Heart Forward Conversations from the Heart

2020 will go down in history for many things, including the significant push for a diversion of mental health related calls from law enforcement to a different model.  The CAHOOTS program, initiated in Eugene, Oregon, has captured the imagination of many throughout the country who are looking for a tested approach which shifts the burden to a peer-led team.  

CAHOOTS stands for Crisis Assistance Helping out on the Streets and was started in Eugene, Oregon in 1989.  It originated as a collaboration between a local nonprofit clinic and the city and has grown into a 24/7 service.  Multiple vans serve the city and offer an alternative to the traditional reliance upon first responders of police or paramedics which can often be a traumatic experience for all involved.  

Ben Adam Climer, who started his career working in homeless outreach in Los Angeles, moved to Oregon in 2014 and worked on the CAHOOTS team for five years, first as a crisis worker  and then as a trained Emergency Medical Technician (EMT).  

Climer is now consulting with a number of local jurisdictions who are looking to shift crisis calls away from the traditional law enforcement response to specialized teams with clinical workers, trained crisis workers and/or peer responders.   Climer walks us through how CAHOOTS is dispatched in Oregon and describes the types of calls they are uniquely equipped to handle.   He also shares data about the positive outcomes, both financial and human in scale.  Most noteworthy is the importance of de-escalating situations by not resorting to forceful interventions and avoiding costly hospital and jail interventions.

 To contact Ben-Adam Climer
Ben Adam Climer | LinkedIn
Articles:
CAHOOTS: A Model for Prehospital Mental Health Crisis Intervention (psychiatrictimes.com)

Huntington Beach latest to create non-police team to handle mental health, homeless issues – Orange County Register (ocregister.com)

You Tube:
(153) Los Angeles CAHOOTS Presentation - YouTube

Vincenzo Passante is a psychologist who lives in London but hails from Trieste, Italy.  He was raised and educated in Trieste, which gives him a unique vantage point to contribute given the mission of this podcast.    In this conversation,  we compare and contrast the system in Trieste against the vision behind mainstream mental health care in the UK. Vincenzo left the British National Health Service after two years of disillusionment. He worked in a crisis service and then, briefly, for a psychotherapy service. While in both settings there were amazing, talented professionals, the structure of the service was organized around deeply institutional rules which left very little space to the value of human subjectivity, a key ingredient in the Trieste system. Astonishingly for him, during this period he found out that virtually nobody there knew about Trieste and the possibility of helping people in a different way.

 Vincenzo – who speaks both English and Italian fluently – has had the benefit of not only studying  philosophy in high school and during his Psychology degree at university, which adds an intellectual bent to his view of the world, but he is quite knowledgeable about the writings of Dr. Franco Basaglia.  As Basaglia sought to close the asylums in Italy, he had a clear vision for a community-based system of care which focused upon the wholeness and dignity of the  people who depended upon that system for treatment and support.   He has also been able to read some of Basaglia’s  seminal writings that have yet to be translated into English.  So, this conversation affords us the opportunity to do a deeper dive into Basaglia.  

Vincenzo started a podcast in 2019 to spread awareness about Basaglia’s views and their practice in Trieste (and elsewhere). He wanted people to know how health and illness can coexist dialectically within people and society, without the need for separate institutions to exclude those who do not fit.  The podcast -- called A Place of Safety?  --  because that is how the  British system describes institutions who exclude people from society, affords him the opportunity to challenge the British approach to mental health treatment and educate people about a better way.  Perhaps, he thought, a good way to start is to reclaim the meaning of words and talk about a vision of “safety” that does not endorse violence and exclusion. 

Articles

An intellectual emergency in UK mental health services by Vincenzo Passante Spaccapietra - Asylum Magazine

Social media

Facebook 

Twitter

https://www.youtube.com/channel/UChIqzfr0zDkGO63SidfDwOA

Alex Barnard is an assistant professor of sociology at New York University, and received his PhD in sociology from the University of California, Berkeley in 2019. He is writing a book, tentatively entitled "Mental States," that examines why people with similar illnesses have very different trajectories between institutions of care and control in France and the United States. His work uses interviews, on-the-ground observations, and archives to examine why these countries developed very different mental health systems starting in the 1960s and the consequences of these choices in clinics, social service agencies, courts, and in the lives of service users themselves. 

 Since 2018, he has been working on a parallel project focused on analyzing the evolution and functioning of California's conservatorship system, which provides intensive, legally-mandated services to people with severe mental illness deemed as unable to meet their basic needs.

 He has written a report, "Absent Authority, Absent Accountability" aimed at helping to identify how to get professionals the resources, information, and coordination to make conservatorship a positive tool of transformation for vulnerable Californians. 

Update 10/5/23
Part Two of this conversation with Professor Barnard is available here. 
The conversation focuses upon the publication of his September 2023 book  Conservatorship: Inside California’s System of Coercion and Care for Mental Illness. 

 Links for this episode

 Professor Barnard’s website

From the “Magna Carta” to “Dying in the Streets”: Media Framings of Mental Health Law in California

 Contact information:

 [email protected]

 Twitter

Barbara Wilson, LCSW, has had a distinguished career in social service and helping people for over 50 years.   She is well-known in Los Angeles County as a tireless advocate for improved services to people coping with serious mental illness and the families who care for them.  She also is credited for being one of the first in the state to sound  the alarm approximately seven years ago that a precious housing resource for people with mental illness was slipping away due to the fiscal realities facing board and care operators whose rent revenues were not keeping pace with escalating costs.

In this interview, Barbara walks us through an important chapter in California’s history.  Any young student in social work would do well to sit at the feet to learn from this wise woman.  Policy makers interested in  reform should take heed.

Barbara describes the role of a psychiatric social worker during a time where they had the responsibility –and the authority -- to partner with people and take into consideration their whole life needs.    This is exactly what they do in Trieste, and still do in Trieste.  This is why people don’t slip through the cracks in Trieste.    

In the 1970’s, there was a statewide system in place to serve people with mental illness, with very few bureaucratic layers.    She was assigned to the 90044  area code.  As she describes this, it reminds me of the “micro-areas” in Trieste where one social worker has a broad command of the human needs in his or her assigned catchment area.   So, in fact, it appears that once upon a time, in California,  we did provide a social  safety net that involved social workers looking out for the interests of people.

Barbara was  responsible for the re-entry of people coming out of the state hospital system back into the community.  She describes the origin of the board and care system, where well-meaning people would open their homes to guests.  

The unravelling of these safety nets occurred in the 1980’s.    We hear about the increasing bureaucratization – social workers moving into desk jobs --  and the dismantling of a system that bestowed a sense of trust upon social workers to do the right thing for their clients.

Feeling overwhelmed by the needs of the people she was trying to serve and the constraints of a system that was taking away her freedom to serve them,  she took an early retirement as the 1980’s came to a close. 

After raising her family, she re-entered this space, urged on by desperate families looking for help and advice on how to navigate an increasingly broken system in behalf of their loved ones.  We’ll hear how Barbara’s life seemed to go full circle; the whole person safety net care she provided as a public psychiatric social worker in the 1970’s now became a skill she could rely on as she started her own business (now a non-profit) Mental Health Hookup.  

The message:  we can do better, because we used to.  Tomorrow’s leaders are encouraged to listen and learn from the past.

Links

Mental Health Hookup

Facebook link

(2) Mental Health Hookup | Facebook

Report co-authored by Barbara Wilson:

A Call to Action:  The Precarious State of our Board and Care System  Serving Residents Living with Mental Illness in Los Angeles County

We ended Season One as the pandemic held its grip on our country in the middle of December.  Now, a little over four months later, the sun is shining more brightly.  There is a vaccine.   The scary Covid surge has abated and we have a functioning government that is making public health,  returning to school and jumpstarting the economy  a priority.

So, I am ready to return to our conversations.   The theme remains the same.  The American mental health system is broken and voices for change will be featured each week.  We are inspired by the global best practice in Trieste, Italy.

We are going to explore more provocative topics this season:  old-fashioned social work, California's Lanterman-Petris-Short Act, the world-view of Dr. Franco Basaglia, how the CAHOOTS mobile crisis response model really works and how it can be adapted to local jurisdictions, how do human rights apply to the treatment of people with mental illness in American society and more.

First episode airs on April 30, 2021.

To support this podcast:
Heart Forward LA - Main Giving Page (networkforgood.com)

This podcast is produced in collaboration with Peer Mental Health.

This is the second of a two-part conversation with  Dr. Roberto Mezzina and Dr. S. P. Sashidharan that brings Season One of this podcast to a close.

Roberto  joins from Trieste Italy where he served for 40 years in the Dipartimento di Salute Mentale, and most recently headed their world-renowned mental health system.  Dr. S.P. Sashidharan calls in from Glasgow  and both were part of a small delegation invited to Los Angeles in September 2018 to tour our systems as part of a collaboration between Trieste and Los Angeles County.

In this interview, we complete the recollection from their September 2018 visit to Los Angeles.  They discuss a meeting that was organized with parents of loved ones with mental illness.  We discussed how families are marginalized in the American mental health system and how traumatic that may be for all involved.  

They also discuss their impressions from spending time with members of the Mental Evaluation Units for both the Los Angeles Police Department and the Los Angeles Sheriff’s Department.    In Trieste, the last entity one would call for a mental health crisis is law enforcement, but in the U.S., law enforcement has been pulled into this, not by their design.  In this case, what they observed was compassionate and professional.

We also explore the closure of forensic hospitals in Italy and the transfer of individuals into small therapeutic communities.  

Finally, we touch upon the respect paid in Trieste to human rights for people with mental health problems – a concept which is not particularly prevalent in our American system.  And in this time of Covid, all people may be experiencing the pandemic of loneliness.  Social connections are frayed; there may be lasting lessons and sensitivities that come out of this collective experience that may inform reforms in the future.

 Guests

Dr. Roberto Mezzina, International School Franca and Franco Basaglia and former director of the WHO Collaborating Centre, DSM, Trieste, Italy.

Dr. S.P. Sashidharan, Institute of Health and Well Being, University of Glasgow.

Financial Support

 To donate to support the expenses of producing this Heart Forward podcast, a contribution of any amount is appreciated:
Heart Forward LA - Main Giving Page (networkforgood.com)

With appreciation
Our collaborating partner  Peer Mental Health
Technical support  and podcast editing:  Paul Robinson

Resources

World Health Organization (WHO) Quality Rights Initiative

Mental health at the age of coronavirus: time for change (nih.gov)

 There is much to be gleaned from this very rare opportunity to have two extremely thoughtful and committed psychiatrists in the same Zoom room.    Dr. Roberto Mezzina joins from Trieste Italy where he served for 40 years in the  Dipartimento di Salute Mentale, and most recently headed their world-renowned mental health system.  Dr. S.P. Sashidharan calls in from Glasgow  and both were part of a small delegation invited to Los Angeles in September 2018 to tour our systems as part of a collaboration between Trieste and Los Angeles County.

Before they share recollections from that Los Angeles visit, Roberto and Sashi describe their early career and how they discovered Trieste as young psychiatrists in the 70’s.  Roberto had the opportunity to work alongside the visionary Dr. Franco Basaglia as he crusaded to close the asylums in Italy and create the community-based system of care.  

You will hear about how the Trieste system is recognized by the World Health Organization and learn about the commitment to human rights in their approach to care.  In Trieste, there are no locked doors and no reliance upon restraints.   They believe la libertà è terapeutica– freedom is therapeutic.  

Listening to this from an American context will be challenging because their views sound almost radical given the human-centered approach.  Sashi will raise the notion of an “Anglo-American blind spot” insofar as how psychiatry is viewed.  As he says, “we have become inured to our practices which constantly and repeatedly deny people of their liberties.”

Sashi and Roberto will describe their experience seeing restraints used in the psychiatric hospital and the shock of walking through Skid Row (described by Roberto as an “open air asylum”) in one of the richest nations in the world.  But most compelling is their reaction to the plight of mentally ill inmates chained to furniture at L.A. County Twin Towers.  

Yet, they have not given up on us, and continue to offer encouragement.  They saw bright spots during that week which are referenced:  in particular Anthony Ruffin and the L.A County DMH HOME Team, the Downtown Woman’s Center and The Center in Hollywood (recalled as the “Sacramento Center” by Sashi).  They were impressed by the compassion and expertise demonstrated by the Mental Evaluation Units for both the Los Angeles Police Department and Los Angeles Sheriff’s Department.  They call out the leadership of Dr. Jonathan Sherin, embracing the values of change as head of the county’s mental health department.

 Guests:
Dr. Roberto Mezzina, International School Franca and Franco Basaglia and former director of the WHO Collaborating Centre, DSM, Trieste, Italy.

Dr. S.P. Sashidharan, Institute of Health and Well Being, University of Glasgow.

 Resources

The Man Who Closed the Asylums, by John Foot

 Trailer to movie about Dr. Franco Basaglia

C'era una volta la città dei matti  (Once upon a time there was a city of the crazy people)

Note:  there are subtitled versions available

Far too often in American communities, people living with mental illness are marginalized from community supports and experience the debilitating impacts of social isolation, loneliness  and even the downward spiral into homelessness or incarceration.   Imagine the countervailing impact of a welcoming place to go – where everyone knows your name – as the theme from “Cheers” reminded us.  This is Fountain House and in this episode, we will hear about how the clubhouse movement offers an alternative; the promise of the therapeutic benefits of social connection and the dignity of vocation and purpose for people living with mental illness in our communities.

Dr. Ashwin Vasan, M.D., Ph.D., is the President and CEO of Fountain House in New York.   An expert in public health policy and political and social advocacy, as well as a primary care physician and academic, Dr. Vasan is committed to improving the lives of vulnerable people. He was hired in September 2019 to lead the advancement of Fountain House’s work around mental illness, homelessness, criminal justice, healthcare, and social welfare for marginalized people and communities. 

Fountain House in New York City was the first clubhouse established in this country back in 1948.  As stated in their mission:  Fountain House is dedicated to the recovery of men and women with mental illness by providing opportunities for our members to live, work, and learn, while contributing their talents through a community of mutual support.

Heart Forward LA is partnering with Fountain House to imagine the possibilities of bringing the clubhouse movement to Los Angeles.  It is no coincidence that several decades ago, Fountain House also inspired people in Trieste as they were imagining how to plant the ethos of the clubhouse culture throughout their entire city.  

Miriam Feldman – one of the strongest women I know -- recounts her journey as the mother of a son struggling with schizophrenia.  She points out that as a mother, you tend to worry about child abduction or car accidents.  Nothing prepares you for serious mental illness.  

From her book:   “This is the story of how mental illness unspools an entire family…it exposes the shortfalls of our mental health system, the destructive impact of stigma, shame and isolation, and, finally, the falsity of the notion of a perfect family.”  Mimi lived across the street from me, and her son is the same age as mine.  I did not know about this story until I read her book!

Why does this have to be such a secret?  And why does it have to be so hard?  In this interview, you’ll hear about the things that must change if we are going to interrupt this tragic cycle of illness, despair, hospitalization and derailed dreams.    Fortunately, Nick did not end up homeless or incarcerated, but this is too often the circle of life for people with mental illness in our country.  Nick’s story adds to the growing chorus that this must change in America.

Mimi’s 2020  book is called  He Came in With It: A Portrait of Motherhood and Madness.  

Her website is a treasure trove of her art, her blogs, information about her book and resource information for families and friends trying to understand mental illness and how to navigate this space.

Here is a “TED-type” talk she recently gave as part of a NAMI Washington State “The Brainpower Chronicles” event in November, 2020.

https://www.youtube.com/watch?v=k4Jc8k8NKHM&t=127s

Link Article in LA Yoga October 2020

Instagram handle:  @mimitheriveter

Links to other topics referenced during this interview.

About NAMI | NAMI: National Alliance on Mental Illness

Schizophrenia and Related Disorders Alliance

Bring Change to Mind 

HIPAA – the Health Insurance Portability and  Accountability Act

Gould’s Farm