Posted by boBB on June 1, 2000, at 13:04:31
In reply to Re: Drug Related Violence , posted by SLS on May 31, 2000, at 7:51:54
Scott wrote: "I think it is critical to recognize that an antidepressant can make this same person feel *worse*. Now, what are we going to do about it?"
What are we going to do about it, indeed that is the question, Scott.
Opinions may vary about the degree of risk of violence/aggression/suicide associated with recently developed ADs, but even staunch advocates for the drugs are obliged to recognize a common risk. We can dicker till hell freezes over about whether the pleasure of enjoying a sunny day is worth the risk of a drug-induced suicide, but the possibility of drug-related violence implies a need to find a broader remedy for clients who are prescribed this class of ADs, and to find other remedies for problems the ADs do not seem to resolve.
Frankly, I am tired of the personal attacks and irrelevant ridicule that almost always follows introduction of new information into a group such as this. I am dismayed at the pervasive criticism of discussion that we should individually take responsibility for more than our individual lives, and I know that by continuing to attempt intelligent, broadly sourced discussion I am just inviting more of the same.
Still, there are things we can do, as a society, to be better prepared to deal with the potential harm to society caused by these drugs. My opinion of the drugs has nothing to do with it. It is not *my* opinion that there are risks - there are well documented risks, and families of victims and survivors of the last years school shooting in Colorado asked their legislature to do something about it.
What can we do?
This is something I have discussed with school safety personnel in my community, and part of what inspired me to look further for documentation of how the drugs create a risk. Generally, I suggest we need a more collaborative approach to the delivery of mental health services.
Collaborative approaches have been recently discussed on this board (in threads in which I took no part whatsoever). People talked about finding a pdoc who is also a therapist. The discussion of therapy vs. medications has repeatedly returned to a discussion of the way various approaches work together.
I am suggesting that not only do we need better coordination between therapists and the psychopharmacologists, physicians or psychiatrists that prescribe drugs, but we need a new level of collaboration between these direct mental-healthcare providers and social workers, school counselors, school safety officer, teachers, administrators, clergy, employers, families and other community members. I am focusing on youth problems here, because they are generally considered to be a more urgent social responsibility, but we need the same approach, I maintain, in delivery of mental health services to adults.
I will explain some recent precedents for collaborative approaches in delivering social services, and I will try to offer a sketch of how a collaborative approach would function among mental health providers, social service providers and community groups.
In such a collaborative approach, there are obviously privacy concerns and issues about the ability of sundried professional interests to work together, and I will leave these concerns largely unaddressed here, except to say that such a collaborative effort might work best if it is facilitated by individuals whose specific function is to mediate collaboration. In much the same way the Dept. of Justice Community Relations Division mediates racial disputes, trained professional facilitators can stand outside the various professional interests of a broad-based coalition and focus on the function of the coalition as a whole.
Two national initiatives have recently fostered collaborative approaches to social service delivery. The Welfare Reform Act of 1996 is most notorious for the deleterious effect of kicking people of the welfare roles with no place to go. I don’t want to offer an assessment of this reform process here. It has worked in some ways as it was intended, and other areas are problematic. The worst problems may lie in the future when the most needy individuals meet their lifetime cap on public assistance.
But welfare administrators I have spoken with say their clientele, after a few years of reform implementation, reflects many of the hardest to serve cases. In their effort to meet the diverse needs of these hard-to-reach individuals, welfare offices have joined with local mental health providers, and other social service providers to address needs. Welfare recipients are being directed toward assistance with education, with substance abuse problems and, in cases were mental disability likely precluded employment, assisted with applications for social security disabilty payments. Welfare offices are promoting day care and public health insurance programs for children in an effort to advise people recently nudged into the work force that they are still eligible for public assistance. These collaborations have been fostered by a top-down instruction to states and to area welfare agencies accompanied by advice on how to meet the needs of clients at risk of loosing public assistance.Another, more concerted approach to collaboration is found in the Workforce Investment Act of 1998. The Act replaced the former Job Training Partnership Act with a block grants to states. To qualify for grants, states were required to establish five-year plans for administering one-stop job centers. These one-stop centers are intended to offer a “no-wrong-door” place where job seekers can at once apply for unemployment insurance, veterans job benefits, job training, financial assistance with education, tribal benifits, elderly assistance programs, they can work on their resume, or use personal computer work stations to search on-line job banks. The centers are still in their infancy, and many are experiencing typical difficulties associated with administering broad-based institutional collaboration. It is not my intent to critique their progress, but to demonstrate that inter-disciplinary collaboration is a trend among social service agencies.
Another example would be one state’s juvenile justice reform process. State legislation empowered and directed judicial districts to call broad based community teams to assess a variety of prevention programs, treatment programs and justice agencies that deal with youth, and to recommend funding proposals intended to move dollars from housing offenders toward the prevention of first-time and recidivistic juvenile delinquency.
Now, how would this work in terms of mental health services? To reach the full spectrum of mental health clients, effective collaboration would necessarily involve both privately funded and publicly funded mental health and social services.The simple step I encouraged local school safety personnel to consider is for health workers in the schools to attempt to learn who has been administered a potentially agitating medication, and to develop a dialogue with the attending physician regarding development of side-effects or perhaps simply the failure of the drug to work. Such a dialogue is well-precedented in the role teachers and parents are playing in identifying ADD. Of course, even the AMA (or was it the APA?) recently criticized the overdiagnosis of ADD by teachers and others who could not distinguish between ADD and normal rambunciousness, but such a critique might be evidence of multiple organizations ability to establish and then refine collaborative efforts.
Beyond simply recognizing unwanted side-effects, school officials or school counselors are in a position to recognize antagonizing circumstances, such as a pervasive atmosphere of intimidation at many schools. This dialogue might go either way - school officials advising therapists of destructive influences for which a client needs guidance, or therapists advising schools in some situations that drugs, therapy or other approaches will not likely reverse the harm caused by an oppressive atmosphere. A product of recognizing the harm of the atmospher might be keep-the-peace efforts that involve conflict mediation training for teams of students, or as many states have established, school violence hot lines. Kids should be encouraged to call these hotlines just as often when Jocks bully unpopular kids as they are when the Gothic set causes fear among other students.
The expansion of individual youth counseling into family therapy is another example of effective collaboration. Another example would be a well-run county mental health office that assigns case workers to insure clients living on their own are able to maintain a tolerable living environment, or sometimes to assist with basic chores like shopping or house cleaning. In the private sector, client-centered therapies may need to reach beyond the client to address work-place issues. The rash of postal office shootings did not occur in a vacuum or because of a full-moon. They occurred after cost-cutting measures increased workloads and put pressure on supervisors to increase production, even counting the length and cadence of local mail-carrier’s steps. Such economically motivated decision making needs to be balanced with formal consideration of human factors.
The general idea I am proposing is that drugs alone do not always work. Drugs alone may work for some people, but in other cases, administering a bottle of pills and releasing a person into a community can lead to tragedy. Broad based collaboration is difficult and sometimes leads to confrontation and ruffled feathers. If I have any opinion to offer, it is that a few ruffled feathers, and some professional confrontation may be a far better option than continuing to mop up blood and to plaster over bullet holes in the floors and walls of our schools and workplaces.
Maybe many of those on this board are powerless to help implement collaboration, but in the interests of the many people here who are not getting what they need from their mental health providers, I feel it is fair to consider whether we can expand collaboration and find new approached for service delivery in the 21st century. It doesn’t require anyone to take any whoop-ass. It might require participation of teaching universities, practicing clinician, and official agencie representative, as well as the pleas of clients and the demands of advocates.
poster:boBB
thread:35331
URL: http://www.dr-bob.org/babble/20000526/msgs/35541.html