresolved grief is the most urgent mental health issue facing TCKs -- the children as well as the adults they will become.

Herself a TCK, Ruth Van Reken has spent a lifetime writing and advocating and teaching about the psychological impact of an internationally mobile childhood.  Along with the many benefits come challenges that must be faced with each move the child makes.  She states, “The issue is that transition always involves loss, no matter how good the next phase will be. Loss always engenders grief and the greater you have loved a situation or place or people, the greater the grief.”

The layers of loss run deep:  Friends, community, pets.  Family, toys, language.  Weather, food, culture.  Loss of identity.  Loss of a place of comfort, stability, a safe and predictable world.  Home.

These children are losing the worlds they love, over and over.  They cycle through the stages of grief each time they move -- or they don’t, and push it down, submerge it, only to have it bubble up later in life, unexplained.

The grief of children is often invisible.  They are told they will adapt, they are resilient.  They are told they’ll get over missing that friend, they’ll get another pet, they’ll have a nicer room in the new house.  Their family is rushed; they don’t have time to mourn their losses.

And they are children, and don’t know how to express what they are feeling.

Some mental health professionals call it trauma.

Kathleen Gilbert has researched grief among TCKs, and writes, “Losses that are not successfully resolved in childhood have an increased likelihood of recurring in adulthood... For TCKs, questions about who they are, what they are, where they are from, what and who they can trust are examples of existential losses with which they must cope.  And the way in which they process these losses will change, or may even wait until long after their childhood.”

So when she comes to you, don’t ask her where she’s from, or what’s troubling her.  Ask her where she’s lived.  Ask her what she’s left behind.  Open doors.  And just listen.  Give her the time and space and permission she needs to remember and to mourn.  She has a story -- many stories.  And she needs and deserves to be heard, and to be healed, and to be whole.


Morning Zen Guest Blogger Nina Sichel 

© Nina Sichel

Nina Sichel is co-editor of the collections Writing Out of Limbo: International Childhoods, Global Nomads and Third Culture Kids (2011) and Unrooted Childhoods: Memoirs of Growing Up Global (2004). She leads memoir-writing workshops in the Washington, DC area and continues to collect stories and research about international and cross-cultural childhoods. She can be reached at nsichel@yahoo.com.

Ruth Van Reken is quoted from an email exchange; Kathleen Gilbert’s essay “Echoes of Loss: Long-term Grief and Adaptation among Third Culture Kids” appears in Writing Out of Limbo.

Blended grants - The homogenization of family and youth voice has begun...

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The latest grant announcement from SAMHSA caught my eye, and I found myself muttering under my breath, "Okay, here we go. The homogenization of family and youth voice has begun."  

SAMHSA has just released an RFA for fiscal year (FY) 2014 Statewide Peer Networks for Recovery and Resiliency grants. Eligible applicants are SAMHSA Network grantees in the nine states where there is an RCSP-SN award and either one or both a Statewide Consumer Network  and Statewide Family Network. The kicker is they have to submit an application together. 

In the description it states that the purpose of the grant program is to:

  • Create statewide networks that represent mental health and addictions recovery communities to improve access to and the quality of behavioral health systems, services, treatment and recovery supports statewide.
  • Bridge and unify recovery networks for mental health consumers, families of children with serious emotional disturbance and youth, as well as those in recovery from addictions.  
  • Link formal statewide substance abuse recovery networks with formal statewide networks representing mental health consumers and families to represent a single voice for behavioral health statewide.

The funds for this effort are coming out of CSAT so Statewide Family Network grantees can breathe – the funds are not coming out of the pot that covers current Statewide Family Networks. But don’t get too comfortable. This grant announcement looks like a clear example of the long-anticipated move by SAMHSA to merge program efforts together where possible and create “one voice for behavioral health” as they state in the description.

I must be getting’ old cuz I feel like I have been to this rodeo before. Let’s see, oh yes, it was 1988, and a group of rowdy parents had the nerve to say “Our issues are getting lost and not addressed by providers, communities and current children’s mental health advocacy voices.” Hence, the birth of the National Federation of Families for Children’s Health, that began its work under a mission to provide a different voice for families. A voice that spoke directly to those parents who had children young and old, with mental health challenges in school, home and community, and not just those who had a serious mental illness and were approaching adulthood.

Come to think of it, there was a similar rodeo that I first encountered in the early 1980’s that has progressively gotten worse leading up to current day. Fairly consistently I have heard the lament from state level Children’s Mental Health Directors that they are at the bottom of the funding food chain. Heck, in some states, they have completely done away with specific children’s mental health sections. And I just love the politically correct euphemisms used to camouflage the eradication of a clear children’s mental health voice by using wonderful descriptors to describe consolidation efforts like  “Community Policy Management,” “Advocacy and Customer Service,” Community Services Division,” and dare I say it, “Behavioral Health.”

Remember folks, the train known as health care reform has left the station. We are entering the new age of rampant consolidation in an effort to save money. With all of the wonderful components of the ACA that are afforded to people in this country, one of the potential, and increasingly visible, casualties is the loss of a clear voice for children’s mental health. We can’t let that happen.

What Network Faithful can do 
First, let’s applaud SAMHSA for trying this approach out in nine states. Who knows, it may work incredibly well, and that would be a wonderful thing. But let’s not leave this one up to chance. I want to encourage all Network faithful to pay attention to how these grant efforts roll out. You can bet that our good friends in the substance abuse and consumer movement communities will be paying attention. We need to be vigilant as well.

We will keep you posted on developments (who applies, who gets funded) as they emerge. For now, if you are in one of the nine states and are eligible, we hope you apply. Gotta be in the game if you are going to be part of the change.

And the change is a comin’.

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

SAMHSA/HRSA integrated care core competencies manual needs stronger focus on primary care providers

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Morning Zen Guest blogger ~ COL (Ret) George Patrin, M.D., CMHNetwork Advisory Council Member 

Subject: Review of SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) Core Competencies for Integrated Behavioral Health and Primary Care “promoting development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings,” purported to be “the first ‘national home’ for information, experts, and other resources dedicated to bidirectional integration of behavioral health and primary care.”

This CIHS Core Competencies manual is a “valiant effort to improve the effectiveness, efficiency, and sustainability of integrated services, which ultimately improves the health and wellness of individuals living with behavioral health disorders.” It is jointly funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) and provides training and technical assistance to community behavioral health organizations receiving SAMHSA Primary and Behavioral Health Care Integration grants, as well as to community health centers and other primary care and behavioral health organizations leading the field in providing better mental health care to their reliant population more efficiently. It is a very thorough and detailed manual laying out processes to truly incorporate mental and behavioral health into a primary care clinic settings, whether Pediatrics, Family Practice, or Internal Medicine. This represents a great effort to generate a national focus on integrated care with a single, widely recognized set of multidisciplinary competencies with a service approach for both behavioral health and primary care work forces. That said, all specialties should look to establishing integrated relationships with their Primary Care colleagues.

To truly support total health and wellness, “comprehensive first contact and continuing care for… any undiagnosed sign, symptom, or health concern,… health promotion, disease prevention, education, diagnosis and treatment…” competency processes must be centered on primary care rather than mental health care, both being vitally important, of course. To their credit, SAHMSA did ensure psychiatrists, psychologists, social workers, advanced practice psychiatric nurses, marriage and family therapists, addiction counselors, mental health counselors, psychiatric rehabilitation specialists, psychiatric aides and technicians, and peer support specialists and recovery coaches were all included in formulating these credentials. Unfortunately, this document risks acting as a 'lobby' for behavioral health professions in not detailing Primary Care professions as well up front. Additionally, Senior Content and Expert Key Informants are nationally recognized experts in National Mental Health and Family Health Medical Services, but the Primary Care voice didn't come through as strong in achieving holistic recommendations. Certainly, if every office carried out every process outlined in this initial manual they would be more "integrated." But for the average practice this manual may be too overwhelming for the sheer number of items it calls to address, producing more ‘box checking’ than actual integration if we are not careful.

Behavioral health is distinguished from “general health” in this manual, “recognizing imperfections in the distinction and language used to describe it.” But is “Behavioral health… distinct from healthy behavior?” I think not, as behavioral choices lead to healthy or unhealthy lifestyles, ultimately. Point is, people with undiagnosed or improperly treated mental illness, acute and chronic, are not in control of their behavior, or choices, until we assist them in understanding their condition(s).  Susan Blumenthal, M.D., Public Health Editor, The Huffington Post, and Former U.S. Assistant Surgeon General wrote “Mental health is fundamental to overall health. An important step forward is to recognize mental illnesses are like other diseases and must be diagnosed early and treated effectively. A critical component to reducing the toll of mental illness on individuals and communities is ensuring universal access to mental health care worldwide (A Mission to the Mind, June 5, 2014).” To seriously address the stigma of obtaining mental health care, integration of behavioral health processes into primary care services with comprehensive care plans is the best place to begin. The committee also notes: “the term ‘health conditions’ …is not specific to behavioral health.” They wisely call for the creation of “updated integrated care plans in consultation with healthcare consumers, family members, and other providers, including individuals identified by consumers as part of their healthcare team” within the care coordination core competency.  A wonderful competency premise raised by this committee is focusing recommendations on “consumers and family members as partners in the healthcare process whose strengths, goals and preferences should drive healthcare decisions.” We will get this right if we keep this premise the driving force. The first step in making this happen is to have our client, the consumer, sign an informed choice document on first visit listing the trusted individuals to call on should the patient be incapacitated from making healthy life-sustaining choices. This important detail is not addressed in the manual. We must not allow our interpretation of HIPAA directives to stop us from laying out crucial processes in this foundational credentials manual. 

It is gratifying the team came up with a single integrated set of competencies, realizing “most competencies required for integrated care were common to behavioral health and primary care providers…(and) separation would promote continued silos between disciplines and professions and foster an unnecessary interprofessional divide.” ALL Specialties and Consultants should heed this advice. The mandate to concentrate on “competencies generic to most basic forms of healthcare, such as those related to interpersonal communication” is crucial, and a great beginning, as “they are absolutely essential to the effective delivery of integrated care.” A major concern, however, is the authors have put their viewfinder on what the provider of integrated care can actually ‘do’ today, basing the competencies on ‘what is’ in practice currently, rather than what ‘must be.’ Implementing integration competencies training for our employees may not result in truly integrated processes if we avoid addressing integration of business processes frustrating our consumers and employees in delivering promises integrated care can deliver. “Levels 4, 5, and 6 integration, (involving) either close or full collaboration and one of three organizational models: some systems integration, integrated practice, or transformed/merged practice” must be addressed, or we risk perpetuating the current business model focusing on what we get paid for today, rather than what we should be doing. Unfortunately, our sick-care system concentrates on crisis intervention services today because that is where we are spending the most health care dollars. We need to reduce that expense by reducing need for these services with much less costly proactive preventive integrated services. Artillery units know we will not hit the target (outcome) we desire if we don’t aim with the proper trajectory. If we aim low in our expectations, we will not achieve desired outcomes! We have a long way to go in this regard, although transformational payer leaders are beginning to understand the difference between fee-for-service and bundled (capitated) prevention practices. Fact is, we need both types of incentives based on services provided by the type of practice – primary versus specialty care. To develop competencies with the end in mind, they must be written to the proper end state, accepted by all team member professions, and credentials should support this skill set with administrators as well as concentrating on clinical knowledge. “Knowledge and attitudes make the desired behavior possible, (and) demonstration of (an) essential skill(s) is the desired outcome” in our employees, but let’s set our teams up for success, and base those skills on a new paradigm of shared business resources and clinical skill-sets upon integration. For example, advisors suggest “competencies may not be applicable to care managers or navigators” indicating the recommendations are based on old disease and utilization management methods, rather than hands-on, consumer-centered clinical support and referral access processes at the ground level, in the clinic. Some call this "the medical home" model. This distinction is paramount to generating appropriate job descriptions and job roles to improve employee satisfaction, retention, and formal performance reviews, which ultimately drive consumer satisfaction.

While this directive did consider the “issue of culture… in all efforts to understand health, illness, treatment, resilience and recovery,” it appears to have concentrated on the culture of the consumers only. Ultimately, we must turn the magnifying glass on ourselves to identify core cultural and business changes required to truly provide patient (consumer)-centered wellness services, an approach leadership has missed to date. Writers state “effective delivery of integrated care requires system modifications to support changed practice,” but then go on to say “system design was outside of the scope of this project.” I submit this is the most important aspect of developing “core competencies” to lead integration. “Financing and organization of care delivery” are the major barrier to “ultimate competence of providers (and their teams) working (our) delivery systems.” Under the mantle of transformation, aside from locating a behavioral health specialist within the walls of a primary care clinic, processes still serve to separate specialties under separate funding streams and supervisory responsibilities. Integration refers to collaboration between primary care providers and all specialists and subspecialists on behalf of our client, the patient, not just behavioral health. To truly remove barriers in accessing the most urgent area, mental health, we must 'reassign' current assets, to include employees, from current Behavioral Health Clinics and services to Primary Care settings, whether on site or virtually connected to provide same day services. Additionally, funds for training need to be shared as well. This will be the biggest hurdle to drive true integration and elimination of redundancy and waste in the provision of services centered on patient needs and family concerns rather than the business bottom line.

Tearing down silos, then, is our biggest challenge to achieving a one team effort, eliminating referral and treatment patterns requiring patients to wait for access and once in, hand-carrying information from one office to another, one provider to another. Ultimately, the primary care provider is the most trusted health contact, the hub of information, and the constant adviser to ensure all processes are in the best interests of the whole patient without overlap or adverse side effects. All specialists, from behavioral health to pharmacy and all sub-specialties, should propagate a flow of information in and out of the Primary Care Team hub to and for the patient, who is, after-all, everyone’s client. Credentials competencies should address "Who works for who," meaning, how is information  shared. Working off a comprehensive care plan, then, in a shared electronic health record (EHR) is paramount to building the ultimate integration model.  This should have been listed as a key competency in administration. Unfortunately, presence of an integrated EHR doesn’t guarantee all team members are accessing it or sharing their work within it, often because misconstrued HIPAA rules dissuade us, or lack of time due to work productivity demands prevents us from accessing past history and plan(s) in it. And let’s be honest, obtaining an EHR does not mean vital information in historical paper records is being transferred to it. This is a procedural competency not addressed in this initial effort.  

An ongoing concern of integration efforts is emphasis and management by behavioral health (BH), in this case the Annapolis Coalition on the Behavioral Health Workforce, a non-profit organization dedicated to “improving recruitment, retention, training and performance of the prevention and treatment workforce in the mental health and addictions sectors of the behavioral health field,” not primary care as a whole. It seems the recommendations, then, are meant to “shape curricula and training programs on integrated care,” but for behavioral health trainees primarily. An important detail not clearly outlined is a call for all sub-specialists to be cognizant of the need to keep primary care colleagues trained to the top of their license in each specialty area. We must all “educate others within (our professional circles).” BH specialists must understand they are to train PC colleagues to the top of their skill set in evaluating and treating MH conditions so the specialist can truly, then, operate at the top of their license, eliminating redundancy and cost. The integrated specialist should be carving out perhaps 20% of their time to train and provide acute consultation during the course of a work day. Fact is, after appropriate transformation to preventive efficient care medicine, centered on the consumer, we may need fewer specialists and certainly less hospitals to admit them to. Jobs will change and need for many specialists, yes, even psychiatrists, may decrease. We all need to get ready for this cultural awakening of the future and avoid letting ‘job protection’ guide our efforts. The way forward is in “preparing and further developing a workforce to deliver integrated care” as a multidisciplinary team unencumbered by silos of funding and political isolation to protect income streams.

* * * * *

patrinCOL (Ret) George Patrin, M.D., spent over 23 years as an Army Pediatrician and Healthcare Administrator concentrating on Family Advocacy and Healthcare Process Improvement. His final assignment was as Northern Regional Command Special Projects Officer for Patient-Family Centered Healthcare assisting in writing DoD Patient Centered Medical Home (PCMH) Guidelines and Training. He has been a staunch advocate for both soldier and family member readiness throughout is military career. He is a sought after speaker on parenting education, child abuse prevention, school learning and behavior problems, and healthcare administration optimization. Dr. Patrin is a member of the Children's Mental Health Network Advisory Council. He can be contacted at patrin.george@gmail.com.

We are caregivers - A mother's story about her young adult son who lives with paranoid schizophrenia

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Morning Zen Guest Blogger ~ Melanie Jimenez 
Writing the truth to help fight the stigma that surrounds the diagnosis and to help people better understand the illness. 

We Are Caregivers 
Often there isn’t a lot said about the caregivers for someone with schizophrenia. We tend to show up in stories written by the media after a tragedy happens and then we are put under a microscope for people to determine if we have done the right thing in raising, caring for, and protecting our loved ones. Often the judgment comes down on us from those who don’t have the first clue what it’s like to be a caregiver. It’s so easy for them to say what they would have done differently if THEY were the ones deciding the fate of our loved ones with schizophrenia. It’s so easy for them yet it is one of our most difficult jobs and one that we pour our heart and soul into daily.

To begin with and most importantly there is love. We, as caregivers, love our person with schizophrenia with our whole hearts. If we are parents to someone with schizophrenia there is also an even tighter bond because our child was created by us, born to us, and lovingly raised by us. We have ALL given pieces of ourselves, sacrificed our own way of life for them and have spent many late nights worrying and praying. Behind the closed doors of our homes or a therapist’s office or a psychiatrist’s office we put our heads together to decide what is best for our loved one and sometimes our choices work but more often we are less than successful. You see, it’s isn’t easy caring for our loved one. Besides making normal life decisions, we are also forced pretty often to decide FOR our loved ones what is best for them. Sometimes, though, we fail in our choices and find ourselves in a quiet room, our heads in our hands, defeated. The beautiful thing about we caregivers, though, is that we never give up. 


Then there is tenacity. We caregivers are fighters to the bitter end. We fight for proper medical care, humane treatment and respect for our loved ones. We are advocates of the strongest kind and we are a force to be reckoned with. Often you will find us fighting for rights to see our loved ones locked behind hospital doors hoping for a chance to talk to their doctors and offer insight that no one has but us. We are found on trails and surface streets wearing our t-shirt in support of our cause while we walk, run and bike for miles to raise money for research. We sit quietly at our desks writing a check or two to our favorite organization that supports and educates others about schizophrenia and other mental illnesses. In the smallest, yet biggest way, our sometimes quiet voices raise up in earnest to defend our loved ones to family members and friends who just don’t seem to get it. We are fighters, we are advocates, we are the voice of our loved one with schizophrenia. 

In the end, we are human. We are flawed and we make mistakes. In the end, after we have given our heart and soul, sometimes we aren’t successful in our fight. In the end, love does not always conquer all. In the end though we did everything we could and we did it with love, with intelligence, with experience and with a fight rivaling that of a mother bear defending her cubs against the predators that threaten their life. 

We are caregivers. We are mothers, fathers, wives and husbands. We are children fighting to understand our parent with schizophrenia and we are friends accepting our loved one for exactly who they are. We are caregivers, people from around the world giving all we have to love, protect and care for our loved one with schizophrenia. We are caregivers and we will be here to the bitter end even when society has walked away condemning our loved ones for simply being human. 

We are caregivers and we are strong. Do not underestimate us. We are here and we are not giving up.

melanieMelanie Jimenez is the creator of the blog Understanding Schizophrenia. She started the blog to help bring awareness to the realities of schizophrenia. "I wanted to be sure that people got a perspective other than the one that the media portrays. My blog shows the candid and raw point of view of what it's like for me raising, living with, and loving my son who has paranoid schizophrenia." You can read more of her written essays here.


Basking in the aura that is Maya Angelou

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angelouThe country, and indeed the world, lost an iconic figure last week with the passing of Maya Angelou. I was fortunate to have had two encounters with this great lady, and both left an indelible mark on who I am as a writer and as a person today. If you ever need to be reminded of grace, beauty, poise and incredible kindness driven by a steely strength of resolve for what is right, spend some time reading her books or listening to the many interviews conducted with her over the years. Here is one of my favorites of her being interviewed by Diane Rehm.

1983 - First encounter
I first met Maya Angelou in 1983 in a chance encounter at an antique/junk shop outside of Winston-Salem, North Carolina. At the time, I was doing consulting work with various social service agencies around the state and made it a habit of taking the back roads and stopping along the way at antique shops to look around and maybe buy something. More important, it was a chance to visit with the proprietor and local folks who would invariably be hanging out, drinking a cup of coffee and just letting life sink in.

On this particular day, I was jaw-boning with the owner and in walks this tall, elegant woman who I instantly recognized. I had read "I know why the caged bird sings" a few years earlier, and there had been recent news coverage about her appointment as a professor at Wake Forest University with plenty of photographs of this amazing American treasure.

When she walked into the store, it was more like a glide. I am not a student of auras but if there ever was a more radiant aura than the one that surrounded her you would be hard pressed to find it. It may sound like I am exaggerating but I am not. As soon as she entered the store her visual presence was matched with this incredible voice as she gave a hearty, booming, yet soothing hello to the owner of the store. She was a frequent visitor and greeted him like an old friend. After greeting him, she turned to me, looked me dead on in the eyes and said "and who is this fine young man?" Okay, here is what you need to understand about how she said those words to me. First, double the time it takes to say that very short sentence, and that will give you an idea of the pace of her question. Then think of the feeling you have when you are savoring a fine meal - one that permeates all of your senses. That is how each and every word spoken felt. I had never heard anyone speak like Maya Angelou before that chance meeting (I was all of 27 years old) and I have never heard anyone speak that way since, other than her.

The next 30 minutes were magical. She had the ability to speak to you like you had been her neighbor for years, even though you had just met. What a relief for me, as it helped me move from acting like a star-struck 12-year old at a Justin Bieber concert (I have been to one, I know what they look like) to what I love most - just a couple of old friends shootin' the breeze.

I asked her what she was looking for in the shop, and she said that she loved to go into places like this and look for old hymnals so that she could experience the poetry of the words from long ago. "You can find so much inspiration in the pages of these books," she said.

After she left I looked at the owner of the shop and said, "That was amazing." "Yeah," he said, "She comes in a lot and I get the same feeling every time."

1995 - second encounter
maya2Fast forward 12 years to 1995. At the time, I was coordinating the national conference for the Federation of Families for Children's Mental Health. I remember calling Barbara Huff, Executive Director at the time, and saying to her, "Okay Barbara, you are always preaching to me that the conference has to be totally for and about families, so what about giving them the gift of a keynote presentation by Maya Angelou?" Without hesitating, she said in the wonderful mid-western accent of hers, "Oh yeah, that is a great idea, let's do it!"

It was a bold move for a relatively new national organization still finding its way, but Barbara was determined to send the message that the Federation conference was a place for families to revel in their shared strength and become inspired by speakers who walked the walk. I will always be grateful for Barbara's leadership and willingness to go out on a limb to bring the magic and inspiration of Maya Angelou to the families of the Federation.

The day before her presentation I had the opportunity to conduct an interview in her suite at the Willard hotel. I have never been in the presence of royalty, but this must be how it feels. What made it better was that I was received at the door by one of her assistants and with the formality accorded to royals, led into the sitting area where she was relaxing comfortably on a grand sofa, looking as regal as one would look in a photo shoot for Vanity Fair. Talk about a dramatic entrance!

She rose and greeted me with those piercing eyes and booming yet soothing voice as if we were old friends. When I first contacted her office to plead with her to come to the Federation conference, I had told her assistant of our chance meeting 12 years earlier, thinking that somehow that brief encounter would get her to say yes. I'm pretty sure that had little to do with it, but her greeting to me in the grand suite of the Willard hotel was "My dear Scott, how good to see you. I am so sorry I don't remember you from all those years ago, but I do love the antique shop where we met. I still look for old hymnals," she said with a beaming smile. "Would you like some coffee, some tea or water?"

Instant melt. Just like that I was no longer in the grand suite of the Willard hotel, with an internationally famous writer, poet and symbol of triumph over struggle. It was just me and Maya sittin' on the porch in a couple of rocking chairs.

If you were at the Federation conference in 1995 and had the opportunity to attend Maya Angelou's presentation, I encourage you to share your reflections. My solid bet is that your experience was similar to mine - mesmerizing, spell-binding and oh so inspirational.

As part of her remarks that day she read her poem Still I Rise. Watch this video of her reciting this powerful poem to get a sense of the strength and grace of this most amazing American treasure.

Maya Angelou1928 - 2014

Rest well Dr. Angelou. Your spirit carries on in the lives and work of many.

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

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