Monday, 30 November 2020

RLC Articles

The RLC produces a newsletter each and every month that offers monthly calendars, announcements and articles. Although old newsletters are archived on the website, the articles - often on important advocacy-related issues - run the risk of being buried and difficult to find. In an attempt to make that information more accessible, we still also list RLC-published articles from the newsletter (and other relevant sources) here for your ease and perusal.


A New Model Begins: Adult Community Clinical Services

ACCS replaces CBFS in July in Massachusetts, but what on earth does that mean? Some years back mental health residential services were reconfigured and became Community Based Flexible Services (CBFS). Now, CBFS is ending, and in its place, Adult Community Clinical Services (ACCS) has moved in.

But what is ACCS?: According to the Massachusetts Department of Mental Health (DMH), ACCS will “deliver evidence based interventions within the context of a standardized, clinically focused model to promote:

  • Active engagement and assertive outreach to prevent homelessness; 
  • Clinical coverage 24/7/365 days a year 
  • Consistent assessment and treatment planning 
  • Risk assessment, crisis planning and prevention 
  • Skill building and symptom management, 
  • Behavioral and physical health monitoring and support 
  • Addiction treatment support;  
  • Family engagement; 
  • Peer support and recovery coaching  

Reduced reliance on emergency departments, hospitals and other institutional levels of care.

How is it different than CBFS?: Well, some of that remains to be seen, but some of the differences highlighted by DMH include:

  • A standardized staffing model for teams providing services
  • A clinician is assigned and accountable to each person receiving services at all times (as opposed to simply for therapy, or at the point of assessment and treatment planning)
  • Increased focus on involving and centering the family
  • Increased focus on the integration of and access to peer support
  • Standardization of assessment for problems with substances and access to relevant supports
  • Standardization and increased clarity around determinations for rates paid to providers for services
  • Standardization of contract monitoring, outcome measures, and criteria for enrollment

There are some clear positives that are born of ACCS. For example, this new contract represents the first time that DMH has made a strong commitment to the integrity of the peer role. This includes writing in requirements that people in peer roles not be responsible for administration of psychiatric drugs, and that providers implement these roles in a way that is consistent with the Massachusetts Peer Specialist Code of Ethics. (You can learn more about ACCS directly from DMH by clicking HERE.)

However, ACCS also brings with it a number of question marks and problems, as well. A summary of some of these concerns follows:

1. Experienced People are Losing Their Jobs: Historically, licensure has not been required to lead a program or team. As a result, there are many very experienced people who are passionate about their work but who don’t have clinical licenses (or don’t have the right clinical licenses) and who are being required to take a demotion or lose their jobs altogether. This could mean (and almost certainly will in at least some instances) that a young, inexperienced clinician will head up a team in place of someone with far more experience and knowledge of the actual systems and needs of people being supported.

2. There May Not Be Enough Licensed Clinicians to Go Around: Not only has the new requirement for a licensed clinical lead led to other people losing their jobs, it’s not terribly clear whether or not there are enough licensed clinicians (or nurses, or Licensed Alcohol and Drug Addiction Counselors, etc.) around to truly fill the need. Historically, it’s been very difficult for most providers of DMH’s core residential services (including CBFS and, now, ACCS) to hire (and/or retain) licensed clinicians onto teams. Licensed clinicians often prefer to work in private practice or fee-for-service clinics where they’re able to focus on one-on-one therapy (or similar). This new requirement could end up being a set-up that does little more than ensure that providers are involved in a (even more than usual) never ending cycle of hiring for key roles, and that program leads are frequently new and unfamiliar with the programs they are heading up. Additionally, while the new structure increases staffing levels, if providers are forced to carry vacancies due to inability to fill positions, will the increase be a reality or an illusion? And, could the plan to increase available support actually lead to a decrease due to all these vacancies?

3. ACCS Doubles Down On a Clinical Focus In Spite of the Fact that It Doesn’t Appear That That’s What’s Wanted or Needed: CBFS was certainly a clinical service, but ACCS has increased the clinical emphasis by a stretch. Meanwhile, when we look at international outcomes, it would appear that services that have a more connection-focused approach that makes space for individual meaning making of distress (such as Open Dialogue in Finland) are getting the best results, while outcomes have failed to improved or even declined for anything considered ‘mental health’ in most westernized nations that prioritize more rigid clinical approaches. A rigid clinical approach is also inconsistent with both person-centered and trauma-informed approaches (both of which are also named as desired elements of ACCS), as well as so much feedback that already exists in the state from people who say that it’s the connection and support to figure out their own path that is truly needed.

4. The Rigid Formula Regarding Roles On Teams is a Mixed Bag: On the one hand, it’s wonderful that DMH has required three people in peer roles for every one hundred individuals in services. But that ‘wonderful’ only applies to providers who weren’t already at or over that threshold. Unfortunately, for some providers, the new rigid formula is actually requiring that they undo some of their progress, and reduce the number of peer supporters available within their organization. Overall, many providers have made some of their most progressive steps based on the flexibility to be creative. Much of that flexibility is being lost with the implementation of ACCS. Will creativity and progress be sacrificed as a result?

5. The ‘Evidence-Based’ Focus is Misguided: Unfortunately, evidence-based is often defined more by who has the money to pay for the research to convey their outcomes in a positive light than anything else. In an April, 2018 article, “The Corruption of Evidence Based Medicine”, Dr. Marcia Angell (former editor in chief of the New England Journal of Medicine) was quoted as saying the following:

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor”

What this ultimately means is that sometimes (too often) systems get stuck with ineffective strategies, while more affective approaches get overlooked for their lack of status.

6. It Appears That Providers May Be Encouraged to Misuse some ‘Evidence-Based’ Approaches: There is a heavy emphasis on Motivational Interviewing in the new ACCS contract. While the problems with Motivational Interviewing are many (enough to merit a separate article), it is at its heart designed to be an approach used without an agenda and toward simply building energy to take action toward change. However, the original Request for Response (RFR, the document that outlines what is required from providers interested in submitting a proposal to implement a service) had this to say about Motivational Interviewing:

“Contractors utilize Motivational Interviewing and other engagement techniques to help Persons resolve any ambivalence about receiving the service and address barriers to engagement.”

This at least appears to suggest that providers use Motivational Interviewing with the agenda of engagement in services. Will evidence-based practices be used for genuine support or manipulation?

7. So Much is Unknown: The ACCS RFR openly acknowledged that certain parts of the plan were unknown at the time it was written, and providers have since raised many other questions including:

  • How will ACCS providers and Behavioral Health Community Partners (another new part of the picture being contracted out through Masshealth) ensure that they are clear who is supposed to be doing what? (For more on Community Partners, click here!)
  • How will DMH ensure fidelity to the new requirements to support the integrity of peer roles?
  • How will the new system be ready to go in July, including new supervision, certification, and licensure requirements that leave no room for grandfathering in or grace periods?
  • How will providers support the effective discharge of so many people who’ve been receiving services? (ACCS has a lower capacity than CBFS did, and a large number of people—as many as 15 to 20% of those served prior to July 1— are relatively abruptly losing the services with which they are most familiar)

For the first time in many years, Massachusetts is experiencing a substantial bump in its mental health budget; An increase of over 80 million. (For a little perspective, 80 million could fund about 150 peer respites and 5 Soteria Houses.) The bulk of that new money is going into ACCS (largely to support requirements like the hiring of  licensed clinicians), a service that will have a reduced capacity for the number of people with whom it can work, and will not be giving any raises to individuals offering most of the direct support. Overall, the state seems to be stepping forward into this new ACCS territory amidst a great deal of uncertainty. Either way, ACCS is here and only time will tell how it really works out.


“I never heard from my outreach workers and DMH worker about this change until last week because they were told not to talk about it to clients.”

– Person receiving DMH services on June 21, 2018 (10 days before ACCS went into effect)

A few weeks ago, we sent out a special e-newsletter inviting people to give feedback on the new Adult Community Clinical Services (ACCS) program that replaced Community-Based Flexible Supports (CBFS) as of July 1. ACCS is the largest Department of Mental Health-funded (DMH) service across Massachusetts, and is essentially what used to more simply be thought of as DMH residential and outreach services.

Since releasing the survey, we’ve received 72 responses. 5 responses came in from people receiving DMH services. 23 were received from people working in peer roles in what is now ACCS. There were also a handful (8) of responses from parents and interested citizens who are watching the process unfold. However, the largest number of responses came from providers (primarily those directly providing services through ACCS, but also a few who were losing their jobs with the end of CBFS or who worked in clinics and other settings that interfaced with these services). There were 36 provider responses, to be exact. The bulk of these responses (40) were from Western Massachusetts, but another 31 were from other parts of the state (with one from out of area).

What follows is a summary of what people had to say.

Read more: SPECIAL REPORT: ACCS Survey Results

The Problem with ‘Mental Health First Aid’

According to the Mental Health First Aid website it is an eight hour course that “teaches you how to identify, understand and respond to signs of mental illnesses and substance use    koala         disorders in your community.” It is geared particularly toward first responders, family, and others in the community who don’t typically offer support to people in distress for a living. Its mascot is a cuddly Koala named ALGEE (an acronym that stands for Assess for risk of suicide or harm; Listen nonjudgmentally; Give reassurance and information; Encourage appropriate professional help; Encourage self-help and other support strategies).

On the surface that doesn’t sound so bad. However, Mental Health First Aid is rife with problems. First, it is yet another approach that is largely absent any input from people who actually have psychiatric histories themselves. In fact, so many people with first hand experience with deep emotional and/or mental distress were upset about Mental Health First Aid that they have invested a great deal of time in creating alternatives to it. For example, Emotional CPR was developed by a large team of people with psychiatric histories. (Find out more about that approach here) The Icarus Project has also periodically worked to create similar approaches. (Find out more about the Icarus Project here.) And, of course, the Western Mass RLC offers many trainings and supports (Alternatives to Suicide, etc.) that are useful.

But the problems don’t stop there. In 2016, Patrick Hahn (a professor of biology at Loyola University) published an article in the Baltimore Sun speaking to his experience attending a Youth Mental Health First Aid training in which he found that the training seemed geared toward pushing more young people toward more psychiatric drugs without regard for scientific evidence. Also in 2016, Sera Davidow (Director of the RLC) wrote a piece detailing the many disturbing aspects of a Mental Health First Aid training detailing the many disturbing aspects of a Mental Health First Aid training she’d just attended, including an exercise in which she and other participants were required to order which ‘disability’ or ‘disease’ (e.g., breast cancer, schizophrenia, diabetes, etc.) was the worst. Closing out the year, Jan Nadine Defehr of the University of Winnipeg published an article about the approach, claiming that it was a tool of social control masquerading as something much more benevolent. Then, in 2017, Philip Hickey, a retired psychologist living in Colorado, wrote an article on Mental Health First Aid in which he reviewed its website and related outcomes, finding it to be largely a tool to funnel more people into the mental health system without regard for efficacy.

In spite of its acronym, Mental Health First Aid does not do a good job of promoting genuine connection, listening, or supporting someone to make meaning of their experiences. It prioritizes referral into clinical services over all else. Although, as with any approach, a participant’s experience may vary substantially based on the trainers and what they’ve                 decided to do with the material, it appears to be a tool to further entrench a medical model way of thinking about emotional distress, regardless of an individual’s personal beliefs, culture, or knowledge of what works for them. Unfortunately, Mental Health First Aid isn’t going anywhere soon. It is heavily funded, and has been promoted by both the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Council on Behavioral Health. Nonetheless, it is important that we determine for ourselves how we want to approach each other during times of struggle. We can (and need to) do better.

For more on this topic:

Drug Companies Pray on Children, by Patrick Hahn, Baltimore Sun

Mental Health First Aid: Your Friendly Neighborhood Mental Illness Maker, by Sera Davidow, Mad in America

Inventing Mental Health First Aid: The Problem of Psychocentrism by Jan Nadine Defehr, Studies in Social Justice

Mental Health First Aid: Another Psychiatric Expansionist Tool by Philip Hickey, Mad in America

The Problem with Saying Suicide is Caused by Depression

On June 5, Kate Spade, a famous American fashion designer, reportedly took her own life. Only a few days later on June 8, Anthony Bourdain, a celebrity chef and author, died by suicide, anthony katetoo. And, on that very same day, the Centers for Disease Control and Prevention (CDC) released data suggesting that suicide rates have increased by nearly 30% since 1999.

There have since been an array of responses. The New York Times suggested that one of the biggest contributors to the suicide rate is the lack of gun control. Seasoned journalist, Rob Wipond, used a CDC chart to compare the rising rates of suicide with the rising prescription rates of those drugs classified as antidepressants. (He found that the two closely mirrored one another, which you can see by clicking here.) Meanwhile, Felice Freyer at the Boston Globe (not a member of the Boston Globe’s ‘Spotlight on Mental Health’ team!) took one of the more nuanced view, noting that suicide rates often go up among those who are experiencing financial or   relationship crises, and/or problems with substances.

However, on the whole, most media outlets (and individuals) are drawing the same old link between suicide and psychiatric diagnosis. They are saying the cause was “depression”, ignoring that for most people that is an incomplete answer (at best) that ignores the very real struggles many individuals are facing. They say the solution is “treatment”, disregarding that many people who kill themselves are in treatment and that it doesn’t seem to be helping (as evidenced not only by their individual stories, but also by the CDC’s report and other research that tells us important facts like that hospitalization appears to lead to an increase in the risk of someone making a serious suicide attempt).

By looking for such simplistic explanations and solutions, we miss the opportunity to do what’s truly needed: Make real change in how our society regards death, suicide, and the best ways to support one another through our darkest moments. On June 9, Clinical Psychologist, Noel Hunter, released an article, “Rising Rates of Suicide: When Do We Acknowledge that Something Isn’t Working!?” What follows is an excerpt from her piece:

"Telling a person they are “ill” for suffering or being sad serves to further alienate the individual. It often results in the person feeling defective, and puts the problem inside the individual instead of recognizing that cultural and circumstantial factors are a problem. Studies have demonstrated over and over again that a biological illness perspective on human suffering leads to decreased empathy, increased desire for social distance, and increased prejudice and discrimination.

Worse, this focus on mental illness and individual suffering can sometimes lead those who are diagnosed to develop a lack of responsibility for how one treats others, lack of empathy for those not seen as sick, and a preoccupation with one’s internal state to the detriment of connection with others. Internalizing an illness explanation for one’s suffering leads to alterations in identity, reinforcement of abusive dynamics, decreases in hope and self-esteem, and decreased likelihood of seeking help.

In other words: we, as a society, are being told that if someone is suffering, the correct approach is to convince them of ideas that will likely lead them to feel marginalized, helpless, hopeless, worse about themselves, ashamed, retraumatized and less likely to reach out to others for connection and support when, in fact, connection and support are the very things most likely to heal. Logic at its finest."

We would do well to look at what the evidence and people’s stories are truly telling us and work together for change.

“Although heavily promoted by the medical profession and drug companies, there is little scientific evidence to support the claim that depression is a genuine medical illness that causes suicide… The great disaster of this myth is that once the professionals assume that depression is the cause rather than just another symptom, they then look no further.”

- David Webb, Thinking About Suicide

The Problem with Suggesting that Racism is Caused by ‘Mental Illness’

If you haven’t heard news of Roseanne’s Tweet about Valerie Jarret (a black woman born in Iran who served as   Barrack Obama’s senior advisor)… Well, then you’re probably not reading roseanne newthis either. A brief summary:

On May 29, Roseanne Barr Tweeted the following:

Muslim brotherhood & planet of the apes had a baby=vj.

There was immediate criticism following the Tweet calling out Roseanne for being racist. But, not long after, a number of people also began to rush to Roseanne’s defense, suggesting that her bigoted statements were the result of her “mental illness”.

Now, in fairness to Roseanne, to call her a ‘racist’ as if racism is rare and existing only in a small group of people is off track. In reality, racism is a systemic issue that is about prejudice plus power and the voices and experiences that are centered and prioritized in society. In some ways, Roseanne’s words said less about her than they did about where we are at as a country right now. Yet, none of that excuses her bigoted remarks, and the problems with asserting that racism is the product of psychiatric diagnosis are many. They include:

  • It’s another excuse for participating in bigoted behavior and racist systems without personal accountability
  • It re-enforces the idea that people with psychiatric diagnoses cannot be held responsible for their actions
  • It misses the mark on the real history of the intersection between psychiatry and racism (including that individuals of color are much more likely to be given more severe psychiatric diagnoses and subjected to forced treatment)

Ultimately, we do not need another excuse to make space for systemic racism in our society, nor do we need additional messages circulating that people with psychiatric histories are so “out of control”. Instead, we would be much better served by making space to support one another through our darkest moments, while still holding high expectations that we treat each other with basic respect, and that we work together to undo all systemic oppressions that exist around us.

For more on this topic, read ‘Dear Roseanne, The Blood is At Your Doorstep’ by Sera Davidow by clicking here!!


Did You Know? Abuse at Whiting Forensic

Whiting Forensic Sign and BuildingJust a handful of miles south of us in Connecticut, one of the largest investigations of abuse by an institution of individuals with psychiatric histories is currently underway.
As of just a few days ago, 37 employees at Whiting Forensic have now been suspended as a part of investigations of abuse, with nine of them (so far) formally arrested on felony warrants. Among those arrested is forensic head nurse, Mark Cusson, who has been arraigned on eight counts of cruelty to persons. Much of the abuse was caught on video, and included diapers and dirty mops being rubbed on someone’s head, as well as physical violence.
This was all reportedly brought to a head by a whistleblower who named the abuse, and by the fact that much of it was caught on video. According to an excerpt from an article in the Courant:
The State Department of Public Health recently issued a 102-page inspection report on Whiting, saying as many as 40 staff members "were identified in the video log as being abusive or witnessing abuse and not reporting it, and that another eight workers were talking on their cellphones or had left the immediate area while they were supposed to be constantly observing the patient who was the victim of the abuse.
What happens at Whiting has big implications for all of us, no matter where we live. Being hospitalized (often against one’s will) in a psychiatric facility is an extremely vulnerable position to be in, and human rights violations are common. We should all be paying attention and offering our support and voices to what happens with our neighbors in Connecticut.
To keep up-to-date on the Whiting Forensic Investigation,
check out the Facebook Page for Advocacy Unlimited: www.facebook.com/AdvocacyUnlimitedCT/
To read this article in its entirety, please select "read More" below.

Read more: Did You Know? Abuse at Whiting Forensic



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