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BANDWIDTH SHORTAGES & KNOWLEDGE GAPS CALL FOR POLICY-MAKING

12/2/2019

There are 4 BIG things the Mental Health Profession needs to do:

Science Up
Incorporate Strength-Based, Person-Centered Care
Acknowledge the HUGE GAPS in their Knowledge Base
Refuse to Allow themselves to be used for purposes of justifying PUNISHMENT.

So most clinicians and forensic evaluators are not totally oblivious to concerns of the above -- BUT the full ramifications of those concerns are largely not appreciated.

  THE BOTTOM LINE: It takes time and energy to THINK these issues through -- and most clinicians and evaluators are so busy pedaling or trying to make a living that they don't have time for that.

       Our Researchers are certainly RINGING THE ALARM BELLS -- but the STRENGTH OF THAT BELL often depends less on the SCIENCE and more on the INTERNAL POLITICS of the American Psychiatric Association and their propriety interests in an out of date and dangerous DSM.

   Several Countries, including the US are engaged in FOCUSED Translational Research efforts -- bringing research to clinical practice.

   Translational Research is a VITAL PIECE of our HEALTHCARE SYSTEM that has to be greatly expanded -- primarily @ the FEDERAL LEVEL.

However, States could begin Demonstration Projects such as developing clinician-researchers with Support from appropriate Universities (examples can be found in the UK).

Finally a word about Forensic Psychiatry in the Criminal Justice System -- truly, no good deed goes unpunished.

Sadly, for a lot of Forensic Psychiatry -- "I was just following orders" -- is the "raison d'etre" for:

a lot of "anti-social personality disorder" diagnoses and
ultimate punishment, including death.

As a group, people get pretty amazed by each other. On the one hand, many people might be amazed at how "disorganized" I am.

On the other hand, --- "Mental Health Profession -- Do you just NOT have any CRITICAL THINKING SKILLS?"

OMG-- we MUST provide more Support in Translational Research and Ethical Decision-making to the Mental Health Profession -- and a lot of that needs to start with policymakers.

If the Mental Health Profession & Forensic Psychiatry had the BANDWIDTH to reform themselves -- THEY WOULD.

They haven't reformed themselves & they don't have the BANDWIDTH to do it.

What does that mean for policy makers?

COMING TO TERMS WITH --THE LONG TERM NEEDS OF PEOPLE WITH SERIOUS COGNITIVE DISABILITIES

11/30/2019

A lot of my articles include the phrase "COMING TO TERMS WITH" -- that's because we have only "partially" reformed our PARADIGMS to reflect CURRENT KNOWLEDGE.

Some jurisdictions have been experimenting with "diverting" inmates with "mental illness" charged with low level crimes such as misdemeanors for over 30 years.

New York was one of the first to start diversion of people with mental illness charged with felonies (the Nathaniel Project)-- and the cornerstone of that program is ASSERTIVE COMMUNITY TREATMENT.

The Criminal Law is becoming very similar to the world of Physics where prior understandings are simply breaking down and won't work anymore.

If our big filter in the Criminal Law is INTENT -- and that INTENT is greatly impacted by Executive Functioning Deficits represented by a wide range of Cognitive Disabilities -- where are we?

Punishing people with Cognitive Disabilities, and
Under-estimating the difficulty faced by the Individual & ultimately the risk to the Community

REAL REFORM is not just about being NICE -- because as Seattle has found and others will find -- that will NOT work.

It is addressing the very large needs of people with Cognitive Disabilities -- some of which may be with individuals for the rest of their lives without major advances in treatment.

----Philosopher of Science Thomas Kuhn, author of "The Structure of Scientific Revolutions"

Nathaniel Project

Assertive Community Treatment/ Flexible ACT Index

Jail Diversion Updates

But Holmes said he also thinks the public's "consternation" over the situation in Seattle's streets is pointing toward a deeper problem.

"We're finding out that the system is really at its maximum. I think the judge and I even agree on that — that those services really are at their limit," Holmes said.

PARANOIA, WHITE SUPREMACY, HUMAN XENOPHOBIA, & LATERAL PROBLEM SOLVING

11/30/2019

The murderer in the Charleston Church massacre apparently and not surprisingly had severe mental health problems -- so much so that he fought to keep his mental health history from coming out in Court.

Several mental health professionals have referred to RACISM as a mental illness.  We think they are right with PARANOIA under-girding it.

Further, this PARANOIA seems to attach itself to whatever is in the HISTORICAL ENVIRONMENT -- which over the course of thousands of years -- changes quite a bit.

So it is important to look @ the specific context -- but it is also important to see these challenges in different historical contexts.

With respect to the current challenge of White Nationalism and White Supremacy -- we think it is at least worth trying to engage in Lateral Problem Solving.

  For most of us, it is a lot easier to say we are angry than we are hurt or scared. Some of White Supremacy is wrapped up in some real concerns about the ECONOMIC SURVIVAL of some people.

Ironically, to really embrace that -- we have to embrace EQUALITY --- and providing for the ECONOMIC SURVIVAL of ALL of US with entrepreneurship, supported entrepreneurship, employment, and supported employment.

BEYOND THAT: We need a COMMUNITY that includes ALL OF US.

BET*-- Charleston: The Complicated Consideration of Mental Health and Racism

Clarence Page: "Can Racism Itself Be A Mental Illness"

Global News: Mental Health Impact of Discrimination -- Living in Color -- Mental Health

Harvard Professor Orlando Patterson -- author of "Freedom in the Making of Western Culture," winner of the National Book Award.

MOVing BEYOND LIP SERVICE TO REAL COMPLIANCE WITH FEDERAL DISABILITY CIVIL RIGHTS LAWS

11/25/2019

WE NEED FEDERAL TECHNICAL ASSISTANCE & ADMINISTRATIVE ENFORCEMENT

It is a kind of progress to have policymakers give lip service to Cognitive Disability Concerns in the Criminal Justice System.

In fairness, it is beyond lip service -- there is SOME ACTION.

This "ACTION" is patchy, incomplete and FAR FROM SCALE.

Well, does that matter? Well, yes it does -- not only practically but from the standpoint of:

Olmstead
Parity, and
Medicaid Network Adequacy

The problem is people with Cognitive Disabilities really need:

SUBSTANTIAL FEDERAL TECHNICAL ASSISTANCE to the States to Comply with these Laws
The US Dept. of Justice to incorporate its 2011 Guidance on Olmstead into Federal Regulations
Federal Executive Agencies to provide Plans of Correction for States to come in Compliance
Modification Procedures for States if they can still comply with the law.

The idea was really to give the States as much FLEXIBILITY as possible to achieve the ends of these DISABILITY LAWS --- nobody is against that.

BUT this is COMPLICATED STUFF, and it is certainly COMPLICATED:

THERAPEUTICALLY
LEGALLY
ECONOMICALLY, and
POLITICALLY

  This really gets to the point we made about Hickenlooper -- if POLITE & CORDIAL Hickenlooper isn't going to comply with the law -- who is? Well, you can probably multiply that many times for Progressive Polis.

We don't know what is going to come out of this "Behavioral Health Task Force" --- but we aren't aware of SIGNIFICANT MEMBERSHIP from people who are JUSTICE-INVOLVED.

  Which brings us to our concern to use SOCIAL IMPACT BONDS for HOUSING -- while there was initial interest and maybe there will be again -- it has apparently fallen through the cracks @ the Polis Administration.

    Do you really think it would have fallen through the cracks if Homeless People were in charge of those State priorities?

    So the point is NOT Virtue Signally --- the point is when we don't INCLUDE EVERYBODY their interests don't get addressed.

We need the FEDS to provide MODEL TEMPLATES for the States that the States can MODIFY without sacrificing compliance with the LAW.

    FURTHER, none of these DISABILITY CIVIL RIGHTS LAWS require anything that isn't "REASONABLE" -- and States still haven't substantially complied.

TA -- Technical Assistance. Image Credit: ExpandEdSchools.org

WHERE IS THE POLIS ADMINSTRA-TION ON PROVIDING MORE HOUSING?

11/24/2019

This past week we inquired of the Polis Administration what progress had been made in the consideration of Social Impact Bonds to provide housing for people with disabilities, especially those people meeting Medicaid's criteria for long term care.

One of our most popular pages is the Housing & Homelessness Index.

This hits people with long term cognitive needs the hardest with homelessness while people with physical disabilities may be institutionalized.*

Our last update from the State was in March.

Housing & Homelessness Index

SIDE NOTE

An Outcome Contract is really a round-about -- with OUTCOMES that serve the Individual in the CENTER.

How Medicaid Mental Health Contracting became such a FAILURE is that it served:

the State, and
Providers

reasonably well -- but it didn't serve those with the most Intensive Mental Health needs.

Further, it is NOT clear that our current Mental Health Centers are the right folks to serve those people -- those Mental Health Centers have literally spent decades trying to avoid serving them.

*Many people with mental illness are institutionalized in Colorado:

Jails & Prisons -- this is the greatest source of institutionalization (several thousand)
Nursing Homes (roughly 2 Thousand), and
a Small Minority in Mental Health Institutes (less than a Thousand)

Update Nov. 24, 2019

Well, the idea seems to have fallen through the cracks @ the Polis Administration.

We want to be very clear that we do NOT think the problem is:

the people with the Polis Administration are "BAD"/ "INSENSITIVE" people
even though we do think some of the Executive Agencies unknowing slip into "organizational deviance," i.e. corruption .

We do think our current systems of INCLUSION or LACK thereof seem to be providing consistently bad results.

Orchid, other institutional advocates, providers, and state personnel are NOT necessarily the best spokespeople for every Homeless or Incarcerated Person with a Cognitive disability.

Not everybody can be part of a "STAKEHOLDER GROUP" -- but we do have the technology so we CAN get insight and preferences from the people themselves -- what they believe they need and would be most helpful.

From my experience -- Housing & Placements are right up there.

The Genteel Small Town Corruption of Medicaid Mental Health & Human Services

Tough Talk: Corruption, Organizational Deviance & Disability Civil Rights Laws

TOUGH TALK: Corruption, Organiza-tional Deviance & Disability Civil Rights Laws

11/23/2019

Federal Administrative Technical Assistance and Administrative Enforcement could solve the Small Town Corruption seemingly endemic in State Medicaid contracting.

Unfortunately, the FEDS have given the States not enough rope to hang themselves, BUT to hang or incarcerate THOUSANDS of people with Cognitive Disabilities.

We think "organizational deviance" is really the form of Corruption seen in CO Executive Agencies such as the CO Dept. of Health Care Policy & Financing & Human Services -- but very "polite" deviance.

Because they are NOT defying their own organization -- they really don't see the problem in failing to comply with:

Fair Housing
Olmstead
Parity,
Medicaid Network Adequacy,
Safe Staffing levels
Etc.

CORRUPTION is pretty tough talk -- and yet it fits. We're not interested in any individuals being held "accountable" and we don't think any individuals are going to be held "ACCOUNTABLE." What we do want is real SUBSTANTIVE COMPLIANCE. What we do know is that we have not received a satisfactory response from HCPF on our FAIR HOUSING concerns. The Denver Fair Housing Center now has a new Enforcement Coordinator and we're hoping the Center will work with HCPF to address the situation and we have seen no indication that the Polis Administration intends to comply with Olmstead..

CORRUPTION AS--

"ORGANIZATIONAL DEVIANCE"

PUBLIC HEALTH & THE CRIMINAL JUSTICE SYSTEM

11/22/2019

Over the last few years it has become increasingly clear that the Criminal Justice System is the Cognitive Disability Destination of Last Resort -- and First Resort for many.
Medicaid and Providers, especially under Managed Care, have dumped their most difficult mental health patients on the Criminal Justice System.
    Recently the US Centers for Disease Control (CDC), Australia, the UK, Canada and Denver -- have recognized the large incidence of Brain Injury in jail and prison populations.
Scandinavian Countries and the UK have recognized the large incidence of ADHD in incarcerated populations.
    There is widespread KNOWLEDGE that substance problems are endemic to many in jails and prisons.
  So basically we have HUGE CHUNKS of our HEALTH CARE SYSTEM that are just MISSING -- and people are falling through those very LARGE CRACKS-- to a Criminal Justice System that will likely make them worse.
States and Countries need to:

Systematically, voluntarily screen jail and prison inmates for:
- Brain Injury
- Mental Illness
- Substance Issues, and
- Developmental Disabilities
Have an on-going process, including Justice-Involved Stakeholders as well as a wide range of others, to

to provide a COMPREHENSIVE and EFFECTIVELY WORKING PLAN to address the needs of Justice-
Involved people with cognitive disabilities. Further, this should include addressing the needs of victims.
*With Measurable Goals
*Reasonable Time Frames, and
*Funding to Support the Plan
That's Olmstead -- we should already be complying with it (@ least in the US), and a whole lot of people are suffering the consequences because we aren't.

Brain screening for prisoners could cut reoffending and suicides
(April 20, 2019)

Screenings & Functional Assessments

We must come to terms with the HUGE need for Public Health in the Criminal Justice System to perform:

Screenings for BI, MI, Substance Issues & DD
Functional Assessments, especially with respect to "need for supervision"
Ultimately services and in some cases placements

NIMH PUTS NO "FAITH" IN CURRENT DEFINITIONS OF DISORDERS

11/20/2019

NIMH Distances Itself from Current Definitions of Disorders

The RDoC framework is explicitly agnostic with respect to current definitions of disorders.*

For instance, depression as a clinical syndrome has been related to abnormal activity in the amygdala, anterior cingulate cortex, nucleus accumbens, and multiple monoamine systems, while also strongly comorbid with multiple anxiety disorders, eating disorders, etc.

The idea is that studying the individual mechanisms may lead to better understanding of current disorders, or perhaps new and novel definitions of disorders, but in either case improved information about treatment choices.

NIMH RDOC Discussion

RELEVANCE

*NIMH has become more diplomatic since initiating the project. Initially, NIMH asserted that the DSM "lacked validity" because it was based on clusters of symptoms -- not the underlying biology.

Additionally, this statement is consistent with prior statements coming out of NIMH that current mental health practice is more "RELIGION" than "SCIENCE."

Further, even a statement of "agnosticism" with respect to the DSM is HUGELY relevant where those DSM categories are being bandied about in Court.

This is most problematic for criminal defendants who are written off as "anti-social."

We would argue if NIMH isn't relying on those diagnoses -- Courts shouldn't either.

Science Up

The RDoC Matrix looks @:

Genes
Molecules
Cells
Circuits
Physiology
Behavior
Self-Report
Paradigms

RDOC Matrix

FINDING A FIX THAT WILL HOLD

11/18/2019

Moralizing about the Criminal Justice System can be very CATHARTIC and we engage in it regularly.

However, it is becoming more and more apparent -- that more and more prosecutors and judges are willing to agree to THERAPEUTIC PLACEMENTS -- but THERAPEUTIC PLACEMENTS are hard to come by.

Those prosecutors and judges are saying to ADVOCATES -- we need a SAFE place for this person to be -- and if the State isn't providing it -- the default is JAIL or PRISON.

We have made this TELLING POINT before: many Justice-Involved Folks meet the criteria for CO Medicaid long term care on a need for SUPERVISION as a result of disability.

Further, we need States to Seek Medicaid waivers for Medicaid LTC coverage of Housing and lifting of the Medicaid Institute for Mental Disease (IMD) Exclusion Rule.

With respect to the IMD RULE -- we need HARM REDUCTION. So many mental health advocates have not been long term Justice-Involved or Homeless.
A mental institute is:

NOT Ideal
Most People don't need them,
But some Justice-Involved People are not going to be released to:
- Housing
- An Assisted Living Residence,
- A Nursing Home
- Etc.

Although many could be, and where appropriate that should be done.

  Use of the mental institutes for Mass Competency Exams is not the best use of resources.

A lot of these cases could be triaged early on and resolved with therapeutic placements outside the jail.

We really need the CJ System available to address TRULY DISPUTED FACTUAL Matters.

  Issues of "Punishment" could be at least somewhat if not largely resolved if we had a CONTINUUM of THERAPEUTIC PLACEMENTS, including SECURE PLACEMENTS.

CO's Mental Health Continuum of Care Hell

MORE EVIDENCE OF A TIPPING POINT--MICHIGAN OFFICIALS SEEK TO EXPLORE MENTAL HEALTH & PRISONS IN NORWAY

11/17/2019

So a lot of the "Innovation" in Norway is NOT necessarily unknown in the US, especially Assertive Community Treatment (ACT) -- it was developed in the US in the 1970s.

BUT so far US State & Federal Governments have NOT had the Courage to require this important step in a COMPREHENSIVE CONTINUUM OF CARE where REASONABLY MEDICALLY NECESSARILY.

We don't mean a right for someone to BUY A LAWSUIT under Parity -- we mean State & Federal Program Design and Administrative Enforcement.

What is Colorado's Behavioral Health Task Force doing to remedy that?

Assertive Community Treatment & Flexible ACT Index

Detroit News Article -- Nov. 7, 2019

Detroit News Article: Treatment Teams See Successes in Norway -- Oct. 10, 2019 -- references Assertive Community Treatment

History of the Penitentiary

How Norway Is Teaching America To Make Its Prisons More Humane

Aug. 22, 2019

The broken prison system is in desperate need of reform. U.S. prisons are trying to find answers overseas.

Vox News: How Norway Designed A More Humane Prison

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Val's Blog

BANDWIDTH SHORTAGES & KNOWLEDGE GAPS CALL FOR POLICY-MAKING

COMING TO TERMS WITH --THE LONG TERM NEEDS OF PEOPLE WITH SERIOUS COGNITIVE DISABILITIES

PARANOIA, WHITE SUPREMACY, HUMAN XENOPHOBIA, & LATERAL PROBLEM SOLVING

MOVing BEYOND LIP SERVICE TO REAL COMPLIANCE WITH FEDERAL DISABILITY CIVIL RIGHTS LAWS

WE NEED FEDERAL TECHNICAL ASSISTANCE & ADMINISTRATIVE ENFORCEMENT

WHERE IS THE POLIS ADMINSTRA-TION ON PROVIDING MORE HOUSING?

TOUGH TALK: Corruption, Organiza-tional Deviance & Disability Civil Rights Laws

CORRUPTION AS--

"ORGANIZATIONAL DEVIANCE"

PUBLIC HEALTH & THE CRIMINAL JUSTICE SYSTEM

NIMH PUTS NO "FAITH" IN CURRENT DEFINITIONS OF DISORDERS

FINDING A FIX THAT WILL HOLD

MORE EVIDENCE OF A TIPPING POINT--MICHIGAN OFFICIALS SEEK TO EXPLORE MENTAL HEALTH & PRISONS IN NORWAY

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CORRUPTION AS--"ORGANIZATIONAL DEVIANCE"

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CORRUPTION AS--

"ORGANIZATIONAL DEVIANCE"