Our local YMCA is about 20 minutes from our house. We first visited when James took swim lessons there over the summer. He loved being in the pool (and we loved doing it with him) so when the summer session ended, we knew we should sign him up for the next level. We checked session schedules online and noticed another option he’d love—a gymnastics class called “Me and My 1-Year-Old.” We decided to sign up for a family membership and so far, it’s been more worthwhile than I expected. Here’s the big reason why: child watch.
Daniel and I both work from home, so one of us is with James pretty much all the time—and we love it! As two former latch-key kids from a very early age, we are so happy and feel so unbelievably fortunate to be home with him. Still, it’s not always easy to create boundaries around work time, family/James time, and personal time (I know I’m not alone when I say that as a parent, my perception of “me time” tends to swing between feeling selfish and indulgent). This is why the child watch at the Y has been a blessing. Every day, they offer free child watch to members—a great option that allows parents time to work out or heck, take a hot shower, for up to 2 hours a day. I haven’t worked up to that amount of time just yet—and maybe I never will who knows, but I love that James can play with other kiddos safely while I’m in the gym.
At first, I was a little hesitant (can you tell I’m a first time parent? Ha) and left James for just a short time to see how he did, but he always seemed perfectly happy when I picked him up or checked on him. Anytime I felt guilty or nervous that he might be upset, I reminded myself that before we signed up we took a tour and met with some of the folks who work in the child watch area. The area was clean and safe. I knew that if he did get upset, I’m always nearby and an employee would come get me.
So if you’re looking for a short break from time to time, see if you have a YMCA or another similar family gym nearby. You can use the time to exercise, answer a pressing email or two, make a phone call…or sit in the lobby and read a book if that’s what would recharge you. Take care of yourself.
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In and around Chicago’s Little Village neighborhood, long-standing causes of friction like gun violence and poverty have for some families combined with newer fears of immigration crackdowns and deportation of loved ones—and mental health professionals hope to address toxic stress that can have long-term effects on the lives of very young children.
Aiming to rectify the shortage of mental health care available to infants and children younger than 5 in Little Village and Lawndale, the Erikson Institute, an early childhood graduate school, has opened a new clinic there, its first free-standing health center outside its River North home base.
An opening reception was held recently, though the clinic has been operating since May, and social workers had started doing visits in the area for 18 months leading up to that.
“There’s lots of anxiety around separation—divorce, deportation, incarceration while awaiting deportation,” said Marcy Safyer, who oversees all clinical operations for the institute.
Much has been learned over the last two decades about how trauma and diversity during early childhood and infancy can have a long-term negative impact, and Erikson officials, along with community-based organizations that make referrals to the clinic, hope its presence there will help fill a gap in such mental health services.
Little Village is a young neighborhood, with about 30% of its 80,000 residents younger than 18 and 10% younger than 5, according to the institute. That’s one reason the Erikson chose this neighborhood for its first free-standing clinic.
Inside an otherwise drab office building on West 26th Street near Pulaski Road, colorful dots about the size of dinner plates mark a path through a first-floor hallway leading to a small, bright office where age-specific therapy rooms with carpeting and soft rugs are designed to be inviting and to make children feel safe and comfortable.
An infant room has a rocking chair and a play mat for babies to lie on and learn to roll and sit. Toddler rooms have larger toys with rounded edges—police cars, two play houses, stuffed animals and throw pillows.
Some of the children the clinic serves, Safyer said, have experienced or witnessed a parent being deported, or an incident of domestic or gun violence.
“They can’t talk about it, but they will put on a police uniform and play it out,” Safyer said, noting the rooms even have play handcuffs. “That’s part of the therapeutic process. Anything to allow them to show.”
The neighborhood is vibrant, and local organizations work to prevent violence but also to support children after violent acts and to be available for young gang members who, if they decide to walk away, have a loving adult to turn to. There’s consensus among those groups that the neighborhood lacks adequate mental health services for kids.
Katya Nuques is executive director of Enlace Chicago, an organization in Little Village whose focus includes violence prevention, immigration, education and health.
“Enlace has definitely struggled to find appropriate mental health services for young children,” Nuques said. “We are thrilled for the resources this center will provide.”
The center, which is working to be able to accept Medicaid as payment, has been getting referrals from organizations like Enlace and El Valor, an early childhood education provider that has a center in Little Village. The clientele consists of about 20 families, but the center has capacity for nine social workers with caseloads of 10 to 12 families who are seen two hours each week.
When new families arrive, they receive an assessment from social workers, which includes home and school visits to observe the children and how they interact with others. Treatment rooms have cameras so therapists are able to review clients’ behaviors later.
And though the center is billed as infant and early childhood mental care, it’s as much about treating parents as children.
“The work we do is inter-generational,” Safyer said. “Parents bring stress and anxiety to the relationship, and the science shows that it’s the quality of the relationship with a parent that shapes the architecture of a child’s brain.”
Parents are also the crucial link to getting children in the door. And that alone can be a challenge.
Erikson officials said some families have cited a fear of travel around the neighborhood as a reason for not wanting to visit the center. A gang boundary running north and south divides the neighborhood roughly halfway between Kostner and California avenues, and for young men involved in gangs or their family members, crossing that boundary to reach the facility could be risky. Even afternoon sports activities for local children are divided into two separate leagues on each side of the boundary. Erikson officials said social workers will make house calls if a family expresses safety concerns.
“Our job is to strengthen and support the parent-child relationship,” Safyer said, “because it is that relationship which allows each child to reach their full potential.”
The importance of mental health support even for very young children has come into sharper focus in recent decades.
While conventional wisdom used to be that children 5 and younger were too young to understand or be affected by what was happening to adults in their world, a watershed study in 1998 upended that thinking. The Adverse Childhood Experiences study found correlations between adverse childhood experiences and negative health outcomes later in life, including stroke, heart disease and cancer, along with depression, suicide and substance abuse.
Research has shown that children have physical responses to trauma even if they don’t have the language to explain it. Because so much of a child’s development happens in the first five years of life, trauma and stress during that period can have an outsized effect on a child’s development.
“People want to believe that little children, babies, are not affected by things if they can’t talk about them or articulate an understanding of them,” said Bradley Stolbach, a professor of pediatrics at the University of Chicago who’s worked with childhood trauma patients for two decades. “But that is not really the case. … Trauma affects people at a physical level, so the impact is on the brain and the body even if the person is not aware of that at the time.”
This is especially true, he said, for attachment-related trauma like divorce, deportation or incarceration that would interrupt or sever a child’s relationship with his or her primary caregiver. That’s why the therapy rooms at the Erikson clinic have two play houses—so that if children can’t speak to anxiety over separation, they can still act it out with the toys. And though there are myriad risk factors in a child’s life, the most important protective factor, according to experts, is the presence of a loving, reliable caregiver.
“It’s extremely important that children, early in their lives dealing with adversity, get the right kind of intervention that can address trauma and address attachment-related injuries. That’s the foundation for development going forward for the rest of their life,” Stolbach said.
Stolbach gave the example of a child he treated who was about a year old when his mother was killed in front of him. At age 8, the boy was peeing his pants.
“Because he was a baby, nobody wanted to ever talk to him about what had happened. But he knew some from what he had heard and he knew at a biological level because that trauma happened to him,” Stolbach said. “And so part of the treatment involved answering whatever questions he had about what happened to his mom. Through doing that, he stopped peeing his pants.”
Another early childhood development expert, Dr. Andrew Garner, a pediatrician with University Hospitals in Ohio, said that as important as the ACE study was, “we had lots of clues before then that show us what happens in childhood doesn’t necessarily stay in childhood.”
With advances in epigenetics and neuroscience, he said, “it became clear we’re filling in the pieces and peering inside the black box and … beginning to understand how experiences become biologically and socially embedded.”
Later research showed how trauma changes the body’s physiology. Garner co-authored a 2012 report for the American Academy of Pediatrics that introduced the term “toxic stress”—coined by the report’s other co-author a couple of years earlier—to a wider caregiving audience. That term doesn’t describe a particular event or stressor but the inability for the body to turn off its physical stress response, usually because of the absence of a loving and steady caregiver.
“Because the early roots … of problems in both learning and health typically lie beyond the walls of the medical office or hospital setting, the boundaries of pediatric concern must move beyond the acute medical care of children and expand into the larger ecology of the community, state and society,” the policy stated.
Now, gang intervention workers, cops, firefighters, teachers and others who work with kids or are often exposed to trauma incorporate trauma-informed practices into their jobs. It may not be child-specific, but there’s a push to professionalize trauma-sensitive practices within these institutions.
“This is not just touchy-feely psychobabble—we’re talking hardcore biology,” Garner said. “When kids experience significant adversity and bodily stress response is turned on, in the absence of buffering protective factors like engaged, caring adults, that ongoing stress response results in changes. Those changes in turn can have long-term effects. Toxic stress was a way of having people understand that when the stress system gets turned on and doesn’t get turned off, there can be consequences.”
One way childhood trauma leads to poorer health for women
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The first medically integrated urgent care center with behavioral health in the country opened Friday in Neptune, according to Hackensack Meridian Health officials, which was celebrated with a ribbon-cutting ceremony.
The health network announced the urgent care center as part of its strategy to improve access and treatment for people with mental health issues and addiction.
“Brain health shouldn’t be treated any different than physical health,” said former Rep. Patrick Kennedy, an advocate for access to mental health services who joined hospital officials and other politicians at the ceremony. “It’s outlined discrimination.”
Patients at the new center will have access to a behavioral health team that includes mental health technicians, licensed clinical social workers, advanced practice nurses, and a psychiatrist who can be contacted through telemedicine, which allows health care professionals to evaluate, diagnose and treat patients through technology communications.
“What I love about this center is that it really is a model of what we need more (of) nationally,” Kennedy said.
Robert Garrett, CEO of Hackensack Meridian Health, said the hospital system believes it’s a simple concept that other hospitals and healthcare groups can easily adapt, since the health network expanded and retrofitted its existing urgent care center.
One in five adults int he U.S. experiences a mental health issue and 60 percent of people with mental health issues didn’t receive care last year, according to a release on the opening.
“Adding psychology to urgent care services allows us to treat patients with behavioral health issues in as non-stigmatizing and non-threatening a manner as possible,” said Donald Parker, the president of the network’s Carrier Clinic and Behavioral Health Care Transformation Services.
“It is difficult for a general practitioner to have the time and the ability to handle psychological issues when a patient walks through their door,” he said. “We need equal levels of those skills in urgent care and this concept does just that, addressing physical and psychological health challenges on par with each other.”
Hospital officials also noted they expect to see significant financial benefits from the center, as emergency room visits help drive up healthcare costs.
“We believe it’s a novel concept across the nation as well [as the first],” Garrett said. “We hope others will follow suit and really get behind the concept of behavioral health urgent care.”
The urgent care center is located at 2040 Route 33 in Neptune, across from Hackensack Meridian Health’s Jersey Shore University Medical Center.
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This is especially true, he said, for attachment-related trauma like divorce, deportation or incarceration that would interrupt or sever a child’s relationship with his or her primary caregiver. That’s why the therapy rooms at the Erikson clinic have two play houses — so that if children can’t speak to anxiety over separation, they can still act it out with the toys. And though there are myriad risk factors in a child’s life, the most important protective factor, according to experts, is the presence of a loving, reliable caregiver.
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OAKLAND, Calif. – After almost 12 months without a contract, some 4,000 Kaiser Permanente mental health clinicians in California, and their union, the National Union of Healthcare Workers, are continuing to demand that the giant health care corporation establish the conditions the clinicians need to care for their patients in a timely and effective manner.
After starting their day Sept. 17 with a 6 a.m. picket line in front of Kaiser’s Northern California Regional Headquarters here, dozens of psychologists and other clinicians were joined by patients, community and labor supporters who rallied to urge the giant health care corporation to provide its mental health patients the same prompt, quality care it provides those with physical complaints.
Mickey Fitzpatrick, a psychologist at Kaiser’s facility in nearby Pleasanton and a member of NUHW’s bargaining committee, outlined the problems he and his colleagues face. At Pleasanton and Kaiser’s other northern California clinics, he said, schedules are routinely fully booked many weeks in advance, forcing patients to wait as long as six to eight weeks for a return appointment.
Fitzpatrick said he and his co-workers are so desperate to help their patients that they skip lunches, work overtime and cut short other essential functions in order to do the needed clinical work.
“Kaiser has $46 billion in cash and reserves,” he said. “Yet it chronically understaffs its mental health clinics. Even when it tries to hire more therapists, it can’t keep up with its growing membership and replace the therapists who are leaving in frustration because they can’t provide the care they know their patients need.”
Signs carried by rally participants told of the tragic consequences the delays have had for some patients.
Jennifer Shanoski, president of the Peralta Federation of Teachers and a teacher of chemistry at Oakland’s Merritt College, told the crowd, “I’ve seen first-hand how mental health challenges can get in the way of learning, teaching, parenting, and simply living a decent life here in the San Francisco Bay Area. I’ve seen my students struggling with stressors – school, relationships, and survival in an economy so obviously geared for the super-wealthy.”
Noting that nearly half of U.S. adults will seek mental health services at some time in their lives, she shared her own story of seeking care for herself and her young son, only to finally end up paying for private care because of Kaiser’s delays.
“I know I’m fortunate because I could afford to pay those costs,” Shanoski said. “Not everyone can, and no one should have to. And when people can’t pay, that can lead to tragedy.”
Laura Fischler, a social worker at Kaiser Pleasanton, spoke of the problems patients face when they try to use the telephone service Kaiser has introduced in an effort to cut wait times. One such client “disclosed to me that he had attempted to hang himself in his garage, and didn’t feel comfortable telling the therapist on the phone about that,” she said. “He had decided before meeting with me, that if it didn’t go well, he knew where there was a gun in the house.”
Every Kaiser therapist’s biggest fear, she said, is that while coping with long wait times between therapy sessions, one of their patients will take a tragic action the therapist did not foresee.
Meanwhile, mental health staff at Kaiser’s clinic in nearby Pleasanton were holding a one-day strike on behalf of their patients.
The mental health workers chose Sept. 17 for a day of action because, they said, Kaiser had given them an ultimatum: Either agree by that date to accept the same substandard contract that two months ago, 92 percent of them had voted to reject, or lose a 3 percent retroactive pay increase covering the year they have been working without a contract.
Kaiser had also rejected a counter-proposal from the mental health workers, to significantly reduce wait times by hiring additional full-time clinicians, to establish crisis services at every clinic, and give clinicians enough time to conduct critical patient care work including following up on referrals, responding to patients’ calls and communicating with social service agencies.
In a statement Sept. 16, NUHW President Sal Rosselli called the health care giant’s rejection of the union’s offer “a blatant attempt to intimidate workers into ratifying a contract that doesn’t go far enough to improve Kaiser’s mental health care system,” and “further evidence that executives at Kaiser’s health plan and The Permanente Medical Group don’t care about addressing the giant HMO’s mental health crisis or respect their mental health clinicians.”
It’s already been a long road for the clinicians.
After working without a contract starting in October 2018, they held a week-long strike in December. In June they called off a threatened open-ended strike following progress in bargaining, and in response to California legislative leaders’ urging both sides to return to the bargaining table.
In a survey their union conducted earlier this year, 71 percent of Kaiser clinicians said wait times for treatment appointments have grown longer over the past two years, and more than three-quarters said they must give patients return appointments further into the future than is clinically appropriate.
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At a time when the Pentagon is preparing itself for a clash with a well-funded and equipped military power, lawmakers are warning that support for special operations deployments should not go away, and even more investment should be made in mental health care for special operations forces as well as other troops and veterans.
Special operations forces do a lot more than kick down doors, Rep. Adam Smith, D-Washington, chairman of the House Armed Services Committee, said Wednesday, and they’ll need to stay strong to keep playing that role, whether the next great conflict is with an insurgency or a great power.
“We’ve more than doubled the size of the SOF force in the last 10-to-12 years, and it’s become an enormous part of our foreign policy and our defense policy,” he said on a panel at the New America Foundations’ SOF Policy Forum in Washington, D.C.
Special operators build partnerships, train local forces and are sometimes the first on the ground to see changes in a country’s stability, he added, and none of that changes despite the National Defense Strategy’s focus on countries like Iran, Russia and China.
Congress needs to “make sure we provide funds and support so the people who have to perform that mission can do it,” he said.
That funding should include support for mental health and for the families of those troops, said Rep. Michael Waltz, R-Florida, a Green Beret and current lieutenant colonel with the Florida National Guard.
“Even when the operators are not deployed and they’re back here, they’re not really here,” he said, describing a training, certification and pre-deployment preparation cycle that notoriously grinds on SOF troops.
For their efforts, he added, operators are also bearing the brunt of the casualties in Afghanistan, where the emergence of a local ISIS faction has increased the counter-terror mission.
“We just buried a fifth Green Beret in two weeks, on Sept. 11, and just lost another one yesterday,” he said.
In March, Waltz introduced the SFC Brian Woods Gold Star and Military Survivors Act, which would allow re-married surviving spouses access to on-base facilities for their children, provide financial assistance for childcare for children of survivors and require the Pentagon to pay for fallen service members to be transported to their hometowns, as well as a national cemetery, after they are flown home through Dover Air Force Base, Delaware.
There are often no good options when SOF troops come home, Waltz said. When they survive, it might be at the cost of a severe physical injury, or more commonly, a mental one.
A co-sponsor of that Gold Star family bill, Rep. Seth Moulton, D-Massachusetts, a former Marine officer, has also introduced legislation to require annual mental health evaluations for all service members.
He saw a small victory this year, he said, when the House Armed Services added a provision to the next defense authorization bill to require troops returning from combat deployments to be seen by behavioral health specialists after two weeks back home.
“If we don’t show America that we take care of veterans when they come home … people aren’t going to volunteer,” Moulton said. “Families aren’t going to sign up for this. And we’re not doing a good enough job.”
Moulton, who has been getting his health care at the VA in order to speak more intelligently on how it serves veterans, said he’s also concerned for post-service support as well.
“Let’s just put it this way: I could tell you some stories,” he said. “I have a great primary care physician. There are some things they do really well. I had surgery a few years ago, and they sent me home with the wrong medication.”
It’ll be necessary to pay attention to the health of operators, Waltz said, because the tempo they’ve been keeping may not be likely to ease up.
“I think this is only the beginning of a generational war on extremism, despite multiple administrations wanting to wish the problem away,” Waltz said. “If the families start truly breaking, the force starts to break.”
So what can SOF forces expect in the future, with this shift away from counterinsurgency?
They’ll still be on the ground, getting a picture of conflicts before they explode, Smith said.
“The future of warfare I see – yes it’s great-power competition, but it’s not like 200 years ago, you know, when you built up for the great war you were going to have with your rival ― it’s great-power competition happening in smaller competition in a different way,” he said.
It won’t be huge fields of battle, he added. It’ll be about deterring adversaries with close relationships with allies on the ground.
And SOF is perfectly suited for that role, Waltz said, so it shouldn’t be left behind in the shift.
“I am worried that the pendulum will swing too far, a la the 1980s, back toward great power competition,” he said. “I think that’s the Pentagon and the industrial base’s comfort zone.”
Learning languages and understanding cultures aren’t big jobs creators, he added, “but it is absolutely critical and we cannot walk away from that.”
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In 1993, when I was 3 years old, my family left Pakistan for the United States. My parents were searching for a brighter, safer future and better educational opportunities for their children. All of that came true for me, but now it is being threatened by President Trump’s decision to rescind the Deferred Action for Childhood Arrivals (DACA) program, which gives young undocumented immigrants — often called Dreamers — the right to live and work in the United States without fear of deportation.
I’m now working in my dream job as a psychiatrist in a hospital and Veterans Health Administration clinic just outside Chicago. It’s a career I chose after overcoming a great deal of hardship, including an impoverished childhood. It allows me to give back to the country I now call home. But though I’m filling a critical labor gap in the health care workforce, I worry that my days here may be numbered.
This month marks the two-year anniversary of the president’s DACA decision. Later this fall, the Supreme Court will weigh whether Trump’s move to end DACA was lawful, putting my future, and that of 800,000 others like me, in the hands of nine judges.
We could have had a legislative solution by now. In June, the House of Representatives passed with tremendous bipartisan support the American Dream and Promise Act of 2019, which would give Dreamers a pathway to citizenship. We need the Senate to follow suit.
Without the protection offered by the act, Dreamers’ futures and their contributions to this country will be at risk. No longer would I be able to help my patients, including many veterans, find emotional stability and peace of mind.
This comes at a time when skills like mine are needed more than ever. An estimated 1 in 5 Americans need treatment for issues like anxiety or depression, yet more than 40% of them never receive care. The situation is especially dire in rural counties, 80% of which lack a single psychiatrist. Some of my patients drive hours to see me, while others must wait months for an appointment.
The work of therapists like me matters. I recently met a patient who had refused his primary care doctor’s recommendation to undergo treatment for alcohol addiction. I sat with him, gave him space to share his story, then gently explained the importance of recovery and how treatment would help him address his mental and physical addiction to alcohol. He told me about his wife and children, and how he often felt like a burden on his family. He wanted to get better and stay sober so he could return to work and provide for them. He eventually enrolled in long-term outpatient treatment for alcohol abuse that could save his life and restore his family.
Dreamers like me didn’t have a choice about being undocumented residents of the United States. We came with our parents, who made the decision to come here. When my family moved to the U.S., we applied for asylum and followed all the rules. But when my father left our family, unbeknownst to us some of the paperwork requesting that we appear for asylum interviews disappeared with him.
My undocumented status disqualified me from in-state tuition, so I was forced to rely on loans from my mom and family friends to complete college. My status would have prevented me from being accepted to medical school. But when DACA emerged in 2012, it opened a world of opportunities. I was accepted at three medical schools, and enrolled in Loyola University’s Stritch School of Medicine.
After Trump’s decision to end the program, I almost wasn’t accepted into a residency program, since employers were wary of hiring someone who might get deported mid-program. Fortunately, I matched at Loyola University Medical Center, which openly and actively welcomes DACA recipients.
Deporting Dreamers makes no sense, especially at a time when the U.S. population is aging and health care workers are needed. Dreamers like me are doers. We work hard and contribute economically. There are more than 62,000 of us in Illinois alone, 94% of whom hold jobs, according to research by New American Economy.
Dreamers like me shouldn’t have to wait for the Supreme Court to render a decision on DACA. Congress should pass the American Dream and Promise Act and give us a pathway to citizenship. It would benefit not just the Dreamers but also the health care system and all of the other sectors of the country we contribute to.
Aaima Sayed, M.D., is a psychiatrist at Loyola Hospital and Hines VA Medical Center in Maywood, Ill.
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A multi-year process has led to successful implementation of an innovative, evidence-based approach to improve care for veterans with mental health conditions in the US Department of Veterans Affairs (VA) healthcare system, reports a study in a special October supplement to Medical Care. The journal is published in the Lippincott portfolio by Wolters Kluwer.
“Evidence synthesis provided the basis for implementation of the Collaborative Chronic Care Model (CCM) for mental health conditions in VA mental health clinics,” according to the report by Mark S. Bauer, MD, of the Center for Healthcare Organization & Implementation Research (CHOIR) at the VA Boston Healthcare System and colleagues. Titled ‘Evidence Synthesis in a Learning Health Care System,’ the supplement includes 14 original articles, presenting new insights and perspectives from the VA Evidence Synthesis Program (ESP). The ESP is dedicated to making high-quality evidence accessible inform efforts to improve health and healthcare for veterans.
Implementing CCM for mental health care in the VA – Toward a ‘Learning Health Care System’
Originally developed to improve care for patients with chronic medical illnesses, the CCM approach focuses on health care changes to promote teamwork and increase patients’ involvement in their own care. Dr. Bauer and colleagues outline the multistage process – from evidence synthesis, to testing in a formal implementation trial, to policy impact, to scale-up and spread – by which the CCM model was implemented for managing mental health conditions in veterans.
The process started with an evidence synthesis produced by the ESP, focused on emerging research applying the CCM approach to mental health care.
This evidence synthesis indicated that CCMs can improve outcome among various mental health conditions treated in various treatment settings.”
Mark S. Bauer, MD, and coauthors
However, they noted that the evidence supporting the CCM came from randomized controlled trials – with little information about whether it could be implemented in routine clinical practice.
To address this knowledge gap, a health system/researcher partnership between Dr. Bauer’s research team and VA mental health national leadership was established. This collaborative researcher/leadership approach led to the development of a step-by-step guide to implementing the CCM approach – “focusing on creating conditions under which locally designed solutions for local challenges can be developed in accordance with CCM-based guidance.”
The next step was a formal implementation trial, addressing both the implementation and outcomes of the CCM model by Behavioral Health Interdisciplinary Program (BHIP) teams at nine VA medical center mental health clinics. The results demonstrated improvement in key outcomes with the CCM approach, including fewer hospitalizations for veterans with mental health conditions.
The evidence had a policy impact, as the VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the “foundational model” for improving integration of mental health care by BHIP teams throughout the VA system. Based on early experience, the CCM approach was scaled up and spread to other VA medical centers, with strong support from VA mental health leadership. To date, implementation efforts have reached 30 VA medical centers, most of which have aligned their mental health care processes with the CCM model. The VA-wide Plan for Modernization, which was launched this year, includes a milestone based in part on this CCM work. Dr. Bauer and colleagues discuss the relevance of their experience to the development of a “learning health system” – a key aspect of the VA’s commitment to continuous improvement in care for veterans, including real-world implementation guided by a solid evidence base.
The Guest Editors of the Medical Care are Mark Helfand, MD, MS, MPH, and Nicole Floyd, MPH, of the Evidence Synthesis Program Coordinating Center at the Portland (Ore.) VA Health Care System and Amy M. Kilbourne, PhD, MPH, of the VA Quality Enhancement Research Initiative, Washington, D.C. In an introductory editorial, they write: “The articles in this series demonstrate what can be accomplished when research synthesis is integrated with qualitative information from health system personnel and patients and quantitative data from health systems in the context of an overarching framework for health system learning.”
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The British Dental Association (BDA) is calling for better oral health care for patients in hospitals.
A survey, published in the BDJ, shows junior doctors aren’t confident diagnosing oral health conditions.
Half of the doctors surveyed don’t routinely assess the mouth as part of an oral health assessment.
‘Dental care for inpatients, particularly the elderly, must be recognised better in our hospitals,’ Peter Dyer, BDA chair of hospital dentists, said.
‘Failure to engage on oral health can jeopardise the recovery of older patients.
‘Pre-existing problems go untreated, and conditions – including cancers – may not be spotted.
‘The result heaps more pressure on our NHS.’
Almost two-thirds (61%) of doctors weren’t able to spot signs of oral cancer in patients, the survey shows.
The study asked 146 junior doctors about their knowledge of handling oral health conditions.
Of those surveyed, 97% of doctors expressed an interest in receiving further training in oral health.
‘Yes, doctors need appropriate training,’ Mr Dyer continues.
‘But health bosses must also ensure appropriate dental services are actually available for inpatients.
‘Oral and dental diagnosis with referral to the appropriate department for treatment can be key if we want to reduce unnecessary care and prolonged stays in hospital.’
Use of non-dental services
Children’s use of non-dental services to treat oral pain costs the NHS £2.3m every year.
Last year, research by the Queen Mary University of London (QMUL), found thousands of children with oral pain are going to pharmacies, A&E and other non-dental services.
The study found that 65% of pharmacy visits by parents were to get pain medications to treat children’s oral pain.
‘The fact that only 30% of children with oral pain had seen a dentist before going to a pharmacy highlights a concerning underuse of dental services,’ lead researcher, Dr Vanessa Muirhead from QMUL, said.
‘Children with oral pain need to see a dentist for a definitive diagnosis and to treat any tooth decay.
‘Not treating a decayed tooth can result in more pain, abscesses and possible damage to children’s permanent teeth.
‘These children had not only failed to see a dentist before their pharmacy visit, they had seen GPs and a range of other health professionals outside dentistry.
‘This inappropriate and overuse of multiple health services including A&E is costing the NHS a substantial amount of money at a time when reducing waste is a government priority.’
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Mentally disordered individuals are becoming enmeshed in the criminal justice system at alarming rates. Experts tell us that there are now more such individuals in our jails and prisons than there are in our hospitals. Depending upon how you define “mental disorder” between 20 and 80 per cent of Canada’s inmate population suffer from a mental disorder.
The criminal justice system is left having to deal with individuals who are in the system because of untreated or inadequately treated mental illnesses rather than deliberate criminality. It is not a good place for them to be. Unfortunately, for many, the criminal justice system has been the only place where they have received adequate treatment and support.
The Death of a Butterfly: Mental Health Court Diaries is a collection of short stories and vignettes that collectively, it is hoped, paint a colourful picture of how the mentally ill fare in the criminal justice system. There is good news, and there is bad news.
The focus is on the comings and goings of our mental health court, which opened in 1998 in downtown Toronto. Some of the bits are “snapshots,” while some are stories that continue over the course of several days or months. While the content is disparate, it is one fluid story in the sense that it is a depiction of how days in the court are spent. The work of the court is varied, as are the depictions; but they are typical days. And while the focus is on the mental health court, some of the more protracted matters ran their course in the regular trial courts as time and space required.
The stories highlight medical issues, psychiatric issues, social issues and legal issues — often at the same time. The stories are all real but the names have, for the most part, been changed (including in the following excerpt) even though the proceedings are matters of public record. There is an eclectic array of individuals travelling through the courthouse for all sorts of different reasons.
Many of the stories are based upon actual court transcripts and psychiatric reports that I was lucky enough to have retained; other stories are based upon my memory of the events and notes contained in my bench books which I have saved over the past almost 20 years.
The material was collected over many years as it occurred to me to record interesting events in the courtroom. In a sense Butterfly is a “scrapbook.” The content points to many problems throughout our legal and mental health systems. As a composite, these many pieces tell a singular story, and I am mindful that the system can always improve.
I am hopeful that the reader will find these depictions as interesting as I have found my work over the past 40 years.
Mr. David Chesswood was returning after lunch to be sentenced. His matters, involving criminal harassment, were too serious to be considered for diversion.
Diversion is typically only available for the low- to mid-range criminal offences. (Diversion involves offering accused who are charged with less serious offences the option of participating in a rehabilitative program, which, if successfully completed, will result in their charges being withdrawn by the Crown. This is good not only for the Crown, who has one less matter to prosecute, but also for the accused, who avoids the possibility of a criminal conviction. It is also the route that best ensures the community’s safety.)
I had taken his plea of “guilty” several weeks before but had ordered a pre-sentence report (a report prepared by a probation officer that provides the court with relevant background information about the accused) due to the very odd and concerning nature of the offences he had committed. This was followed by a psychiatric assessment pursuant to the provisions of the Mental Health Act.
Mr. Chesswood described to the author of the pre-sentence report that he “went insane” approximately five years ago and was hospitalized for a “nervous breakdown.” This is generally a euphemism for a first psychotic episode, as there is (Hollywood notwithstanding) no medical condition known as a “nervous breakdown.”
He was of the view that his breakdown was the result of “a lot of pain and hardship and [he] was unable to deal with anger and [his] behaviour became strange. [He] didn’t seek help and started drinking, typically to the point of unconsciousness.”
As is unfortunately all too often the case, he then started smoking crack cocaine a few years ago whenever he “became depressed — it gave [him] a lift.” He drank to “numb [his] mind and take away the pain. [He has] a lot of pain inside [himself].” This self-medication inevitably aggravates the individual’s psychiatric condition. As well, excessive drug abuse may actually cause conditions that mimic very closely major mental disorders.
According to his father, David was deprived of oxygen at birth, which he and his wife were told might cause brain damage. For the first two years of his life, David experienced seizures and was periodically hospitalized. However, as he got a little older the convulsions ceased, the hospitalizations stopped, and everything was “normal” until the age of 18, at which point he became more reclusive and started his experimentation with drugs and alcohol.
By this point, he spent most of his time on his own composing music. After a very bad final year in high school, David recovered well enough to move on to the University of Toronto, where he completed three years of a four-year degree in history and philosophy. He then abandoned school again, moved out of the family home, and began spending all of his time composing music.
David’s father said that over the past five years, his son had been in a state of steady decline. He had become violent and aggressive toward family members, and the police had to be called on several occasions.
David’s mother and father feared for their lives when he had been drinking or was high on drugs. Despite all of this, they remained firmly beside him and urged that he be institutionalized so that he could become stable prior to any further attempts to reintegrate him into the community. They were unable to handle him at home in his current condition.
David was clearly an extremely bright student, earning a 92.5 per cent average prior to his “breakdown” during his last year of high school. He had been committed to the hospital as an involuntary patient on at least one occasion, and he was previously admitted to the CAMH Concurrent Disorders Program.
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His parents were of the view that this program was not particularly effective, as it only had one hour of counselling once per week. David was eventually discharged from the program as a result of his leaving sexually explicit and harassing telephone messages on the voicemail of female staff members at the program. He provided the facile, or less than insightful, response that he was intoxicated when he left the messages.
David’s diagnosis had been delusional disorder, in partial remission; major depressive disorder, in partial remission; and poly-substance abuse disorder (cannabis, alcohol, and crack cocaine).
David describes himself as a “good, caring, and loving man” who has experienced “some really bad luck” in the past five years. However, his insight is described by his psychiatrist as “fleeting and superficial.”
The principal charge presently before the court is that of criminal harassment. His psychiatrist, Dr. Mitchell, is the complainant. He had left dozens of messages on her voicemail, which were disturbing in the extreme. They were chilling — graphic, violent, pornographic and obscene. When interviewed, David did not see the “criminality” in what he had done, but rather, viewed the whole thing as a form of “amusement.”
He stated that he wanted a “date” with Dr. Mitchell, but did not know how to go about getting one: “I thought she might be lonely or single and might enjoy a pornographic message,” he said.
The author of the pre-sentence report felt that David might do better with a male psychiatrist in that David was of the view that “women committed crimes against [him] by not loving [him]. All women purposefully stay away from [him]. It’s a conspiracy against [him].” While he self-described as a “porno addict,” he denied fantasies, interests or behaviour consistent with a paraphilia or sexual deviance.
At the end of it all, the diagnostic picture was disappointingly unclear. Despite previous diagnoses, the present assessment could not provide any conclusive answers or suggest any course of treatment other than that David and intoxicants, alcohol in particular, were a bad mix. The psychiatric assessment did not point to a defence of “not criminally responsible on account of mental disorder” and neither party was pursuing it.
As is often the case, he had spent a significant period of time in custody while these various assessments were being conducted. By the time he was before me for sentencing, the custodial component of any reasonable sentence had already been served. I placed him on probation for the maximum period of three years with terms that he comply with any treatment directed by his probation officer. He agreed to these terms.
The conclusion of David’s matter was, from my perspective, unsatisfactory but not atypical. I am sure that his parents are not optimistic that their son will comply with the terms of my order. I’ll keep my fingers crossed.
With the “That’s the list, Your Honour,” I requested that everyone have a good evening and made my way up the five flights of stairs to my chambers thinking to myself on the way up how perverse it was that the criminal courts were trying to do the work that should rightly be picked up by the mental health-care system. Who would have guessed that the criminal courts would be reconfigured as principal dispensers of mental health care? And then, with the new role assigned by default, would not be provided with adequate resources to get the job done?
Something is desperately wrong with our system.
Just as the jails have become the de facto psychiatric hospitals, the police are having to respond to individuals in psychiatric crisis and then decide what is best to be done. It is time for a reset.
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