August 28th, 2012

_A Girl Named Zippy_, Haven Kimmel

This was a book club pick; I got it used on Amazon in paperback and then donated my copy. If I want to reread it, I'll get it on the kindle. I did it this way because it was cheaper. I would have picked up a library copy, however I missed going to group last month (I returned the previous month's pick via mail). The book group I attend is in Mayberry, NH (<-- not its real name), the town I used to live in and now live about 30 miles away from.

This book was an unusual pick for our group, in that we had a couple people arrive who each have only attended one other meeting (we have a small set of regulars) AND every single person got through the entire book -- frequently someone, or more than one person will fail to complete the book. Not finishing turns out to be one of the best discussion points, but again, despite everyone finishing the book and rating it 3 stars or better on a 5 star scale, we had a very nice discussion. I think it's actually a really good book, but deceptively so.

This light-toned memoir depicts what, objectively speaking, was a childhood marked by neglect, mental illness (alcoholic father, severely depressed mother), and poverty. At least two of the children (the titular youngest, Zippy, and the oldest, Daniel) also had significant developmental delays that did not receive direct support, partly due to the time, partly due to the place, and partly due to the family situation. The relationship between the parents is, to be blunt, extremely unhealthy: dad spends a lot of time Not Being Around and quite a lot of the time he is around chain smoking and/or drinking heavily. Mom spends her time on the couch eating pork rinds and (re)reading paperback science fiction novels. Outside of school, the only scheduled activity is the Friends church which mom insists they attend and which dad declines (other than kids' commitments and marriages and similar). There's some underemployment and, in addition to neglect of the kiddies, there's neglect of the house and so forth.

Remember, tho, I said it was light in tone, so it's from a kid perspective and the town is tiny, so the neighbors keep the kids mostly safe. There's a big age gap between the author and her two older siblings (this has all the indications of a let's-save-the-marriage-with-another-baby situation), with some humor inherent in the relationship between the teenaged boy and girl (fighting over the lone bathroom, etc.) and their treatment of their much younger sister. Zippy wanders the small town at will, vastly curious, climbing trees, going to the drugstore to get a lemon phosphate, etc.

Oddly, while I thought it was brutally obvious that the parents would divorce after the mother started college after the end of the book (events apparently documented in a sequel, _She Got Up Off the Couch_), no one else in the group picked up on what I did, altho, in an unusual twist, they agreed with my interpretation once I reread out loud the passage in which mom borrows Zippy's grown-up-bike and rides off down the road, leaving dad and Zippy to contemplate this extremely unusual act on her part.

While the Friends' church in Mooreland isn't quite like what I have been led to understand Friends' meetings to generally be like, the inner spirituality of Quakers does come through clearly in the character of Delonda and in the way she shapes Zippy. It's an enjoyable read; I'll try the sequel, as well.

Of Psych Beds and Negative Reviews

I've been ranting recently about psych beds, fears of institutionalization and generally ridiculous attitudes towards the mental health system. I have a lot to say on this subject, most of it probably offensive, so I usually limit it to face-to-face conversation with people who know me well and who understand where I am coming from. But I'm going to dig into it here, for a couple reasons, notably that I'm probably about to embark on a reading project.

First, R. pointed out to me the new facility Massachusetts recently opened in Worcester. Gov. Patrick wanted to close Taunton State Hospital, possibly to balance the budget, possibly for some other reason. People have really enjoyed closing state psych facilities for decades now, because of Thorazine, scandal, the idealism of young lawyers and therapists and so forth when first encountering those who are institutionalized with severe mental illness. Also, I should mention money saving, because state psych facilities are not eligible for federal dollars so it's all out of the state budget. The state legislature -- or enough of it at any rate -- balked. A deal was cut and a very expensive new facility was built and Taunton was partially closed.

http://www.boston.com/news/local/massachusetts/2012/08/15/architecture-and-therapy-merge-new-million-state-mental-hospital/YT9nYRZ8Y2TZ83aiglWMVI/story.html

This was almost certainly a Really Good Thing and may yet turn out to be the turning point for psych beds in the US, but we'll have to wait a while to know for sure.

If you're interested in why we have so few psych beds and why we need more, this is a summary that points to a truly excellent report on the subject from 2008:

http://www.treatmentadvocacycenter.org/home-page/71/81

In short: if you don't have enough beds, you get expensive (and socially unjust) homelessness, incarceration of the severely mentally ill, backed up ERs and avoidable violent crime.

The recommendations at the end of the report are pretty good: fix the funding streams so federal and state money is spent based less on location and more on clinical need, improve community programs (especially the kind that create good interfaces between community services, law enforcement, etc. and AOT which is assisted outpatient treatment aka outpatient commitment -- there's a limit to how much an outpatient mental health community program can do when it is contingent upon moment to moment voluntary participation on the part of the client) and do some consciousness-raising. If you read this far (especially if you followed the link and got the .pdf and read the report), consider your consciousness raised and go forth and evangelize.

I, however, got really interested in some of the citations and went off to Amazon to get a kindle version _The Insanity Offense_ (by the primary author of the paper linked to above). I don't buy things without checking out the reviews and for a while now, I've focused tightly on negative reviews because I find them much more useful than positive reviews. Positive reviews often involve back-scratching: a bunch of experts in the field rave about the book, and when you read the book, the author raves about those exact same experts, leading one to wonder about the cozy relationship between the author, the experts and the reviewers. And that's in a _good_ situation; in some cases, positive reviews are sock puppets of people who stand to gain from increased sales.

Negative reviews, however, give you a sense of the kind of person who didn't like the product. A coffee maker which has a bunch of complaints about the thing setting their kitchen on fire after they'd loved owning it for six months is a coffee maker I don't really want to buy, but I'll take a flyer on the coffee maker with the lid that you have to actually screw on correctly or it leaks all over the place, especially once I realize there's a very hard to spot arrow that shows you how to do it right that all the 1 star people failed to detect.

Here's part of what the one star review on _The Insanity Offense_ had to say:

"The basis of his position is the assumption that medicine has the right, the duty, and the authority to intervene and treat what medicine has defined as treatable (in this case the consensus document Diagnostic and Statistical Manual), and that medicine's decision trumps any individual patient's protest. He is working to change laws so he can prevail. But like other fundamentalists, he ignores challenges that might require more nuance."

I have learned, over the last few years, to quickly identify this kind of person. They post comments on articles and reviews on books and similar, attacking the mental health care profession as a whole when some member of it is digging deep into the weeds on a technical issue. Not Relevant. Seriously. If this is the problem with this book?

The two star review has a two-fold attack on the book: "Difficult problems that beg for clear solutions are used by Torrey to fashion an attack on those who work to make the system accountable and keep the excesses of certain professionals in check." is recognizably code for, hey, we're busy dismantling what remains of services for tough cases. Don't get let your people get in the way of my ideals. The other attack is an assertion of a factual error asserted about the author's handling of federal/state public legal services, which would appear (not having read the book) not to be terribly salient (if he'd screwed up how state psych beds were funded, I'd be worried).

The three star reviews are both fantastically helpful, portraying the book as spending most of its time describing the history of the problem, and very little on how to fix the problem. Alas, as anyone who has actually read "current white papers online from any number of sources" knows, there are almost no "valid solutions to the problem or ... information of successful projects or programs that have helped get the mentally ill off of the streets and into alternative treatments", because we are (goddess I hope) at the nadir (or apex, depending on how you choose to frame it -- it is as bad as it will -- hopefully -- ever get) of this particular problem and it's not going to get better until more people perceive it as a problem.

But that's helpful to me: I'm looking for someone to detail the linkages between failure to provide (commitment oriented) mental health services and Really Expensive and Bad Problems for the rest of us (backed up emergency departments, expensive homeless problem, excess violent crime, mentally ill people in prison). I know these linkages exist; I'm looking for a pithy summary with some decent research to back it up. Of course, that's what all the five star reviews promise, but of course they'd promise that -- that's the marketing message. 1, 2 and 3 star reviews of the sort I just described reassure me that the five star reviews are the Real Deal.

ETA: FWIW, I had an aunt who was de-institutionalized and she didn't survive long thereafter, dying after she wandered into traffic near where she was living with her elderly parents. It was an Interstate and I in no way blame the driver; pedestrians aren't supposed to be there. But it was uniquely horrible, in that she survived long enough to be airlifted to a hospital over fifty miles away; I'm sure the amount of pain she was in was unspeakable. I've spent a chunk of my life contemplating who is to blame for her being institutionalized in the first place, whether she had the correct diagnosis, whether she should have had any diagnosis. Over the last decade, additional genealogical research suggests to me that she did have some sort of inherited problem that involved periodic breaks with reality (which does not necessarily determine a diagnosis); she had an aunt with a similar or identical problem who she never met and may never have heard of. While the religious context this occurred in surely did not help matters, I no longer blame the religion for what happened. What I do wish, however, was that we lived in a world that would help people like my aunt and her aunt before her live as long, as healthy, and as fulfilling a life as is possible, given those periodic breaks with reality. And that probably is going to require some kind of commitment-oriented program and/or facility.

ETAYA: The wikipedia article on Torrey is amazing. It does a fantastic job of laying out the political battles surrounding Torrey over the decades.

http://en.wikipedia.org/wiki/E._Fuller_Torrey

This chunk of it constitutes a truly excellent negative review of _The Insanity Offense_ that really does give me pause:

"his book The Insanity Offense is based on unsubtantiated portrayals of certainty on the statistics on violence, outpatient commitment and medication, stigmatizing tens of thousands of people, deeply offending and insulting those who hold views differing from his own, and promulgating one-dimensional solutions. TAC's attempts to associate violent incidents in the news with lack of medication have been described as wild hyperbole, and the use of the term "assisted treatment" has been described as a euphemism for forced drugging.[25]

...

and California Network of Mental Health Clients (CNMHC) has challenged it. "Contrary to Treatment Advocacy Center's explicit claims, the study makes no mention of "untreated" mental illness, schizophrenia, manic depression, or any other diagnosis. Equally, there is no basis for extrapolating the 4.3% of the national population. TAC arbitrarily raised DOJ's homicide estimate from 4.3% to 5%. Then they arbitrarily attributed these homicides to less than 1% of the U.S. population, the number TAC says have "untreated schizophrenia and manic-depression."

In another error: 4.3% of 16,914 (the total homicides in 1998) is 727, not 1,000 as TAC claims. And DOJ's predictions for 1999 will lower the figure still further to 645.""

ETA Probably time to start a new post:

This is really interesting: http://www.mentalhealthrecovery.com/recovery-resources/articles.php?id=20#

I will be digging through some of the citations.