Sunday, January 06, 2013



By Ramya Chari | The Rand Blog |

December 21, 2012 :: In the coming weeks and months, we will hear numerous calls for better mental health programs and policies as a way to prevent tragedies such as the Newtown, Conn., shooting. As news and details trickle out, we may or may not emerge with a complete picture of what led Adam Lanza to take his anger out on his mother and 26 innocent lives.

The latest reports paint a picture of a mother struggling to care for her troubled adult son. And as many families can attest, the challenges of caring for a young or adult child with severe mental illness or emotional or behavioral disturbance are profound and heartbreaking. In our national conversation on mental health, we should remember the role of families when thinking about mental health treatment and ensure that our policies open up opportunities to support parents, siblings and relatives, and enhance their capacity for care.

On the surface, Connecticut appears to be strong in terms of its mental health care system. In its 2009 report on America's mental health systems, the National Alliance on Mental Illness gave Connecticut a B while the nation as a whole rated a D (no state received an A grade). For all its (relative) strengths though, Connecticut's struggles to deliver care to its constituents illustrates the problems plaguing mental health systems across the country. Mental health care in the United States has undergone systemic changes since the 1960s, moving away from institutionalization of patients and toward community-based programs and services. Connecticut was no exception. In the mid-1990s, the state Legislature ordered the closure of two state-run psychiatric hospitals—one in Newtown (Fairfield Hills) and one in Norwich (Norwich State Hospital). The two hospitals' patients and services were consolidated into Connecticut Valley Hospital in Middletown.

This shift in thinking about how and where mental illness should be treated was an important development. The negative perceptions of state-run asylums did little to reduce the stigma of mental illness in the larger community. Moving treatment into the community, it was hoped, would ensure an individual was integrated rather than separated from others, thus improving the chances of recovery and rehabilitation. In terms of treatment for the patient, the psychiatric hospital was an anachronism and community-based mental health care was the future.

While the intent may have been sound, the execution has not lived up to its promise. By shifting to community-based services, we have also shifted the burden of caregiving from the state onto families. However, corresponding shifts in resources toward communities and families to help with care have not been realized. Across the nation, states have slashed mental health budgets and in the absence of a community-based safety net, jails and homeless shelters have replaced the psychiatric hospital as facilities housing the sickest patients.

In Connecticut, the mental health "crisis" was documented by the 2000 Governor's Blue Ribbon Commission on Mental Health as well as the 2004 Lieutenant Governor's Mental Health Cabinet. Both reports described a struggling community mental health system that was stretched beyond its capacity and unable to absorb the influx of patients who had been formerly treated at the closed psychiatric hospitals. In addition, savings realized from the hospital closures had not been reinvested back into community-based mental health services. Funding for community organizations in Connecticut continues to be an issue to this day. The harsh economic climate of the past five years has translated into spending freezes for community-based providers at the state level that have led to cuts to services and to overwhelmed staff.

At the end of the day, the "providers" who are the hardest hit of all are the families and caregivers who must find a way to navigate through an underfunded and overburdened patchwork system of mental health care. In a community-based model, families and caregivers are oftentimes the first and last lines of support; yet if too many barriers to care exist, many will just give up. For all its problems, compared to other states, Connecticut's mental health system is actually strong, and yet it is still not meeting the needs of its patients and families. So where does that leave the rest of the nation?

In his remarks on the Sandy Hook shootings, President Obama mourned, "these children are our children." And in terms of mental health, the Connecticut story is our national story and its failures will resonate with families in every state across the nation. So once again, in the aftermath of a mass shooting we find ourselves revisiting the circumstances that may have led to the crime and assessing the multiple points of intervention that might have been possible—counselors, therapists, psychologists, psychiatrists, friends, neighbors, relatives, siblings, and parents. While the opportunity to intervene may have been available to many, the perception of responsibility fell onto very few. If we are serious about improving mental health in our country, we must deliver resources to families to ensure they can properly care for both themselves and their loved ones, and to communities so that support services and treatments are readily available and accessible.

Let us learn our lessons from Newtown. The burden and the challenges associated with providing care for mentally ill members of society should not rest on so few shoulders, especially when the consequences of failure may come to rest on the littlest shoulders of all.

· Ramya Chari is an associate policy researcher at the nonprofit, nonpartisan RAND Corporation.



By Lisa H. Jaycox, The RAND blog |

December 20, 2012 :: I've spent much time since Friday imagining the unimaginable—little children murdered in the place that is supposed to be their home-away-from-home, their elementary school. The media fed my curiosity. I could not stay away from checking the news and blogs hourly, despite my family's pleas to stop reading and my own knowledge that it can be too much to read so many details, see so many pictures, grieve from afar.

It's because I want to help. I am a psychologist, and this is why I went into the profession and made trauma my focus. I know from a vast amount of research that many of those touched by Friday's shootings will experience a great deal of distress in the weeks and months ahead. But they will, somehow, miraculously, find a pathway forward to health and productivity. And I am reassured that over the past 15 years or so, we have developed a wide array of practices, procedures, and interventions that are well-tested and helpful for those children that will take longer to recover.

Of course we also know that with an event like this, "recovery" doesn't mean a return to normal, because lives have been permanently altered. Recovery can only mean finding a new normal, a new path forward. And schools, those places of safety and healthy development, can help with that process, by providing a structure and community to support healing.

I've been involved in this type of work for the past decade, and I am reassured that schools play this role in many ways, from the routine delivery of hot breakfasts and lunches to children in need, to sheltering families following disasters, to identification and intervention for mental health problems. Surely they are well positioned to help considerably following a shooting. But what happens when the school building itself was the site of the horror? When the caring teachers and staff are among the victims? When a school entrance, classroom cupboard, or bathroom stall becomes a terrifying reminder? These transformations are part and parcel of traumatic experiences, and cause us all to rethink our concepts of safety and danger, life and death, connection and isolation, healthy and sick.

One thing I've learned over the years is that a strong desire to help does not translate into being allowed to help. Schools and communities that undergo a horrific event like this one need time to settle, reconfigure, and find trusted advisors from both within and outside. Twenty years ago there were few options when a crisis arose—there seldom were local experts. But over time, with sustained efforts and robust federal funding, expertise and capacity to handle trauma and grief, even on a large scale, has grown exponentially. We've come a long, long way since 2001, when there were few resources and little public recognition on how children react to trauma and grieve.

Another thing I've learned: patience. It takes some time for a community to get ready for mental health support. First come the basic needs: funerals, food, shelter, sleep. These take a while to sort out. Structure, routine, and caring adults who can listen are the most important things for a child following trauma. These things can help restore a sense of safety and allow some processing. These have to come first. And many people are able to bounce back—the resilience of kids is incredible. Some will need some support, but we can't know who until later on.

Assistance we provided in New Orleans post-Hurricane Katrina didn't begin until the 2006 school year, a year following the storm. Work we are doing in Chardon, Ohio—where three students were fatally shot at a high school in February—is just getting started. Newtown won't know what type of help it needs, or whether it wants outside help at all, until later. So we wait, with confidence that help is available, and can be successful.

We've learned that specific types of therapies can help those who continue to experience anxiety or depression months after a traumatic event. These therapies contain simple techniques like relaxation, to more complex ones like processing the traumatic event through imagination, stories, or artwork. They have in common a core set of concepts that involve processing the traumatic memory, learning skills to enhance coping, connecting with others, and findings ways to reduce anxiety and improve mood. There has also been much learned over the years about what is not helpful, and can impede recovery.

As I wait to see how the story unfolds for Newtown, I look forward to the stories of heroism, community, and resilience. I look forward to seeing my colleagues help and even learn from their experience so that others can be helped in the future. My hope is that these stories of strength can eventually wash out and replace the ones that are haunting all of us right now.

· Lisa Jaycox is a senior behavioral scientist and clinical psychologist at the nonprofit, nonpartisan RAND Corporation.

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