Laura's Law

I believe it’s been two months since I made an entry here. There are several reasons. One is that life happens: there was a vacation, followed immediately by Christmas and New Year’s and the flurry of starting resolutions. Another is that I’ve been writing this for four years: it’s not always easy to come up with something interesting and informative about mental health every two weeks. But the other is this: the silence from my audience is deafening. I frankly feel I am writing into the void. I can’t remember the last time anyone made a comment. And if no one is listening, what am I doing it for?

So if I don’t hear from any of you, this is my last blog entry.

Meanwhile, let me talk about a local California issue: “Laura’s Law.” It is the equivalent of “Kendra’s Law” in New York state. It essentially is built to guarantee that people with mental health issues that are not getting the treatment they need, and are scraping bottom in their lives,  will be given a chance at comprehensive state assistance - rather than circulate from jail to street to psych ward and back out again, over and over.

In the United States, this type of law is the majority - 45 states have adopted some program approximating “Laura’s Law.” So for once California is trailing at the rear end of a humane and liberal movement. Why is this?

It’s mostly bad press. Those who oppose it seem to have the idea that Laura’s Law will force medication, hospital stays, or even straight jackets and shock treatment, onto people who don’t want them. Nothing could be further from the truth. Let me tell you how it works in Nevada County, the only county in the state which has fully funded the program.

“Laura’s Law” is actually a nickname for Assisted Outpatient Treatment, or AOT. It begins with a request for AOT from any of the following: a family member, roommate, peace officer, agency or hospital director, or a licensed therapist. The next step is to determine if the possible patient meets all the criteria - if s/he doesn’t, the process goes no further.

Criteria include ALL of these:
a serious mental disorder, inability to survive safely in the community, not yet an emergency situation but the patient’s condition is deteriorating, treatment is necessary to prevent a 5150 (imminent danger to self or others), and the patient has not meaningfully engaged in treatment or has refused it. What does lack of meaningful engagement in treatment mean? For instance, in 2 of the last 3 years, they’ve been in hospital or prison, or at least 1 of the last 4 years has featured serious violent and threatening acts, and threats to oneself or others.

If the criteria are met, then a plan of treatment is put together, to include 24/7 on call support. That means help with housing (which must always be the least restrictive that is possible for this person) and basic services, help with entitlement programs like Social Security or Medicaid, Substance Use counseling, support groups or therapy, life skills training, whatever they need to stabilize their life. It does NOT include locks, restraints, seclusion, or forced medication.

What happens is that the person is approached by their local mental health community and  offered this array of services on a voluntary basis. Nevada County says that in their experience, 2/3 of the people they offer this to, simply agree.

If it gets to the length of a Court Order, it is usually in special cases, such as those on probation or parole, those who are Court Wards or Mental Health Court participants, and the like. Somebody visits them ahead of time and gives them a pre-hearing list of what the court is suggesting and discusses it with them. They are also given a Public Defender to argue their point of view. Basically, what happens at the hearing is that the Judge sits down with the patient and goes over the list of possible treatments, and they determine which of these things the patient is WILLING to participate in. Nobody is fined, forced, or jailed. After 60 days the plan gets reviewed to see how it’s going.

What Nevada County has found is that after someone’s life becomes more stable as a result of the help they are getting, they eventually become willing to take the medication.

There now. Does that sound coercive or scary?

Actually, AOT is the law of California right now - it is just left up to each county to activate it by funding it. Is it expensive? The interesting thing is that it’s not. This comprehensive treatment actually saves Nevada County an average of a dollar for every dollar spent. That’s a dollar in the mental heath system. It doesn’t even count the money saved by the jails or courts who don’t have to cycle these same patients out and in again, year after year.

So that’s what I found out, from the horses’ mouths, at a presentation by Nevada County administrators and judges. I hope you’ll support Laura’s Law if it comes up in your community. Emergency-only treatment has not worked for us. Let’s see what a little prevention and a voluntary helping hand can do.

Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at www.lafruche.net or see her catalog at www.lastlaughproductions.net.

Hoarding Disorder, part 2

Hoarding Disorder - part 2

Briefly, here are some of the tips I ran across in my reading.

You can make early progress without too much distress by grouping things. Start gathering everything that is alike and put them in one place (preferably neatly, in a box). All the linens, all the stationary, every pair of black shoes. Just pick a pile, go through it and separate the items into categories. You don’t actually have to discard anything if you’re not ready. It helps you see how much you have that is already redundant. It also gives you an idea of how much space you’ll need to devote to storing any one category. If you go through all your closets and find 4 suits in the same color, it might be easier to think about getting rid of a couple of them, especially if you can see that there is not enough closet room. (So then you can start a new category to gather up: things to give to charity).

For paper clutter, which I think almost everyone has to some degree, you can make some progress just by discarding the extraneous bits: all the plastic covers or extra envelopes. It has been suggested that paper tends to fall under the following broad types: memories, paid bills, bank records, work related, tax things, health and mortgage related. So that gives you a place to start.

Lastly, just for fun, I am attaching a piece I wrote about my own tendency to get buried in “things.” I hope you enjoy it.

Housey

She’d always wanted a room that wasn’t a room. A room that served no housely function. A room with a deep ochre carpet, plush and watery to step into, and oriental poofs and pillows and bean bag chairs and wind-chimes – lots of glass and bamboo wind-chimes hanging from the ceiling, plinking gently in the breeze from a low, open window. She would just sit in this room, and listen, and think. Just that.

The room had a closet and the closet was empty. No agendas. No surprises.

Actually, she wanted a house like this. Every room was open, airy, light-filled and freshly aired. No room was for actual use, other than to enjoy. One had tatami mats and shoji screens. One had masks on the wall, a burnished wood floor, and nothing else. One held a potbellied black stove squatting on bricks, firing up till the red gingham curtains shimmered with heat. There was a room with blue tile and a frog pond. A room with brilliant Eastern billows of cloth hanging from every rafter.

Nothing was on shelves or in drawers or leaning in corners. All was space. Transparent, that’s it – the house was transparent, in the way she wanted her government to be transparent. She wanted a house like this, in addition to the real one. She would walk through it every day. There was no music there, never any other people, no neighbors. A house filled with silence and space.

No. That wasn’t it. Actually, she wanted a life like that.

Instead, she was plagued by mounds of receipts from Taco Bell, cupboards full of wrapping supplies, five crystal punch bowls, and three closets of clothes. Not to mention the bills. She was convinced that they bred in the dark at the bottom of the drawers, so that every time she opened the desk there were new baby bills winking up at her. Bills for things and things and things. Where did they come from, when all she wanted was a limpid blue frog pond?
She heard herself speaking these objects into being. Saying, “Honey, we need some new software”, or “I would love to have an espresso machine like that”. They appeared. They brought with them boxes, warranties, cleaning instructions, websites with pdf files on how to repair, squishy foam peanuts and styrofoam dividers and plastic wrap and another place to find on the counter. She was drowning. She couldn’t breathe.

She dreamed at night that the clothes left the wardrobe and opened the front door to polyester friends. They were having a party and she was not invited. Soon, they would roll her into a corner like an old rug, so she would take up less space. Eventually she would end in the giveaway bin.

She looked forward to this. She wanted to be carted away.


Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at www.lafruche.net, or see her catalog at www.lastlaughproductions.net.

Hoarding Disorder, part 1

I promised an overview of the “new” DSM 5 disorder, which has just come out from under the umbrella of a mere OCD symptom. There is a connection between the two disorders - about 25-30% of people with OCD are also compulsive hoarders. But while hoarding can be a part of the anxious, defensive rituals associated with obsessive compulsive traits, it also affects other people, about 2-5% of the general population. Compulsive hoarding can be fully as harmful as any other mental disorder, destroying relationships, safety and health, ability to work, function and socialize, and more.  One informal definition I ran into was, “When your stuff no longer serves you - instead you live to serve your stuff.”

Some of us can relate to that definition, and some of us might joke that it is a favorite American pastime! But what does it take, under the new DSM 5, to qualify as needing treatment? There are six criteria, and all of them must be met to earn the diagnosis of Hoarding Disorder proper.

The first is trouble discarding things regardless of their value. They may actually be valuable, or the person may just ‘see’ them as valuable. Secondly, the patient feels a strong need to save these things and will experience considerable distress at the threat of getting rid of them. Thirdly, the result is a clutter of possessions that congest living areas to the point of interfering with using those areas (or even using the things being saved for whatever their intended purpose). Any areas still free in this scenario are due only to the intervention of someone else. Fourthly, and here is where we really get to it, this clogging has reached the point of causing serious distress or impairment, say in social or work life or in safety or health (for instance, a person no longer invites people in, even just to the front hall, and their house is a serious fire hazard). Fifthly, an important proviso is that this behavior must not be a side effect of another medical condition such as brain injury; and sixthly it must also not be better explained by another mental illness (the hopeless lack of energy in Depression, for instance, or a Schizophrenic delusion). The doctor may also specify if the condition is accompanied by a tendency to excessively acquire new items even though there is no need or no space; and there is a specifier for how much insight a person has into their problem, from “good or fair” to “absent.”

So what can be done about this condition? Many normal people have small caches or collections in their homes (or perhaps at work), from the drawer full of junk, to the desk full of paperwork that never gets cleared, to decades of junk in the attic. Well, the answer depends on how much insight the person has, first of all. Interventions in which relatives or authorities clear the space without permission not only cause the patient quite a lot of pain and distress, but he or she usually builds the collection right back to where it was before, sometimes within as little as 3 months. Conventional treatment, if the person is willing, generally consists of psychotherapy, particularly an extended series of Cognitive Behavioral Therapy sessions, and sometimes medicines such as anti-depressants. The figures for success of such treatments are not very impressive, however. If you want to know more about causes and treatment, a good place to look is www.compulsive-hoarding.org.

There are a handful of Yahoo groups for hoarders who are working on their behavior, such as “Messiness and Hoarding” and “Declutter Support.” It has also been noted that hoarding tends to be a family disease - 50% of hoarders have at least one first degree relative with the same condition. Sometimes the children of hoarders may not really have the full disorder but need basic training in how to sort through and discard things, which can be very daunting after years of not doing so (There is also a Yahoo group called “Children of Hoarders,” as well as “Friends & Family of Hoarders and Clutterers” and “Friends of Hoarders”).

For those who’d like to change, I discovered a UK site called Cluttergone which not only offers information , decluttering services and self-tests, but has a wonderful and hopeful blog of a woman who took a year-long journey and rediscovered her own home under all her things (In her case, the impetus for hoarding seems to have been a long disability followed by clinical depression. The role of trauma in hoarding is being researched, as well as possible genetic connections). Though it’s 40 entries long, I recommend reading it for the wonderful sense of hope it imparts and for the practical tips on how to get started clearing out the clogs.  It’s here: http://cluttergoneblog.blogspot.co.uk. The Cluttergone general site also has a list of which books on the topics of decluttering, reorganizing and understanding this disorder are worth your time; you can find that here: http://www.cluttergone.co.uk/reading.html.

In my next blog, I’ll give some tips on how to get started on your own decluttering project, plus a fictional piece I’ve written on the topic.

Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at www.lafruche.net, or see her catalog at www.lastlaughproductions.net.

Changes in the DSM part 5: Autism

First, let me give you the good news: the Substance Abuse and Mental Health Services Administration (SAMHSA) has just released a toolkit that explains how the new Health Insurance Marketplace for behavioral health patients works, and how to apply and get help. It is intended primarily for organizations, but I imagine individuals will find it useful as well. Register here: http://tiny.cc/ConsumerPeerFamily;.

Now, to my topic: in the DSM V, 3 diagnoses - Aspergers Syndrome, Autistic Disorder (classic autism), and Pervasive Developmental Disorder Not Otherwise Specified (atypical autism) - have been collapsed into one broad category: Autism Spectrum Disorder. This is a major change that effects many people, and it is controversial.

Some say it is good in that it is more inclusive, and recognizes in its language that mental disorders exist on a spectrum, with “gifted” and “normal” behavior at one end and complete lack of function on the other.  It is probably intended to allow more people, for insurance purposes, to get the support and services they need. For some this will be a blessing.

For others it is a matter for concern: if you widen the pool of people competing for services, but don’t widen the pool of resources, how do they get spread around? Autism actually comes in many different flavors, with some individuals appearing merely eccentric and others being profoundly disabled. If they all have the same label, will those who are most ill be able to get the higher level of assistance they need just to survive? And who will be deciding these money allocations? Are they qualified?

Another problem is the lack of differentiation in terms of treatment. How will we distinguish those who have the ability to converse from those who have only nonverbal behaviors, for instance? These differences are no longer recognized as part of the diagnostic process. Temple Grandin covers many of these questions brilliantly and at length in a book excerpt published by salon.com in May. You can read it for yourself here: http://bit.ly/16K0oDF. She points out that due to the symptom reorganization, many patients who would previously have been diagnosed with Aspergers or PDD could end up in another category altogether, such as disruptive, impulse-control and conduct disorders, or intellectual development disorders.

The American Psychiatric Association says that all previously diagnosed individuals will keep their diagnosis. But we have yet to see the results of this new labeling in action, and whether it will be an improvement for patients, which is what this should be all about. I am skeptical, myself. As Grandin says, “autism is not a one-size-fits-all category.”

When it comes to mental illness, I’d say that’s true of all of us.

Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at www.lafruche.net, or see her catalog at www.lastlaughproductions.net.

Changes in the DSM V - part 4

We continue our survey of the revised DSM, with Obsessive Compulsive Disorder. This is now a category in itself, not included as a subspecies under Anxiety Disorders. The description of this disorder now allows for a whole range of understanding by the patient, from “good” or “fair” insight at one end of the scale down to “absent/delusional” at the other end. It can also be specified as “tic-related” if appropriate.

Under the Obsessive Compulsive umbrella we have a number of subcategories, such as the much heralded new “Hoarding Disorder.”  Once relegated to a mere symptom of a subtitle, it is now recognized as a full fledged set of problem behaviors in its own right. In future blogs, I hope to look into this new animal and tell you what it is, and what qualifies one as a hoarder.

There are also other subcategories, for instance Body Dysmorphic Disorder, which consists of repetitive behaviors based on perceived (but not actual?) defects or flaws. I must admit I am not familiar with this one. Another aspect is the old chestnut Trichotillomania (hair-pulling) Disorder, and the new “Excoriation” (skin-picking) Disorder - another one I’ll have to look into. There is the additional choice that any of these may be “Substance Induced,” which makes sense, and an interesting entry under the title “Other Specified and Unspecified” - Obsessional Jealousy. Frankly, I have always believed that type of behavior to be an aberration, so I was intrigued to see the professional recognition.

In other news, under Dissociative Disorders we have a change in language to note that disruptions may be reported as well as directly observed, which is certainly going to help in diagnosis. It is also now clinically accepted that dissociation may occur in response to everyday events, not just those we label traumatic. And with this, I think we are running into a very basic principal in mental illness: one man’s passing moment is another man’s crisis.  It is the very definition of “abnormal” that we do not respond in the same way as others do to the same stimuli.  That is how people notice we are different in the first place! Where the average person may leave a noisy, chaotic environment with an annoyed shake of her head, the person with psychiatric issues may well leave that same environment crying and shaking, unable to cope for the rest of the day. So I think the recognition that everyday phenomena may function like trauma for some of us has larger implications for mental health treatment.

Also in the Dissociative category, Dissociative identity Disorder is now considered to include certain behaviors that other cultures might label as “possession.” Leave it to Western medicine to find a cubbyhole for everything.

Lastly we have a sort of backhanded mainstream recognition in the new diagnostic class “Gender Dysphoria.” This category recognizes many forms of “gender incongruence” rather than merely cross-gender identification and attraction. It is now a multi-category description rather than a dichotomy.

I am not so sure it is helpful that this is still included as a mental disorder; however, we have come a long way. Homosexuality was listed as a psychiatric disturbance until 1973. It is the only disorder ever removed from the DSM. It was replaced at that time with Sexual Orientation Disturbance, and now with Gender Dysphoria, which leaves room for all the different ways people can be unhappy with the boy/girl status quo. I prefer to think of it as a recognition of how uncomfortable and life-altering it is not to fit snugly into heterosexual roles. Our culture still makes this a difficult way to live, and often people could benefit from therapy as they try to find their way to personal power and personal peace.

No doubt some of you will consider it insulting that the category even exists, and I can understand that. But there will always be labels for those who don’t fit into the mainstream paradigm, and some people are always sure to consider them “wrong” or “sick.” That is the risk we take when we step out and do it our own way. Educating the world is a visionary calling that can take generations to achieve.

In my next blog I hope to address the one major change I have not dealt with yet: the new Autism Spectrum Disorder that has swallowed up other designations such as Aspergers Syndrome. What this means for those affected is a complex issue that I want to study further.

Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at www.lafruche.net, or see her catalog at www.lastlaughproductions.net.

Changes in the DSM V: part three

On we go with our dissection of the new DSM 5. The next category up is Anxiety Disorders. Here we have some important changes.

For one thing, Obsessive-Compulsive patients are no longer in a subdivision of Anxiety, but now have a category of their own. And Post Traumatic Stress Disorder has been moved as well, to be placed under the Trauma Related Disorders rubric.

There is also a substantive recognition of our world view. It is no longer required that the Anxiety patient label their own fears as excessive and unreasonable. There is acceptance of the fact that what you are afraid of is, to you, truly dangerous. In the rest of the world’s eyes, maybe the danger is overestimated. But to you, it is quite real, and as far as you are concerned your fear is entirely rational. The requirement is now merely that the Anxiety be out of proportion to the danger - NOT that the patient agrees that her fears are ‘silly’ or ‘crazy.’ To me, this demonstrates respect for the patient’s reality.

The other new requirement is that the Anxiety be of at least 6 months’ duration, to distinguish it from passing fears.

The Panic Attack category also shows some changes. A set of previously complex terms have now been boiled down to a simple choice between “expected” and “unexpected.” This label can be added as a specifier across various disorders.

Also, Panic Disorder and Agoraphobia have now been unlinked. If a person displays both, then he gets two diagnoses.

The former “social phobia” is now renamed Social Anxiety Disorder and can be typified as “performance only” if necessary. It is no longer “generalized.”

Lastly for Anxiety Disorders, Separation Anxiety is now recognized as occurring in adults as well as children. And Selective Mutism has now come under the Anxiety Disorder heading.

Next post: Obsessive Compulsive Disorders, including the new Hoarding Disorder.

Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at www.lafruche.net, or see her catalog at www.lastlaughproductions.net.

Changes in the DSM V, Part Two

This is the second part of our series on changes in the DSM V - the Diagnostics and Statistics Manual that determines how most of us get diagnosed and funded for our treatments. It’s bound to be a little dry, but I feel that this is information we all need to have access to, since it effects us directly, and impacts our futures.

The Disorders I will tackle today are Bipolar and Major Depressive.

There are fewer changes to Bipolar Disorder than there were in the Schizophrenic and Schizoaffective categories. The primary change is a general increase in flexibility. For instance, in terms of detection, the emphasis now is not so much on specific exact symptoms of X degree, but on changes from the norm in terms of activity, energy, and mood. It is not so much how fast you go, so to speak, it is the fact that you have speeded up from your previous level of activity, speech cadence, etc. This should certainly help with earlier alerts that something is wrong.

Also, the category “mixed episode,” which used to mean an active episode of the disorder containing full features of depression and full features of mania, has now been replaced by the looser term “with mixed features.” The difference here again is one of flexibility. Mixed features can contain a little of this and a little of that in varying doses. You can see how the former definition in which “full criteria” had to be met would be limiting, when in fact symptoms can mix and match in all sorts of unique ways from person to person.

Thirdly, the category “Other Specified Bipolar and Related,” a sort of catch-all category, has been opened up more in terms of whether a hypomanic episode is “long enough” or has “enough symptoms” to diagnose.

Lastly is the addition of a new “with Anxious Distress” specifier, to identify patients who have anxiety symptoms but have not been seen to meet the full criteria of Anxiety Disorder. This specifier has also been added to Major Depressive Disorder.

Major Depressive Disorder is largely unchanged except that if at least 3 manic symptoms co-exist it will be tagged “with mixed features.” The interesting thing about this category is that there used to be a “bereavement exclusion” for those grieving a loved one, and it has now been omitted.

Why? Well for one thing, bereavement was for depressive symptoms following a death which lasted less than two months. It’s now recognized that normal grieving can easily last 1 or 2 years. Secondly, it has been noticed that bereavement can precipitate true depression in the vulnerable, just like any other major stressor. There is therefore no reason to rule out bereavement as the exception. They are now considering a possible new disorder called “persistent complex bereavement.” It is listed in “Conditions for Further Study.”

It has also been noted that bereavement related depression usually occurs in families and people with histories of depression already, and is thus genetically influenced.

Lastly, as I mentioned, is the inclusion of the “Anxious Distress” specifier, just a in Bipolar Disorder.

In a week or so I’ll go on to Anxiety Disorders and other categories. My apologies for turning this out so late...apart from other things going on in my life, this is dry stuff to wade through, and it just takes time.

Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at www.lafruche.net, or see her catalog at www.lastlaughproductions.net.