An electronic circular of the Coalition's Center for Rehabilitation and Recovery
No. 82, April 2012
The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.
THE DIRECTOR’S NEW YORK MINUTE
Paging Dr. House!!
By Courtenay M. Harding, PhD
“Diagnosis is only a current working hypothesis not graven in granite.” All of my supervisors, both psychiatrists and psychologists, have told me that statement over the years. I was surprised because I had thought these designations were really permanent and not changeable. But by observing changes in people during my own years of clinical and research work, I found that many people went from being diagnosed as having Bipolar Disorder to having Schizoaffective Disorder and then Schizophrenia. Many people diagnosed with Major Depressions became Bipolar Disorders within a fairly short time. Part of these changes were due to new psychiatrists rediagnosing the person; part was because of the vagaries of the Diagnostic Manual (the DSM); 1 part was due to the long term effects of psychotropic medications; 2 and part was because people actually changed their symptom presentation. Sometimes, people even lost their symptoms and diagnosis all together! 3
There are also other problems to consider. Schizophrenia is a diagnosis of exclusion1 and the doc is supposed to exclude these other possibilities before deciding about schizophrenia. But insurance companies pressure physicians to come up with a diagnosis quickly and often the differential ones are overlooked. There are many other illness and problems (medical, neurological, and other psychiatric) which masquerade with schizophrenia-like symptoms. In fact, there are 26 of them! 4 So if the person does not seem to be getting better, perhaps it is a good idea to start thinking about other possible explainers which were never considered such as: autism (especially Asperger’s Syndrome), Temporal Lobe Epilepsy, brain tumor, endocrine and metabolic disorders (e.g. Acute Intermittent Porphyria – the liver enzyme problem plaguing King George in the move, “The Madness of King George,” 5 Homocystinuria (a disorder of amino acids), vitamin deficiency (especially vitamin B 12), central nervous system infectious processes (e.g. AIDS, neurosyphillis or herpes encephalitis), autoimmune disorders (e.g. systemic lupus erthymatosa), heavy metal toxicity (Wilson’s Disease – too much copper), some drug induced states (e.g. amphetamines, barbiturate withdrawal, cocaine, digitalis, disulfiram), mood disorders, schizoaffective disorder, personality disorders brief reactive psychosis, and Obsessive Compulsive Disorder. The differential diagnoses in Mood Disorders include 43 other possibilities. It includes not only the list above but also Multiple Sclerosis, hyper-and hypo-thyroidism, bereavement, dementia, cancer (esp. of the pancreas) spinal cord injury, peptic ulcer, mononucleosis, Huntington’s Disease, end-stage renal disease, head injury, Parkinson’s Disease, Lupus, hyper- and hypo- parathyroidism, and hepatitis. Given such possible complications, which not treated, would tend to continue a chronic course – just not the one we thought we were trying to help. Diagnosis is supposed to be a science but is still mostly an art in the psychiatric world because people are so complicated and it takes time to figure things out. We need to get triangulated information from multiple sources to do it right. We need standard lab tests to rule out these other problems. We need a checklist to make sure that we have considered all the options. 6
Imagine that you were suffering from one of 8 enzymes gone awry in your liver and bone marrow but you were misdiagnosed as having schizophrenia because of personality changes and given antipsychotics instead of the correct diagnostic work-up with blood, urine, and stool tests. This to be followed by the correct treatment consisting of learning to avoid triggers, being given heme through a vein (the factor that makes red blood cells red), and meds to reduce symptoms. This sounds like the world of Dr. Gregory House on TV.7 Dr. House actually had a case of a woman in her 30s, who had been misdiagnosed for years as having schizophrenia. But after his usual false starts, House finally correctly diagnosed her as having porphyria, like King George, but unlike the fate of the king, he provided the correct treatment. She lost all of her symptoms of the “schizophrenia” and rejoined her family as a fully contributing member, wife and mother. So I suggest that if you see someone, who has been struggling and doesn’t seem to be getting better, sit down with his or her physician, and raise the question of differential diagnosis and help solve the puzzle. Being curious and persistent may pay off.
1) American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC.
2) Whitaker, R. (2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York, Crown Pubs.
3) Harding, C.M. (2003). Changes in schizophrenia across time: paradoxes, patterns, and predictors. In: Carl Cohen (ED.) Schizophrenia into Later Life: Treatment, Research and Policy. APPI Press, pp.19-42.
4) Harding, C.M. (1998). Re-assessing a person with schizophrenia and developing a new treatment plan. In: J.M. Barron (Ed). Making Diagnosis Meaningful: Enhancing Evaluation and Treatment of Psychological Disorders. Washington, D.C. APA Press. pp. 319-338.
5) MGM (1994). The Madness of King George
6) Gawande, A. (2010). The Checklist Manifesto: How to Get Things Right. New York, Henry Holt and Co.
7) FOX Broadcasting Co. (2004 -2012). House. The TV Series.
From Challenge to Creativity
By Susan Blayer
Throughout my career as a mental health professional, Creative Art Therapy techniques have yielded some of the most gratifying experiences I have had with consumers. My mind flashes to unforgettably beautiful, provocative, moving and sometimes disturbing images created by hands of those living and often suffering with symptoms of mental illness.
One memorable “installation” came to our program from a woman chronically in and out of the homeless shelter. She asked to display a series of carefully chosen pictures she was drawn to, removed from magazines. She mounted each picture on colorful paper and gave the mini-portraits their own titles. Among my favorites were a bird with a nest full of eggs, under which she wrote, “Hope ,” and also, a photo of children running and playing with wide smiles which she labeled, “The Future.” Each image and word combination both gave insight to her personal struggles and ambitions, while simultaneously having a universal quality that others could relate to and find their own meaning within. I never forgot how something so seemingly simple could make one feel a whole range of emotions and conjure an array of thoughts.
There was another woman, who always seemed to keep a cautious distance from me. Because she only called me “White Woman,” for a long time, I never knew if she knew my name. She had painted a gloriously colorful peacock on a black canvas one afternoon in our Art Therapy group. Many times when I saw her, I told her how much I liked the painting, and how talented I thought she was. She never responded, until, months later, when I announced that I would be leaving that particular job. That morning, she came to my office, called me by name, and gifted me with the peacock painting. She said, “You know, it is the male peacocks that are the pretty ones. That sort of reminds me of you.” All I need to do is look up on my office wall to remember this unique person, and that brief moment of connection which is so precious to me.
These experiences, and countless others, with individuals of all backgrounds, ages and walks of life, have shown me definitively that art can be used to connect, express what we cannot always find words for, to work through our issues, and ultimately, to heal. Life’s challenges and personal limitations often require that we call upon our inner resources of creativity to see us through.
This sentiment is demonstrated wonderfully in a rich, touching documentary, “Crazy Art,” which explores the “role of creative expression in recovery from mental illness.” The film follows three artists in California who use art to cope with symptoms of schizophrenia, mania and depression. Here are some of their spectacular works:
In general, mental health providers are familiar with the use of the arts and creativity. It is certainly not a new subject. According to a 2007 article from the journal, Evidence Based Mental Health, “ In Europe and the US, artists, who were interested in the creative abilities of people experiencing mental distress, began working in asylums in the first half of the 20th century. However, it was not until the 1940s that more formal efforts were made to combine the use of art materials and psychotherapy as the basis for “arts therapies.” 1
Contemporary thinkers readily make the connection between art and emotional/behavioral issues. There seems to be a widely-held belief that to create great art, the artist has to have suffered. Certainly, from Vincent van Gogh to Ernest Hemingway to Michael Jackson, some of the world’s greatest artists have spent time wrestling with symptoms of mental illness
Psychiatrist Arnold Ludwig, author of The Price of Greatness, contends, “There is no question that people in the creative arts have higher incidences of depression, mania, alcoholism, drug use, schizophrenic breaks and so forth.” 2 As reported in the book, Ludwig found that artists had higher rates of psychosis, mood disorders, suicidal ideation and substance abuse than those who were successful in less creative careers such as business, science and politics. People, with careers in the latter categories, tend to have a much lower rate of mental illness. Ludwig also discovered that certain creative endeavors yielded higher incidences of certain disorders. For instance, poets tend to live with mania and psychoses, while writers and artists tend to be afflicted with alcoholism. 3
Does this evidence mean that great art will cease to exist once people recover from mental illnesses? I think not. Rather, the correlation seems to highlight the capacity for people with psychological distress to use art as a positive outlet for exploring themselves and managing emotional discomfort.
Perhaps we intrinsically understand the universality of art—including music, poetry, creative writing, dance, and it’s potential to reach the depths of our psyche. This was a component of Carl Jung’s notion of the archetype-rich collective unconscious. Jung noted that the artist is one who "makes it possible for us to find our way back to the deepest springs of life." 4 To that end, my hope is that we can integrate creative art therapies into our services and work with consumers to tap into the these “springs of life,” leading to hope, personal development, social connection and recovery.
Here is a list of relevant links, professional journals and books to help get you started:
1). Crawford, M. and Patterson, S. (2007) Arts therapies for people with schizophrenia: an emerging evidence base, Evidence Based Mental Health;10:69-70
2.) Ludwig, A. (1995) The Price of Greatness. Guilford Press, New York
3.) Cuthbertson, M. (Jan. 2012) Mood disorders and the creative mind: does mental illness lead to creative insights? Retrieved online from The Sheaf: http://www.thesheaf.com/2012/01/20/mood-disorders-and-the-creative-mind-does-mental-illness-lead-to-creative-insights/
4.) Jung, C. (1967) The Spirit in Man, Art, & Literature (Collected Works of Jung Vol. 15) Princeton University Press, Princeton, N.J.)
Dr. Harding Receives Several Accolades
The Center is pleased to report that our Director, Dr. Courtenay Harding, has received several honors of late. First, her seminal work on recovery was declared “a classic in community psychiatry” in a publication entitled, “50 Years of Public Mental Health Outside the Hospital.” Additionally, she was the first non-consumer keynote speaker at the 18th Annual Bi-County Empowerment Conference. Finally, Dr. Harding was appointed to the prestigious Scientific Advisory Committee of the Foundation for Excellence in Mental Health Care. We remain grateful to have the leadership of such a renowned and respected Mental Health Recovery trailblazer.
Congratulations to Center Staff on Her New Achievement
More official good news! The Center is proud to announce that our Benefits Educator and Advocate, Margie Staker, CQSW, has recently been installed as a Certified Benefits Planner through Cornell University’s Employment and Disability Institute. With this certification, Ms. Staker is a credentialed benefits and work incentives practitioner within the New York State Work Incentives Information Network (WIIN). This enables Ms. Staker to be among the select few to provide a higher level of individual benefits counseling to consumers and is a testament to her hard work and dedication.
20 Ways to Overcome Barriers to Recovery
In this half-day workshop, Dr. Harding will provide a window into at least 20 obstacles which may stand in the way and how to resolve many of them. You will receive a clear set of questions to ask, new ways to rethink problems, and some solutions to remove the roadblocks.
Trainer: Courtenay Harding, Ph.D.
Introduction to Benefits Management—Hurry, Space is Limited!
This introductory training is intended for staff new to the subject of benefits
This free half-day training offered in various locations across the city. The training is designed for people interested in learning the nuts and bolts of benefits management. The latest changes in the SSA guidelines will also be discussed. Participants will have the opportunity to:
Trainers: Margie Staker, CQSW & Patricia Feinberg, MS, Certified Benefits Planners
To register for any Center training or to download our current training schedule, please go to: www.coalitionny.org/the_center/training/Note: If you are typing the URL in your browser, the space between “the” and “center” is in reality an underscore symbol “_”.
Department of Health and Mental Hygiene: Mental Health System Planning Forums
Providers are invited to attend The NYC DOHMH Community Forums to help identify important goals and priorities that will improve mental health services and systems for New York City’s children, youth, adults and families. Feedback is welcome on key issues such as how to meet the mental health service needs of New Yorkers and how to better support families and other key individuals in the lives of those experiencing mental health challenges. Public testimony will be 3 minutes per individual or organization.
Please email your testimony in advance to firstname.lastname@example.org. (You may also provide a copy of your testimony at the Forum.) ID is required for entry.
3 Locations and Dates:
Time: 3- 6pm at all locations
Registration: Call (347) 396-7974 by the registration deadline above for each location.
Seats Still Available for April Advanced Management Trainings
As part of the Coalition’s Professional Learning Center, The Advanced Management Training Institute will focus on effective management and leadership during difficult economic times. In a period of continuing reduction of scarce resources, changing social policies, legislative mandates and increasing accountability, being a manager in a behavioral health organization means confronting unprecedented challenges. Ira Hammer and Michael Swerdlow will lead this half-day workshops utilizing an interactive, seminar format and making use of case studies, role-play, simulation and group projects. These trainings are free of charge and will take place at the Coalition's offices located in lower Manhattan at 90 Broad St, 8th Fl.
Developing and Managing Operating Budgets
Utilizing Performance Indicators
RTP Webinar on Culture and Spirituality in Recovery-Oriented Practice
This session will describe three components of culture and spirituality in recovery-oriented care: cultural and spiritual assessments, culturally appropriate interventions, and ways in which spirituality and culture can shape an individual's recovery journey. Three multidisciplinary presenters will introduce a range of strategies that ensure care is responsive to a person's cultural identity and discuss approaches for fostering cultural strengths and spirituality in care planning and recovery practices.
Date: April 4th
Systemic Review of Recovery-Oriented Measures
Early this year, the journal Social Psychiatry and Psychiatric Epidemiology , published an article entitled, “Measures of the Recovery Orientation of Mental Health Services: Systematic Review.” Center Director Courtenay Harding joined a mostly British team to review measures which used recovery concepts such as: hope, optimism, connectedness, identity, meaning, purpose, and empowerment. Regarding the review, Dr. Harding stated, “Because the concept of recovery differed from study to study, it was difficult to compare apples to oranges and further work needs to be done.”
To read the abstract and purchase the article, go to: http://www.springerlink.com/content/r2gj8233x8285222/
Psychiatrists and Consumers to Collaborate
Instead of a standard didactic approach to delivery, the American Psychiatric Association (APA) and its partner, the American Association of Community Psychiatrists (AACP), plan to start their first training module with a video of a panel dialogue between psychiatrists and consumers. All nine modules will incorporate a video component to stimulate interaction and group discussion. The APA/AACP target audience is divided into two primary groups: direct service providers and trainers/supervisors. Training of trainers, who will teach the curriculum, will produce a network of psychiatrist and consumer specialists who can conduct training in various organized settings. Additionally, the curriculum will be delivered in 60–75-minute online Webinars. Pilot testing formally begins May 2012, although much of the material has been tested in select ways since October 2011.
To learn more, go to: http://www.psych.org/Share/OMNA/Recovery-to-Practice_1.aspx
Working Definition of Recovery Updated
In a recent SAMHSA blog posting, it was announced that the working definition of recovery and a set of guiding principles they released in December has been updated. The revised working definition and principles give more emphasis to the role of abstinence in recovery from addictions, and indicate that an individual may be in recovery from a mental disorder, a substance use disorder, or both.
To read the updated definition and learn more about the process , go to: http://blog.samhsa.gov/2012/03/23/defintion-of-recovery-updated/