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Senate Finance Committee Hearing On The Abuse Of Seclusion & Restraints In Psychiatric Facilities

Statement by Laurie Flynn, Executive Director, the National Alliance for the Mentally Ill

For Immediate Release Contact: Bob Carolla/703-516-7963

We commend Senator William Roth (R-DE) for his prompt action in convening a hearing of the Senate Finance Committee following the release of the General Accounting Office (GAO) report on October 1, 1999 on the improper use of restraints or seclusion in psychiatric facilities.

It has been one year since The Hartford Courant published its investigative series, inspired by reports from NAMI Connecticut families, which documented 142 deaths around the country from such abuse during a ten-year period. The Harvard Center for Risk Analysis further indicated that between 50 and 150 such deaths occur every year.

NAMI also has compiled Cries of Anguish; a summary of additional reports of abuse received since the Courant investigation-cited in the GAO Report-which includes over 40 incidents from 20 states. During one five month period, five deaths were reported -four of them of youths under the age of 18. And those are only the ones we know about.

Legislation has been introduced in Congress. After today, two Senate hearings will have been held. The Department of Health & Human Services has published regulations for Medicare and Medicaid funded hospitals and is in the process of developing regulations for residential treatment centers. In spite of HHS' s regulatory initiatives, there still are no consistent national regulations governing restraint and seclusion use in all facilities providing psychiatric treatment. The GAO has confirmed what many of us already knew over a year ago.

Not only is the current system broken-but indeed, there is no system. Most importantly, no comprehensive reporting system exists. It is both a national disgrace and a national crisis. Literally, people are dying. Others are being physically injured. Others are being psychologically scarred for life.

People will not be fully protected unless Congress passes a law to end the current system of horrors. Regulations are not enough, because too often, they are too easily changed. The issue today is not whether Congress should act, but when? How many more people must die before Congress acts? We hope this hearing will be used as a foundation for decisive action in the weeks ahead. NAMI calls on Congress to mandate the reporting of all deaths and serious injuries to state based legal entities which can investigate the circumstances of such incidents. Further, consumer and family facility monitoring groups should be put in place.

NAMI's efforts focus on support to persons with serious brain disorders and to their families; advocacy for nondiscriminatory and equitable federal, state, and private- sector policies; research into the causes, symptoms and treatments for brain disorders; and education to eliminate the pervasive stigma surrounding severe mental illness.

Cultural Competence in a Multicultural Society: A Checklist

by Jean Lau Chin, Ed.D.

Are you culturally competent? What does it mean to be culturally competent in a multicultural society? Does culture matter? Ask yourself thefollowing questions and think about how you translate the answers into practice in your daily life:

How do you value your own culture?

Do you think about your culture?

How do you value the culture of others?

Rapidly Changing Society

We are quickly becoming a global economy given the rapid advances in technology and communication. The ease and speed with which we can communicate with others via the internet far exceeds what we thought possible just a few years ago. Advances in travel and transport have bridgedcountries and cultures such that boundaries and distance are often less meaningful. Communities and cultures transcend the geographic distance once posed as barriers.

Demographic Changes

The U.S. society is also growing increasingly diverse. Demographic changes over the past decade predict that by the year 2050, racial/ethnic groups will make up 48% of the total U.S. population. It will be meaningless to talk of the white majority. Moreover, multiracial families through interracial marriages, cross-racial adoptions, blended families through divorce and remarriage all bring about families and communities where racial boundaries and cultural differences are blurred.

Growing Influence of Different Cultures on Our Daily Lives

There is a growing influence of different cultures on our daily lives. Just look at any food court in major shopping malls. The sampling of food is matched by a sampling of cultures. Spaghetti from Italy, gyros from Greece, sushi from Japan, egg rolls from China, knockwurst from Germany, burritos from Mexico are offered side by side as typical foods of choice.

Multicultural celebrations and ethnic festivals are now more commonplace as we pride ourselves on the diversity in our lives. But is it? Do you really live a multicultural life? Or is the superficial sampling of cultures found in typical shopping malls reflective of your exposure and sensitivity to culture in your life?

A Checklist for Cultural Competence Self- Assessment

Ask yourself the following questions:

How do you value diversity? Are you open to differences by individuals from other backgrounds? What do you do when someone in your neighborhood or workplace has practices different from your own? How do you react? Are you critical, dismissal, demeaning in your words, behaviors, or attitudes?

How do you view health? Do you realize that health behaviors, utilization, and practices are intricately related to culture? The foods we eat, the emotions we feel, and our lifestyle behaviors are all influenced by cultural values, beliefs, and practices. Sociopolitical factors of poverty, racism, immigration and culture all contribute to differences in health status, utilization, and access, i.e. how we get sick, what we do when we get sick, and how we can get care.

What do you expect from your health care provider? Do you expect your provider to be knowledgeable about your culture and sensitive to your beliefs, practices and customs when caring for your health? Or, do you split your health and wellness from your culture and beliefs? When seeking health care services, do you have the choice to choose a provider who is knowledgeable about your culture in addition to being "technically" expert?

Where do you live and work? Are there diverse groups and individuals in your neighborhood, school, and workplace? Is there a tolerance for different cultural practices, e.g., time off for celebration of different ethnic festivals? Is there a recognition of, and tolerance for, different communication patterns and styles of interaction across ethnic groups? Some groups use indirect means of communication more frequently while others emphasize cooperation over competition. How do these differences translate in your neighborhood or workplace?

How do you rear your children? Are they aware of their cultural origins? Do you share beliefs, stories, values about your culture with your children? What are the values you transmit and how are they related to your culture? Sometimes, it is only by observing how others are different that you can be aware of your own culture.

These are but a few of the questions you can begin to ask of yourself. Do a cultural audit of yourself , your neighborhood, your workplace, and your environments to evaluate whether or not they are culturally competent.

Jean Lau Chin, Ed.D. President of CEO Services, provides clinical, educational, and organizational development services emphasizing culturally competent, and integrated systems of care. She is a practicing psychologist in Quincy, MA with 30 years of clinical, consulting, and management experience. For information on cultural competence training and consultation, Dr. Chin can be reached at (617) 965-8964.

Writer Slammed for Attack on People With Mental Health Problems

For Immediate Release: Arlington, VA - The National Alliance for the Mentally Ill (NAMI) today called on for a public apology for a "viciously prejudiced" column by syndicated columnist Don Feder concerning efforts by the mental health community to register people with mental illnesses to vote in the 2000 elections-and has asked for a syndicated national opportunity to respond.

"I cannot emphasize enough the cruel and offensive character of Mr. Feder's column, which crossed a line between partisan commentary and bigotry," NAMI executive director Laurie Flynn declared in a letter to Richard Newcombe, president of the Creators Syndicate in Los Angeles and Patrick Purcell, publisher of the Boston Herald.

"We doubt very much that a similar attack on racial or ethnic minorities or people with physical disabilities would have been published. Indeed, radio talk show hosts and sports commentators who have made such grossly insensitive remarks often have been suspended or fired," Flynn noted.

Coinciding with NAMI's opening of a voter registration and education campaign in New Hampshire, Feder's column asked: "Give me your schizophrenics, your paranoids, your manic depressives-for what?" He then complained about the principle that "everyone's vote counts"-including that of "the person, who not only believes the CIA covered up the so-called Roswell landing, but that he was on hand to meet the aliens."

"Fortunately, Mr. Feder's mocking prejudice is surpassed by modern science," Flynn declared. Mental illnesses today are understood to be biological brain disorders, which can be successfully treated and managed at rates even greater than that for heart disease.

Ironically, Boston University's Center for Psychiatric Rehabilitation released a study the same week as Feder's column, showing that out of some 500 professionals and managers who have struggled with mental illnesses, 73 percent are able to work full-time, with 20 percent earning $50,000 or more each year. "They are among the people with mental illnesses whom Mr. Feder considers it absurd to have vote. Others perhaps include the close family members of three presidential candidates: i.e, Tipper Gore, Barbara Bush, and Hank Buchanan."

"Mental illness is not a partisan condition," Flynn observed.

Seasonal affective disorder. Let the sun shine in when it's dark outside.

- - - - - - - - - - - - By Robert Burton, M.D.

Jan. 3, 2000 | Down in the dumps? Want to curl up in bed rather than go hang gliding? Are you eating lots of candy and fruitcake? Gaining weight? You bet: It's cold and dark out.

More than just a season, winter has become a metaphor for the dark side of life. Most of us accept the winter blahs as normal and wait for spring. But for some, seasonal doldrums can be a real problem. My mother, a tradition-confused West Coast Jew, might have been onto something. She insisted on having a large Christmas tree in the living room, but she refused the usual panoply of ghastly colors. Instead she used exclusively white bulbs. "Colored lights are for the goyim," she would say with the slyest of smiles. When pressed, she would add, "Bright white is better for your spirits." (Another Jewish tradition -- justifying any peculiar taste on the basis of health reasons).

But was my mother right? Were the bright white Christmas tree bulbs therapeutic? Would votive candles have done the job? Or a trip to Florida? Or spending the winter in a brightly lit casino? Are TV and computer monitors evolutionary answers for the winter blahs? I don't doubt that we get bummed out at this time of year, but is this a specific biological condition or a more metaphysical malaise?

In the late 1970s a South African psychiatrist, Norman Rosenthal, first correlated winter depression with decreased exposure to light. After moving to New York in the dead of winter to begin his psychiatric residency, Rosenthal felt tired, sluggish and overwhelmed by his work schedule. When spring arrived, his mood lifted; he felt renewed and energized. The obvious explanation (especially for a shrink) was the change in latitude -- the shorter days, longer nights. Rosenthal blamed his depression on dim lights, not the big city.

He decided to test his theory. At the National Institutes of Mental Health he exposed subjects with a history of winter depression to several hours a day of artificial light. Many reported improvement in their symptoms. In the early 1980s, after his tests, the term "seasonal affective disorder" (SAD) was coined. Symptoms of SAD are very similar to those of non-seasonal clinical depression: change in appetite, weight gain, drop in energy, tendency to oversleep, difficulty with concentration and irritability. The key factor in diagnosing SAD, though, is its seasonal pattern: The above symptoms fade away with the arrival of spring and return in the fall.

Curiously, the single physical symptom that seems to correlate best with SAD is the strong craving for sweets. Rosenthal and others theorize that people with SAD have difficulty in regulating serotonin levels during the winter and that their craving for carbohydrates is a way of compensating. (Carbohydrates are believed to increase the level of the neurotransmitter serotonin, and lower-than-normal levels of serotonin are correlated with clinical depression.) Perhaps this is the evolutionary rationale behind those dreadful fruitcakes.

This theory also explains why many SAD patients respond favorably to selective serotonin reuptake inhibitor (SSRI) antidepressants such as Prozac or Zoloft. Other researchers postulate a disturbance in circadian rhythms -- an alteration in the biological clock that affects serotonin metabolism. (Perhaps we were meant to hibernate in winter.) Though antidepressants are of value, the cornerstone of treatment for SAD is light therapy.

Light therapy comes in all sizes, colors and intensities. Although Rosenthal's original experiments used full-spectrum fluorescent tubes, his later research showed that light from incandescent and halogen bulbs was just as effective. No one bulb is definitely better than another. Even intensity may not matter. Amount of exposure time is also unclear. Despite a lack of evidence for superiority of any specific light source, the standard seems to be full-spectrum non-ultraviolet fluorescent tubes because of their even disbursement of light and cool operating temperatures.

A typical treatment strategy begins with having the patient set up a light box on a table to sit directly in front of while eating breakfast or reading the newspaper. Exercise is also a critical element of treatment. Dr. Rosenthal suggests taking a quick walk during lunch breaks. Even on overcast days, the sunlight filtering through the clouds is beneficial. In the evenings the patient can have another session in front of the light box, perhaps while eating dinner. (Estimates as to optimal exposure vary; some say that 60 to 80 percent of patients feel better with as little as 30 minutes under the lamp.) It's not necessary, or even recommended, to stare into the light. The entire retina responds to light, so it's possible to get the full benefit of light therapy while reading, talking on the phone or even watching television.

I have friends who swear by the light treatment. I personally feel better on sunny days. But how specific is SAD? Is it a discrete disorder, or merely an extension of ordinary depression? I hear "Jingle Bells" or "Rudolph the Red-Nosed Reindeer" and I look around for a sharp knife, a nice comforting loop of rope, a plastic bag inscribed "Here lies a man who detested the holiday season." I doubt that standing in front of a searchlight would make a difference. Even the constitutionally euphoric get depressed when double-parked in standstill traffic while the spouse runs in to a jam-packed mall to exchange that scratchy purple sweater from your aunt in Toledo.

Fifteen years have passed since Rosenthal's original paper, but I'm still a bit in the dark about SAD. If the disorder is related to diminution in light exposure, shouldn't the prevalence of SAD be greater at higher latitudes? Some studies say yes, others show no difference. And some Northerners (Icelanders in particular) appear peculiarly immune to the disorder. Does this negate the light hypothesis or merely point to other complicating factors such as genetically influenced decreased susceptibility to depression? That was Rosenthal's speculation -- but no one knows for sure.

The issues of duration and intensity of light exposure remain unanswered. Rosenthal now believes that light intensity may not be an issue -- in fact levels as low as those mimicking the beginning of dawn can be therapeutically effective. And there is the problem of assessing light therapy against a placebo. I cannot imagine what would be used as a non-light source placebo.

So we are left with a common-sense observation that lack of light seems to cause depression in winter. Science has provided some tantalizing clues but no final answer; there's more to darkness than meets the eye. In the meantime, keep warm, exercise (preferably outdoors), eat sensibly and, above all, keep well lit.

salon.com | Jan. 3, 2000

About the writer

Dr. Robert Burton, former chief of neurology at Mount Zion Hospital in San Francisco, has published three novels ranging in subject from medical ethics ("Doc-in-a-Box") to the pitfalls of psychiatry ("Final Therapy") to the possible consequences of cloning ("Cellmates").

Involvement in Professional Organizations

Expectations of student involvement beyond the classroom are generally limited, although almost all professionals encourage it. Everyone understands that the demands on students are enough to keep anyone busy, and paying professional organizat ion dues can feel like just one more burden when a student's personal expenses are high and income low or nonexistent. What many students do not realize is that professional involvement can make their student life easier, more productive, and more likely to lead to future professional advancement.

Professional organizations like the American Counseling Association, the American Association for Marriage and Family Therapy, and the American Psychological Association were developed to provide support systems for professionals with similar needs. Increasing acceptance of the counseling profession has lead to the establishment of more jobs, better wages, and greater recognition of our value to society. Resources on knowledge and skill development have also increased tremendously so that clients can benefit from counselors having the most up-to-date information available. But these things do not happen by accident. Professional counselors have backed their respective organizations with ideas, time, and money in order to support these efforts.

Students are seen as the future members and leaders of the profession and are therefore given special attention. Most professional organizations have significantly reduced rates for student membership, purchase of materials, attendance at workshops, insurance, and other services. The goal is to encourage students to begin viewing themselves and acting as professionals from the beginning of their training.

Comments typifying the benefits that students report as a result of their activities in professional organizations include the following:

"I like the mail I get. Seriously. Every week I get something in the mail-a journal or newsletter, a workshop announcement, advertisements for new books. It helps me feel connected every time I receive any correspondence."

"I look forward to the state and annual convention every year. I've only gone twice so far, but what a rush! Meeting students from all over the place. Going to programs. Seeing all the leaders in the field. Just all that energy at one place and time is amazing!"

"I'm not really that active in the organization, but I do read the journals every month. I belong to several different divisions, so I subscribe to a number of publications that bring me up to date on what is going on in the field."

These disclosures illustrate what students report they enjoy best about being involved in professional organizations. It is not even necessary to be all that active; some belong mostly for their professional identity. Even this limited involvement brings many benefits. One or more professional journals that speak to the most timely issues being studied in classes begin to arrive on a regular basis. Within the various organizations are numerous specialty divisions that address every conceivable interest-including prisons, group work, family counseling, school or mental health counseling, sex counseling, substance abuse, cultural issues, rehabilitation counseling, gay and lesbian issues, spiritual issues, supervision, and behavioral, humanistic, or systemic approaches. There are also smaller network groups that get together at conventions, or by correspondence, to share information and strategies about working with specific populations such as dual diagnosed substance abusers, multiple personality disorders, sexual abuse survivors, closed head injuries, learning disabled students, and African Americans. Newsletters are also sent to members with additional practical information on what is happening in the profession, job listings, and descriptions of innovative practices. Increasingly, these organization periodicals are including information specifically directed to students and new counselors in the field. These articles, in fact, resulted from our collaboration as editors of two such columns in the American Counseling Association's Counseling Today entitled "Student Focus" and "Finding Your Way."

Professional organizations realize that students do not have the financial resources of other members. Therefore, they use a portion of their resources to subsidize student involvement in a number of ways. For example, most students must acquire some form of liability insurance when they enter practicums or internships. This can be very expensive when purchased individually ($400 to $1,000 per year) but is quite reasonable (as little as $15 to $20 in some cases such as through ACA) when purchased through a large professional organization. Obviously, this is a major bargain for student members.

Members of professional organizations continue the development of their skills and knowledge base by taking professional development workshops and attending conferences. These events almost always have significantly reduced student rates and offer excellent opportunities to take part in specialized training and information sessions beyond what any single university program can offer. For example, if you have a particular interest in learning about a subject that is not ordinarily part of your program's curriculum, you could supplement your education with this training. A quick perusal of the current offerings in any given week (depending on your proximity to a large city) might find workshops on such topics as play therapy, feminist approaches to family intervention, the DSM-IV, strategic family therapy, AIDS prevention and intervention, attention deficit disorders, personal growth for helpers, or using various assessment instruments for clinical applications. Membership in these organizations keeps you informed regarding the content, times, locations, and costs of these events, and offers you rates that are less than half of what nonmember professionals must pay.

Attending professional conferences also offers students the opportunity to make valuable professional connections. Meeting practicing counselors and leaders in the field broadens the network of any professional. This is especially true for students who come from smaller departments or who live in rural areas.

In addition, many students attend specific universities because they believe faculty have insights and professional connections that should help them find initial positions and promote their career advancement. These connections and professional relationships are very often started and continued at state and national professional gatherings. Students who attend such meetings can get the full benefits of the connections their faculty have and begin to develop their own personal professional support network. Other individual services that professional organizations offer to support member needs include credit cards, life insurance, 800 numbers, and travel discounts. An additional service offered by ACA provides a uniquely valuable service to members and particularly to students. ACA maintains a library containing all the historical documents of the organization and its divisions, copies of out-of-date pamphlets produced by the organization, and copies of all journals produced by the organization since its inception. Student members can request bibliographies on a wide variety of counseling-related topics for free or at little cost.

Major national organizations also have state, and sometimes local, affiliates that provide similar services but on a more regional scale. State journals, newsletters, and conferences often provide very specific information and contacts regarding the critical issues and employment opportunities in a given area.

Excerpted from

The Emerging Professional Counselor - Student Dreams to Professional Realities

Author: Richard J. Hazler and Jeffrey A. Kottler copyright ©1994, American Counseling Association

Therapeutic Bond Found to be Key in Improving Depressive Symptoms Regardless of Type of Treatment Used

*APA Press Release*

Psychotherapy, Cognitive-Behavior Therapy, Drug Therapy and Placebo Are Compared

by Janice L. Krupnick, Ph.D., Georgetown University Medical Center, Stuart M. Stotsky, M.D., MPH, Sam Simmens, Ph.D., and Janet Moyer, M.A., George Washington University Medical Center, John Watkins, Ph.D., Atlanta Center for Cognitive Therapy, Irene Elkin, Ph.D., University of Chicago, and Paul A. Pilkonis, Ph.D., University of Pittsburgh School of Medicine

WASHINGTON -- The therapeutic bond formed between therapist and patient has been found to be a leading influence on a patient's recovery regardless of type of treatment used, according to a new study in the July issue of the American Psychological Association's (APA) Journal of Consulting and Clinical Psychology.

"This is the first empirical study to compare the therapeutic alliance established between therapist and patient and its effect on improving depressive symptoms in not only different types of psychotherapy but also in pharmacotherapy," said psychologist and lead author Janice L. Krupnick, Ph.D. Dr. Krupnick and six other researchers determined whether the therapeutic bond had an influence on a patient's depression regardless of the treatment modality by examining 225 depressed outpatients who received either interpersonal psychotherapy, cognitive-behavior therapy, an antidepressant medication (imipramine) in a supportive environment or a placebo pill in a supportive environment by 28 therapists (10 psychologists and 18 psychiatrists).

To improve the validity of the study, videotapes of the 619 sessions were watched by trained clinical observers who rated the depressive symptoms of the patients and the strength of the therapeutic alliance at the third, ninth and fifteenth session. Specifically, the clinical observers rated how much the patient's and therapist's own contribution to the therapeutic relationship helped reduce the patient's depression. "This study's methodology is an improvement over previous alliance studies," said Dr. Krupnick, "because ratings on observations of full-session videotapes were used versus using ratings from clinical observers of only brief segments."

In all the treatment groups, the trained evaluators reported that improvement in the patient's mental state was attributed to the good therapeutic relationship. And that the degree to which a patient could be engaged in a good relationship with his/her therapist was the leading force in reducing a patient's depression.

These findings, said Dr. Krupnick, "especially the strong association between alliance and reduced depression in the imipramine and placebo groups give further support to how important the therapist-patient bond is in improving a patient's mental state." From these conclusions and other research in this area, Dr. Krupnick warns about the dangers of primary care doctors treating depression with drugs when there is no therapeutic relationship. "This could really impede a person's chance of getting better," she said.

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