National Child Abuse Awareness Month: Introductory Remarks

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Bipolar For Life

Prevent Child Abuse ribbonAs I stand on tiptoe, readying myself to launch into what is going to be a very important yet extremely painful month of campaigning, I have to take a moment to remind myself to breathe deeply; that this is not the first time I will be writing and testifying about these things; and that the pain in my chest and throat that I am feeling right now is not a heart attack: it is PTSD.

As some of you may know, I am an Adult Survivor of Childhood Abuse.  I carry a significant burden of PTSD from that.  It’s possible that my experiences as an abused child made me a better Child Abuse Investigator, when I was in practice as a pediatrician.  It certainly fueled my later career as an Expert Witness for the prosecution in child abuse cases.

In the coming days and weeks I hope to write my…

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Showing Kindness and Compassion to Ourselves …posted in mental illness and abuse

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self esteem

Once in a while, I get into a conversation with someone on WordPress that starts to turn onto a “future post”. In fact  it is not uncommon for me to end those conversations with “This sounds like a future blog post”

Through the interaction between intelligent minds, we can find ideas in ourselves that we would not have otherwise accessed. That is one of my favorite things about blogging.

So, today was one was of those times. Here was the last part of my conversation with an intelligent, thoughtful reader.

“You are welcome. More kindness is needed in the world.

The general lack of patience and kindness from the people we interact with, is one of the causes of anxiety disorders anyway.

Think about how you would feel if you would knew with 100 percent certainty, that everyone you ran into today would be kind and understanding with you and try…

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Our Lives Matter

Blog for Mental Health 2015

Mental health patients suffer from different illnesses, have different symptoms, and fluctuating degrees of disability.
Patients with the same diagnosis will present with different degrees of insight and acceptance based on nuanced variables in environment and personality.
A person with a mental illness is a person with a mental illness.
One of the largest obstacles faced by people with mental illnesses is that it is socially acceptable to ridicule their suffering and to abuse them with legal and economic sanctions.
Homelessness is not the result of mental illness.
Homelessness is directly related to the refusal of our social and political systems to admit that the failure of de-institutionalization is the direct result of funding
cuts to the services that are essential for the successful treatment of mental illness.
The debilitating effects of long-term mental illness are worsened to the extent that the patient internalized the lie that he is responsible for his condition.
A diagnosis of mental illness is not the same as being “crazy”.
My definition of therapy goes beyond teaching reasonably healthy people how to manage negative thoughts.
The best psychotropic medications will not ease all the symptoms of severe Schizophrenia.
All mental illness is serious if it impairs one’s life, is ongoing, and causes suffering.
I use the word severe because I think it best describes chronic debilitating mental illness in its advanced stages.
Difficulty in establishing and maintaining relationships is the core disability of severe mental illness.
The biggest lie is that all mental illness is alike.
Clients suffer from very different illnesses.
Even within a diagnostic category different clients have different symptoms.
People have different degrees of disability, and different understandings of how the illness affects their lives.
A diagnosis of the Schizophrenia is based on a select cluster of symptoms commonly observed in people who are diagnosed with schizophrenia but they are always unique to the person.
Every problem in the lives of people with mental illness is made worse by the socially accepted stigma that allows public figures to dismiss people with mental illnesses as “nuts”, “lazy”, and “liars”.
If you have been sidetracked by a crippling disease the last thing you need is a government agency under the control of a political party that stigmatizes the mentally ill as cheats and liars.
I define therapy for someone with a severe psychiatric disability as providing client focused individualized treatment based on the severity of the Axis 1 diagnosis as expressed in the Axis 5 GAF (Global Assessment of Functioning) score of the Multiaxial Diagnosis.
Axis 5 is one of five areas of functioning used in a psychiatric assessment to decide a diagnosis and it’s severity.
Here is an example of a five-axis diagnosis from Substance Abuse Assessment and Diagnosis: A Comprehensive Guide for Counselors and Helping Professionals by Gerald A. Juhnke, Routledge, 2002
               Axis V: GAF = 50 (on admission), GAF = 62 (on discharge)
Some of the language used in the description below is based on my observations as a mental health provider. The hypothetical “client” is a mash-up of several hypothetical case presentations that I wrote for training sessions.
The GAF scale (Global Assessment of Functioning) is a hundred point scale that measures the impact of an illness on the patient’s ability to keep himself alive.
91-100 is superior functioning, which means healthy.
41-50 is sick and getting sicker.
1-10 means that the disease is advanced and lethal.
This is my understanding of the GAF as it is generally used by clinicians.
Our client does not suffer from a short-term condition complicated by a depressed mood related to drinking at 420.
That doesn’t mean an adjustment disorder isn’t painful and shouldn’t be taken seriously.
What it means is that it can be treated with targeted behavioral interventions and that the prognosis excellent.
It is absurd to think that we should treat all psychiatric Illnesses the same.
It is negligent to think that people with severe mental illnesses should respond to the same interventions that we would give to a person with an adjustment disorder or a situational depression.
All people with mental illnesses should be treated with respect and provided with unimpeded access to treatment regardless of severity.
Our client has an Axis 1 Diagnosis of Schizophrenia, Chronic, Undifferentiated.
Our client has a starting GAF of thirty.
The impact of the disease on that part of the brain that processes cognition and reason is so severe that it results in behaviors that impede his ability to interact productively with other people.
Example: client was recently discharged from the hospital with a GAF of 30. He was discharged to a residential hotel in the Tenderloin with anti-psychotic medication and a food voucher. Client made threats at the hotel and assaulted another resident based on command hallucinations. Client was taken to Psychiatric Emergency Services where he was placed on a hold because he reported hearing voices that told him to kill himself because he “is evil”. Client stabilized on medication and stated that he no longer felt suicidal upon discharge. Client did endorse hearing voices but he states they are “normal“.
Client was discharged to his Hotel with medications and a GAF of 30.
For the purpose of this post the Axis 2 is deferred.
Axis 3 refers to general medical conditions.
For the Axis 3. I would use the ICD 9 Code of 261.
Our client weighs 120 pounds and is nearly six feet tall. He does not report using methamphetamine and his urine was clear of substances at the time of his hold.
Client reports a loss of appetite and also reports spending his money on cigarettes and soda.
The client receives General Assistance in the amount of $400.00 a month.
From a clinical perspective the client is unable to care for himself in ways that will facilitate stabilizing his illness. The client is slowly starving. The part of his brain that processes the way he experiences hunger is affected by his Schizophrenia.
If the Axis 3. Diagnosis is unrelated to the Schizophrenia then the client’s insight and judgment regarding his medical condition is used as part of the clinical analyses. If he has diabetes, how does he manage his diet. If he has a heart condition, does he smoke and drink excessive amounts of coffee? Is the client even aware of the medical condition?
With our client there’s a discrepancy.
The chart reports Chronic Pulmonary Disease of which the client denies any knowledge.
When asked about his smoking the client reports that he doesn’t want to smoke but that he has to because he is “evil”.
This kind of comment suggests a delusional system and possible anosognosia.
There is evidence that schizophrenic anosognosia may be the result of damage to the frontal lobes.
The Axis 4 looks at all the environmental and psycho-social factors that both affect the illness and are the outcome of the client’s severity of illness.
Our client lives in a badly managed hotel in San Francisco’s Tenderloin district.
He is often violently assaulted and is the object of bullying and ridicule.
There is reason to believe that placing the client in this hotel exacerbates his symptoms and increases his use of a system which does not recognize the stigma that blinds it to the connection between the environment and the decline in this client’s health.
Life in a violent unpredictable environment without adequate food would be hell for someone with a healthy brain.
How much more painful than for someone with a severe, chronic and under treated case of Schizophrenia.
This is a client who will become completely homeless because he cannot control his illness and is destabilized by the system he must use for treatment.
I place this client’s GAF at 20.
I have not met someone with Schizophrenia who was not grateful to have his mind restored.
I contend that someone with a GAF of 40 and below is gravely disabled.
We have Alzheimer’s Disease as a model for how we treat people with disorders of the brain that impair judgement and behavior.

Alzheimer’s Disease
and Schizophrenia are both crippling disorders of the mind and yet Alzheimer’s disease is intensively researched and Alzheimer’s patients receive long-term treatment when the disease impairs their judgement.
Here is what I think therapy should look like for severe, debilitating mental illnesses.
Treatment focused hospitalizations with an adequate and fully trained staff.
Adequate length of stay based on true medical necessity and not the least number of days required by law.
Supportive psychotherapy as well as CBT and DBT to help clients to better manage those behaviors that are not beyond their control.
Long term residential treatment that give clients therapy, stabilization and access to fully funded vocational programs both in the facility and in the community.
As clients become more stable, supportive housing, day treatment programs, and intensive case management with someone who becomes a single point of reference for co-coordinating care and advocating for services.
Recovery and rehabilitation from a severe mental illness cannot happen in a nation that allows fear and outright contempt for the mentally ill to dictate public policy.
We do not tolerate outright bigotry when it is racist, sexist and homophobic.
Why do we let it destroy the lives of the mentally ill as a matter of public policy?