Andy Steiner

About the Author Andy Steiner

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Culturally specific screening helps identify mental illness in refugee groups

Everyone knew that the first Hmong refugees who came to Minnesota had experienced atrocities during the Vietnam War, experiences that had scarred many for life. But when members of this group were assessed for mental illness during routine health screenings, doctors began to realize that something had to be wrong — not with the Hmong people, but with the screenings themselves.

“It was clear that the screening just wasn’t designed for a Hmong-refugee audience,” said Darin Brink, M.D., a physician and associate professor at the University of Minnesota’s Department of Family Medicine and Community Health. “With the Hmong, we discovered that you can have a concept and a list of questions that work great in one culture, but are totally wrong for another.”

In the standardized screen for depression, doctors asked Hmong refugees a question that is commonly asked of nonrefugee patients: “Did they agree with the statement: ‘Sometimes I think I’d be better off dead?’”

“If most Americans said yes to that this comment, it would be alarming because it usually means that this person is suicidal,” explained Dr. Brink, who also supervises residents working with refugee communities at St. Joseph Hospital’s Bethesda Family Medicine Clinic in St. Paul. “But the Hmong who first came to the Twin Cities almost always said yes to this question.” Why? “From the Hmong point of view, this is a philosophical question,” Brink continued, adding that doctors felt confident that, despite what the screening questions revealed, a majority of their Hmong patients were not suicidal. “From a Hmong perspective, is it easier or more pleasant to be in the afterlife with your loved ones who have passed away? To many Hmong, the answer might be yes. So if you directly translate that question for a Hmong audience, especially one that is new to this country, it is not going to be a good measure of depression.” 

Darin Brink, M.D.

Darin Brink, M.D.

This experience with the Hmong refugee community made it clear to public health professionals in Minnesota that when it comes to refugee populations, there is no one-size-fits-all approach for finding out about the state of a person’s mental health.

For the past several years, a group of Minnesota-based physicians, public health workers, mental health professionals and representatives from different refugee communities have come together to develop a set of culturally specific screening tools designed to measure the mental health of some of the state’s newest residents. In the last few months, a shorter version of those screening questions have debuted at select clinics serving refugee populations.

Early identification important

The statewide effort has been championed by Patricia Shannon, associate professor at the University of Minnesota’s School of Social Work. Shannon, who came to the university after more than a decade supporting refugees and asylum-seekers at the St. Paul-based Center for Victims of Torture (CVT), has been working to develop a new set of measures that can help health-care providers accurately determine whether refugees suffer from post-traumatic stress disorder (PTSD) or depression.

Mental health is just as important as physical health, Shannon believes. These culturally specific tools can help direct people to the help they need. And the sooner mental health concerns are identified and treated, the better the prospects for a refugee’s long-term success in the adopted country.

Patricia Shannon

Patricia Shannon

“Many refugees find that if their mental health concerns aren’t treated early on, they tend to worsen over time,” Shannon said. “I see this system of mental health screening as a great opportunity to address refugee needs as soon as possible, before they grow into a larger disability. Between 30 to 50 percent of refugees report experiencing trauma in their countries of origin. These populations are at risk for serious psychiatric distress. We are trying to make it a major public health concern.” 

When mental illness is not identified or treated in refugee populations, the impact can be long-lasting, on refugees, their communities and their families, Shannon said.  

“What I like to say is that we have a narrow window of opportunity to detect refugees who are suffering with PTSD and depression. When I worked at CVT, it was not unusual for me to see refugees who have failed out of the refugee process because their mental health symptoms weren’t identified early on. This impacts their ability to learn English, to resettle successfully, to maintain employment. They may also have chronic disease or back and body pain from untreated PTSD.”

Blain Mamo, refugee health coordinator for the Minnesota Department of Health, has worked with Shannon to identify the screening questions that are now being piloted. She said that establishing a policy of screening for mental illness as part of standard refugee health exams sends the message that Minnesota believes that a person’s mental health is as important as his or her physical health. 

“If we want all refugees to have the opportunity to be productive and active members of society, we want to make sure they are healthy,” Mamo said. “The focus should not just be on individuals’ physical health but also on their mental health. We should provide holistic health care to all people.”

Screening questions should match cultural attitudes

Developing screening questions designed to tease out whether a refugee is a good candidate for mental health assistance was a long process, Shannon said. Many people from developing countries do not have a vocabulary to describe symptoms of mental illness, and organizers needed to talk to the refugees themselves to understand the correct way to word their queries.

Blain Mamo

Blain Mamo

“One of the ways I started this project was trying to understand culturally based perceptions of mental health,” Shannon said. While people all over the world experience mental illnesses like depression and PTSD, different cultures have different ways of describing them. “There is a lot of variation in how people express depression, for instance,” Shannon continued. “Some of the symptoms may be the same, but the way they are described may be different. Along with that, there are cultural questions about whether it is acceptable to seek help for these issues.”

In order to develop the culturally specific screening tools, organizers pulled together focus groups with members of different refugee groups. Many focus group members were recruited from clinics that serve large refugee populations.

“We asked members of these focus groups, ‘How would you know if someone was not doing well psychologically?’” Shannon recalled. “We asked, ‘What would be some of the words you would use to describe depression or PTSD?’ ‘What would be acceptable ways that doctors or other health-care professionals could ask about these conditions?’”

Once those question were complied, Shannon said that organizers “looked for common symptoms across the groups. We knew we had to use language that all refugee groups would endorse.” After a list of screening questions was compiled and approved, it was piloted with local clinics serving Karen and Somali refugees.

Focus on Karen

One of the fastest-growing refugee populations in Minnesota is the Karen, an ethnic group from the mountainous border regions of Burma and Thailand. The Karen have been persecuted by the Burmese government, subject to ethnic cleansing and forced to live in refugee camps. Over the last five to seven years, the number of Karen refugees living in Minnesota has grown to over 6,500. St. Paul is now home to the largest Karen community in the United States.

“About seven years ago we started to see higher numbers of Karen patients here,” said Jim Letts, M.D, a family medicine physician at HealthEast Roselawn clinic in St. Paul. He explained that the clinic serves some 3,000 Karen patients and employs seven full-time Karen interpreters.  

“We were doing a lot of outreach and partnership with that community,” Dr. Letts continued. “We started to see that a lot of them had faced trauma in their past and were starting to manifest that here with depression and PTSD.”

Because Dr. Letts and his colleagues found it hard to clearly identify symptoms of mental illness in their Karen patients using the screening tools they had at hand, they were excited to work with Shannon’s team to develop the new screening questions.

“We wanted to talk about mental illness with our patients in a way that is culturally sensitive and appropriate,” Dr. Letts said. “Our patients had limited if any experience with speaking about mental health or the terminology of mental health. We needed a tool that they could understand.”

Before the screening tools were developed, Dr. Letts said, “There were many times where at some point during a discussion about mental illness I would realize that a patient thought I was talking about physical symptoms rather than emotional symptoms. In debriefing with interpreters after a visit that didn’t go so well, I’d learn, for instance, that the patient had thought that I was talking about their heart — literally their heart — because of the way the language was lost in translation. What I was trying to get at was their mood or their mental well-being. There were crossed wires.”

Members of Roselawn’s all-Karen patient advisory panel helped vet the culturally specific screening questions Shannon’s group compiled. The same set of questions was introduced at the Bethesda Family Medicine Clinic, which also serves a large number of Karen refugees. 

Mental health screening happens during early physical health screenings for refugees, Dr. Brink said, and also later, during routine check-ups.  

“Say a person comes in because they have pneumonia or bronchitis,” Dr. Brink explained. “By asking our culturally specific screening questions during the office visit, we also may identify a patient as likely having PTSD or depression. At that point, we ask if we can schedule a follow-up appointment to clarify the diagnosis. If it seems like the patient does have the diagnosis and is open to treatment, we would prescribe medication — or they could go to one of our refugee-focused mental health groups.”

Screening goes live

The new set of culturally specific questions is being piloted in three different clinics in Ramsey and Hennepin Counties, Shannon said. She’s also taken her show on the road, traveling to Olmsted County to train public health workers in Rochester, another Minnesota city that is home to many different refugee groups.

The Minnesota Department of Health is supporting Shannon’s efforts to enhance mental health screening for refugee communities, Mamo said.

“We started piloting these questions in January-February of this year,” she said. “We are just rolling them out now. We’ve been connecting with the clinics to see if they have any issues and offering to help where we can. We are also trying to work with clinics in Greater Minnesota, including Rochester.”  

The U.S. government, Mamo said, supports prompt screening of refugees upon resettlement. By including culturally specific mental health screening as a standard part of these exams, Minnesota emphasizes the importance of mental health in overall health. By asking questions specifically designed for a refugee audience, the answers are more accurate, and patients are matched with the treatments they really need.

“We try to steer away from the Western model of asking questions,” Mamo said. “We ask things like, ‘Are you feeling sad?’ ‘Are you able to do your daily activities? ’With these questions, screeners try to ask things that that people would relate to naturally.” 

In the end, the goal of the culturally specific screening program is to make sure that refugees suffering from mental illness get the treatment they deserve, Shannon said. “These conditions are treatable,” she added. “Refugees should not be suffering with untreated mental illness.”

By developing new ways to identify mental illness in refugee communities, Shannon hopes that stigma around seeking help for these conditions can be reduced. They want to send the message that mental illness is part of life for many people, and, like physical illness, it can and should be treated without shame.

Culturally specific mental health screening “should be an ordinary part of providing protection and resettlement services,” Shannon said. “I feel like the public health system can play an important role in normalizing these responses to stress. We believe that refugees shouldn’t suffer for the rest of their life, that they can be successfully treated. When you tell refuges that, it is very relieving. You can see the stress coming off of their shoulders when they see that they are not the only one who’s suffering like this.”  

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Peg O’Connor: Philosophy helps explain deeper truths about alcohol, ethnicity and culture

Ask Peg O’Connor a question, and more likely than not her reply will be more question than answer. A professor of philosophy, and gender, women, and sexuality studies at Gustavus Adolphus College, O’Connor has spent the last nearly 20 years teaching her students to fully examine their worlds in a search for truth and meaning. 

O’Connor didn’t always give her own life the full examination it deserved. As a teen growing up in Massachusetts, and later as a college student at Wesleyan University in Connecticut, at she abused alcohol until a near-death experience forced her to sober up.

This winter, O’Connor, a former AA Heckman fellow at the Hazelden Betty Ford Foundation and author of the popular “Psychology Today” blog “Philosophy Stirred, Not Shaken,” wrote about the intersection of philosophy and addiction in her latest book, “Life on the Rocks: Finding Meaning in Addiction and Recovery.”

“I use the greatest hits from Western philosophy to tease out concepts that are useful for people who are struggling with addiction and living recovery,” O’Connor explained. The book has been called “an indispensable guide to the deeply philosophical concerns at the heart of every addict’s struggle.”

Last week, I asked O’Connor about her thoughts on addiction, ethnicity and St. Patrick’s Day.

MinnPost: St. Patrick’s Day is coming up, and it got me thinking. Some ethnic groups — including the Irish — have a reputation for having higher rates of alcohol abuse. Do you think there’s any truth behind this stereotype?

Peg O’Connor: I think there’s definitely a belief that certain ethnicities drink more than others. But I’m wondering how much truth is actually behind that. I’m Irish-American on both sides of my family. But we’ve been in the United States for a long time. They came over here during in the Potato Famine in the 1840s. So I’m really more American than I am Irish.

What’s more interesting than the statistics is the overarching belief that some ethnicities drink more than others. On holidays like St. Patrick’s Day, that stereotype breeds a strange sort of logic. On days like that, we can justify our drinking by saying, “This is what my people do.” A mindset like that provides enormous cover for problematic behaviors. We can get drunk because supposedly it runs in our blood.

MP: So you’re not a big fan of St. Patrick’s Day?

PO: There are two holidays I hate: New Year’s Eve and St. Patrick’s Day. They provide license for people to do things they normally wouldn’t do. People think these holidays provide a free space on the game board. Many bad things can happen because people have been given an official excuse to do dumb things.

MP: But addiction has a genetic component, right? It runs in families. 

PO: I don’t think we have the answer to that question yet. Some of alcoholism is due to socialization. When you look at alcoholism within families, the question should actually be: “What’s the cause of alcoholism within this family? Is there a genetic component or are we talking about a general disposition, a way of looking at the world?”

Is alcoholism socialization? Is it a learned habit? When there’s a celebration, does your family drink? Do you learn from other people in your family that it’s OK to drink when you’re pissed off? I’d say that alcohol dependence is a learned habit that is clustered in some families of some particular origins.

MP: So alcohol is built into the family culture?

PO: And into the culture of origin. I don’t know if I would say that alcohol dependence has to do with ethnicity as much as it does have to do with socialization. If you go to Ireland, there are pubs in every tiny little town. These pubs are full of Harp and Guinness and Jameson [Irish] Whiskey. There is harp music and dancing and the social life of the town revolves around the pub. In Ireland there is a true pub culture. Some of that has to rub off on the Irish people.

MP: Are there other places where alcohol is a central part of the culture?

P.O: I think colleges are gigantic pub cultures. And a kind of mythology gets created around that culture. The attitude around drinking on some campuses is, “That’s what college students do.” We are all supposed to think it is just the way the world works. It provides some level of expectation for student behavior. My students say to me all the time, “I’m a college student.” Like that’s supposed to make everything OK.  

MP: Tell me about your life with alcohol.

PO: I started drinking when I was 14. I was in Catholic school. My drinking escalated as my high school career went on. I knew I was an alcoholic by the time I was 16. I had a problem and I could identify it as alcoholism. I knew I drank differently from my friends. My drinking accelerated when I was in college. That is hard to imagine because in high school I was already a regular black-out, pass-out drinker. In college, I’d stop drinking for a time and then somehow I’d just start rolling again. I was a full-blown, raging alcoholic.

MP: You were an alcoholic at 16? How were you able to get access to alcohol?

PO: I started going gray when I was 16. I never got carded. I had no problem getting alcohol.

MP: You are sober now, and have been for several decades. How did that happen?

PO: How did I sober up? Kind of by accident. One day, I was going to meet up with some friends and I got t-boned by a pizza-delivery boy. I was almost killed. I had a severe concussion. I woke up in the CT scan.

I was in pain from the accident, but I knew if I started taking painkillers, it’d be “Betty Ford here I come.” Somehow I made a shift in how I looked at the world and I turned them all down. Looking back on that time now, I think that as a consequence of the severe concussion and the depression that followed I felt emotionally flat-lined. I didn’t give a rip that I had lived. I was truly indifferent to the fact I was alive. Then several weeks went by and I realized that I hadn’t had a drink. I said to myself, “I’ll see how long I can go with it.”

That was 1987 and here I still am. To me, sobriety still feels like an ongoing experiment. Things could change. Relapses just don’t happen, but there are a lot of steps up to that point.

MP: What lessons did your family teach you about alcohol?

PO: Now we’re back to the Irish problem. I’ll admit that there was always drinking happening when I was growing up. But I never label other people. I also know that it was at a time in the ’70s and early ’80s when there was so much more alcohol flowing everywhere.

MP: How did you get away with all that drinking when you were a teen?

PO: In the early 1980s there was an idea that adolescents couldn’t be addicted. So that gave me enormous cover. And we had a lot of stereotypes back then about who could be an addict, so a nice Irish Catholic girl from a good family couldn’t be an alcoholic. But I certainly was. I kept up my grades. I got into a good college. I was a high-functioning alcoholic.

MP: What were your college years like?

PO: My college career can be described as falling in love with philosophy while nearly drinking myself to death.

In college I repeated a lot of the bad patterns that I had in high school. Working with college-age kids now I see the level of responsibility that they are taking for one another’s well-being. It’s really impressive. When I was drinking, I put some burdens on my friends that I didn’t understand. But I also know that I kept switching my friendship circles so I was never the one who drank the most.

MP: Now you’re a college professor. What are you observations about alcohol on campus?

PO: The old rule of thumb was what we called “20-60-20.”

This means that 20 percent of students on campus didn’t drink at all. Sixty percent drank sometimes. Another 20 percent drank a lot. What we are seeing these days is different. That 60 percent is emptying out. Those kids are not drinking at all or they are drinking really, really lightly. Then there are the kids who, when they drink, are really, really drinking. We are talking about blood alcohol counts (BAC) much higher than they were 20 years ago. Before, a .2 or.25 BAC would make your hair stand on end. Now we’re seeing BACs of .3 or .35. That’s not all that uncommon.  

College females still aren’t binge drinking as much as their male counterparts, but those rates are going up. A lot of young women pregame drink. And since hard liquor packs more punch and they don’t want to drink too many liquids and have to use the bathrooms at parties, they drink hard liquor while they are getting ready to go out. Then they’ll go out drunk.

There are potentially really serious consequences for young men and women who are drinking in these really dangerous ways.

MP: How did you end up as a philosophy professor?

PO: When I was in school, I fell in love with Kierkegaard. He’s called the Father of Existentialism. Kierkegaard challenged me to think about questions of faith and responsibility and what’s possible. That spoke to me as someone who was struggling with addiction. People who are struggling with addiction tend to be fatalistic. Kierkegaard drew me up short.

Both Kierkegaard and Nietzsche say that everyone suffers. Suffering doesn’t distinguish us. The meaning we make of our suffering distinguishes us. When I discovered this I thought, “I can’t just wallow. How do I transform?” I try to talk about that with my students.

MP: You didn’t exactly transform, you just worked your past into your present.

PO: If I was given the option to erase my years as an alcoholic, I don’t know if would. So much has come from my addiction. It makes me a more compassionate person. It gives me insight and empathy with my students. It has taught me enormous humility. Because of my past, I realize that there is nothing great about me. I could chuck it all away at any time. It’s a relief to think that way, at least for me.

That brings us back to one of the stereotypes about Irish people. We tend to be pensive, deep thinkers. We really chew on things. We are natural philosophers.

MP: So I guess we’re back to the question of, “Is it genetic? Or a learned behavior?”

PO: I guess we are.

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Kelvin Lim: The psychological impact of brain injury can be long-lasting

Kelvin Lim

Kelvin Lim

We all know that traumatic brain injury (TBI) can cause a host of long-term problems, including cognitive disabilities; memory loss; motor function limitations; vision impairment; or change in sense of smell, taste or touch. But fewer people are aware of the long-term psychological impact of TBI: People who have experienced head injuries also may experience a range of psychological symptoms, including depression and anxiety, poor impulse control, verbal or physical outbursts, lack of empathy, general apathy or a tendency toward risky behavior. Some of these impacts are lasting; others fade as the brain heals from the trauma.

March is Brain Injury Awareness Month, and Kelvin Lim, Ph.D., Drs. T.J. and Ella M. Arneson Land-Grant Chair in Human Behavior, vice chair for research and professor of psychiatry at the University of Minnesota, took time to speak with me about how brain injury can alter a person’s mental state.

“The connections in our brain are delicate,” Lim told me. “Those connections are highly susceptible to injury and the result can be long-lasting. The long-term psychological impact of TBI continues to be the subject of much study.”

Earlier this week, Lim and I talked about how TBI occurs, about its potential psychological impacts and about a number of exciting new research studies and treatments currently under way.

MinnPost: Can you define traumatic brain injury?

KL: Traumatic brain injury, or TBI, implies a physical trauma. The biggest source of domestic TBI is car accidents. For example, people who hit their head on the steering wheel experience TBI in gradations of severity from mild to moderate to severe. The majority of TBIs are mild. There isn’t loss of consciousness, no penetrating injury. People with a mild TBI usually recover within a week or two.

Another one of the sources of TBI that many people are aware of is combat injury. I’m a professor at the U of M, but I also work at the Minneapolis VA hospital where I am site principal investigator of the Defense and Veterans Brain Injury Center. There I study TBI as part of military service. There have been so many headlines about how many members of our military who served in Iraq and Afghanistan have the signature injuries of TBI. The most important thing to know is that with proper care, 85-90 percent of people recover from a mild TBI.

MP: What is the best way to treat a person who has suffered TBI?

KL: What does the brain do for us? Everything. It is key for reading. It is central to communication, to thinking. It was one of those “duh” moments for us when we learned that in order for the brain to recover from a concussion, you have to let the brain rest. And by rest I mean completely rest.  

Today in collegiate and professional sports, a period of rest is now required after a concussion. Not so long ago, it didn’t used to be that way. During this time of required rest a patient doesn’t get to use their phone. They don’t read. They really have to have quiet time for the brain to heal. All of the stimulus, all the information that is usually flooding the brain needs to be minimized in order for the brain to heal.

MP: Can you describe what happens to the brain during a TBI?

KL: The brain is a complex network. We have billions of neurons and trillions of connections among all the neurons. These connections are what matters. And there are axons that connect the various neurons. These are what produce the connections. This is part of what we call the white matter of the brain, and it is particularly susceptible to injury.

In TBI what happens is something like this: Imagine the brain as a container of Jell-O. There is actually structure to these connections in the brain, and just like when you drop a bowl of Jell-O on the floor, these important connections can get damaged or disrupted or disconnected, depending on the severity of the injury.  

MP: So how does TBI create psychiatric problems?

KLIf we know that the key part of brain function is the wiring, the damage to the wiring that occurs in TBI, even in concussive injury, can lead to disruption of function. Much of the work that’s being done in psychiatric disorders these days is pointing to those disrupted circuits. For example one of the very important circuits related to depression and anxiety is related to the connection of the medulla to the frontal lobe. Disruptions of these connections can alter brain function, and also drastically alter the state of a person’s mental or emotional health.

Another example is the situation of stroke. With a stroke, you damage brain matter, but you can also cause inflammation to white matter. With the inflammation, the connection is broken. Twenty-five to 30 percent of people who suffer a stroke will develop a depression within three months that usually lasts for one to two years.

MP: How does TBI-related mental illness manifest itself?

KL: One of the things that is commonly observed is that sometimes after experiencing a TBI, people will have a change in personality. Loved ones might say, “This person used to be very mild mannered. Now they are very impulsive, loud, not aware of others or their behavior.” This is a fairly common phenomenon, oftentimes in more severe-to-moderate injuries. This can result in permanent changes in personality and behavior.

MP: Do younger people who experience TBI-related psychiatric illness have a better chance of recovery?

KL: The younger brain can be more resilient. Still, repeated TBI can be devastating at any age. Football players can develop something called chronic traumatic encephalopathy (CTE) after experiencing repeated head injuries or concussions. This is a very specific neurophysical change that experts are observing in people who’ve had repeated concussive injuries, the kind of injury that has been common in the game of football.  

There is also a phenomenon we learned about back in medical school where boxers who’ve been hit in the head too often develop something called dementia pugilistica. It is a condition suffered by people who’ve had multiple concussive brain injuries and ultimately develop a dementia. This doesn’t always happen right away.

MP: Are there any promising new strategies for the treatment of TBI?

KL: There are several new strategies for treatment of brain injury. Our first-line approaches have been tried and we now understand what has been shown to be very helpful in these cases. We are discovering that pharmacological agents like antidepressants can be very helpful.

But depending on the level of brain damage, you are not always dealing with a standard brain. When that is the case, one has to think out of the box to develop new strategies for treatment. We are focusing on the idea using other approaches for changing brain circuitry after TBI.

MP: This must create challenges.

KL: One of the challenges in treating people with TBI who also have chronic problems with depression is that when you mix TBI with anything, things get more complicated. The brain has been damaged and the traditional approaches don’t always work.

MP: Tell me more about some of the studies you are working on.

KL: A new strategy for treatment of TBI is mapping brain-circuitry abnormalities. We are currently investigating using this as a strategy for treatment. If we have problems with connections in the brain, are there ways to decrease the abnormal connection through the use of transcranial magnetic stimulation (TMS) or other stimulation techniques? That’s of great interest to us here at the university.

And there is a very sophisticated technique called diffusion tensor imaging. It is done with an MRI scanner. What this technique allows you to do is noninvasively study the integrity of the white matter fiber structure and pathways in the brain. For many years, we’ve known that TBI causes damage to the white matter. With this tool we are able to examine that, and once we are able to closely examine the white matter, we will be able to develop methods for helping people with this kind of damage to their brains heal.  

This takes us back to the use of TMS in the treatment of TBI. We are starting up a new study at the VA that focuses on this approach. Some of our work is looking at how brain connectivity is altered in people who’ve had a mild traumatic brain injury. We’re also starting a new study funded with people who’ve had mild TBI. We are watching to see how their injury changes over time. We want to learn to what degree mild TBI exposure predisposes a person for greater neurodegeneration later in life.

MP: How many lifetime TBIs add up to neurodegeneration?

KL: We’re not sure yet. We believe that the number of TBIs a person experiences in their lifetime may increase the risk for later neurodegneration. For example take the boxer who gets hit pretty hard and stars and feels confused for 30 seconds. Say he has 10 of those experiences in just one bout. What’s becoming clear to researchers is the cumulative effect of repeated in injury over time. In those cases, the brain doesn’t have a chance to heal.

MP: How would you define mild TBI?

KLThe classification of a mild TBI is a brain injury that causes loss of consciousness or confusion for less than 30 minutes. In these cases, the person’s brain scans are normal, and while they may experience some headache it generally the resolves within a few weeks. Moderate brain injuries include longer periods of loss of consciousness. Severe TMI is more extreme, where people are in a coma for extended periods of time.

MP: Does studying the impact of TBI make you more cautious in your life? Do you make your loved ones wear helmets all the time?

KL: Well yeah. In the year 2016 do I think everyone should wear a seatbelt in a car? Yes. I’m probably hypersensitive to this kind of thing. But I know how serious these things can be. And people may be catching on. Now snowboarders wear helmets. You’re seeing more and more people on regular ski slopes wearing helmets. That makes total sense. We are getting more aware of the basic importance of bicycle helmets. Of course this is very important. People will say, “I’m not going that fast,” but even going 20-30 mph its not good. Imagine hitting your head against a wall at 30 mph. That’s what TBI is.

I’m going to make an important public service announcement: Protect your brain. It is the only one you have.

MP: They haven’t perfected the brain transplant yet, have they?

KLNo. And you wouldn’t want someone else’s brain anyway. 

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‘How are you?’: U of M student campaign focuses on campus mental health

Repeat something often enough and it loses its meaning.

This spring, a group of University of Minnesota student government leaders are hoping to turn that assumption on its ear, by taking one of the most commonly uttered phrases in the English language and encouraging students to actually pay attention to the response when they ask a classmate, “How are you?”

This effort is part of a University-wide campaign designed to focus on the mental health of U of M students, which has been under increased scrutiny ever since Boynton Health Service’s annual student survey found that the number of students reporting a mental health diagnosis had increased by 33 percent since the last time the survey was taken.

For the last two years, the University’s Student Association developed and promoted a spring communications campaign; This year’s campaign, “How are you?” follows “No Gray,” the 2015 campaign, which focused on campus sexual assault.

Junior Emma Mazour, Minnesota Student Association communications director, came up with the idea for “How are you?”  

“I thought, ‘People are always asking, ‘How are you?’ every day, but they don’t actually mean it,” she said. “They don’t really want to know how you’re doing. I just figured since it is already out there, we should re-empower those words to mean something and take the opportunity to check in with people about their mental health.” 

By encouraging people to pause and think about the meaning behind a rote phrase, by opening up an opportunity for an honest discussion about a young person’s emotional state, Mazour and her fellow committee members hope to encourage more open conversation around mental health.

“I wanted to make people rethink their everyday actions,” Mazour said. “Mental health is a part of  life. It’s something that affects so many people, yet it is not usually a topic of conversation. When we realized that the problem is that people aren’t talking about their mental health, it was a natural progression to make it the focus of the campaign and do something positive about it.”

Mental illness touches everyone

This campaign is central to improving the quality of life on campus for everyone, said University of Minnesota Student Body President Joelle Stangler.

“I think mental health impacts the community in a lot of different ways,” she said. “Look at the academic impact: When your lab partner is struggling with mental health issues, it impacts your work on the project. When you are working on a group project, and one of the team members has a mental health issue, it’s hard for them to carry their weight. It also impacts students who are just trying to support their friends.”

The “How are you?” campaign is designed to begin with one-on-one conversations between students, but organizers like Stangler hope that if those conversations reveal serious mental illness, the students involved won’t try to address on the issue themselves. These conversations are intended to be a starting point.

“This campaign encourages peer-to-peer conversation about mental health as a first step,” Stangler said. “We hope that this campaign will ultimately encourage more students to seek help from trained mental health professionals.” Campaign materials feature resources where students can turn for help. 

How Are You? video

Not everybody is comfortable having serious conversations about mental health. Because of this fact, “How are you?” organizers have also partnered with staff from the university’s Student Counseling Services to create a short online training program that gives tips on how to talk to a friend about his or her mental health. The program was launched this week.

“We are utilizing a training Student Counseling Services developed for faculty,” Mazour said, explaining that the group adapted the existing training to make it appeal to a student audience, with four short videos narrated by Stangler: “We are making it accessible to students so if one of their friends is having mental health problems they know what to say. Having conversations about mental heath can be intimidating if you’ve never done it before. We are trying to empower students.”

Social media campaign

Though there were a few live events tied to the campaign, “How are you?” organizers have largely relied on social media to communicate their message.

Last Wednesday, the campaign went live on Facebook.

“We’ve already gotten over 50,000 views,” Mazour said. “People are talking about it. We’ve heard a lot of good feedback. The video is just the beginning.” Through the Humans of the U of M online community, students and other community members are encouraged to share their stories of living with mental illness. Visitors are chiming in to offer support, encouragement and advice for seeking outside help. 

“We’re putting a face to mental illness and trying to reduce stigma,” Mazour said. By focusing on online platforms, organizers hope to make “How are you?” feel, “really accessible. Being online is a way that everybody can feel support and be part of the campaign and participate. Because it’s so easy to access, it’s hard to have an excuse not to get involved.”

The campaign was announced with a YouTube video featuring a range of student leaders explaining why people don’t like to talk about mental health concerns and encouraging more open conversations about the topic. Mazour wrote the script and produced the video with help from G-TV, a student-run digital media organization. 

“It was an entirely student-led initiative, which makes the intent of the video even more genuine,” she said. “Students saw the importance of this issue and they wanted to help out. We all came together to make a difference.” 

More professional help needed

If “How are you?” achieves its goal of connecting students struggling with mental illness with the professional help they need, the university’s already stretched options for student counseling will feel even more strained. There are already waiting lists for individual appointments with on-campus counselors, and while student-run volunteer groups like de-stress have stepped in to fill the gap, student groups say the university needs to hire more therapists and counselors to meet demand.

This represents a change in “business as usual” at the university, Stangler acknowledges. “Only in the last decade have academic institutions begun to be expected to be responsible for mental health on campus,” she said. She hopes that U of M administrators will schedule campus meetings to discuss the topic this summer. “We would like to see the institution pause and evaluate where we are going,” she said, “but in the meantime, we are advocating for increased staffing.”

The desire for action on this issue is apparent, Stangler said.  

“Most of the movement it has been grassroots. Fifty students showed up for a forum last week and expressed a need for mental health funding based on this campaign. I think it is creating a greater level of awareness. The demand hit us quickly over the last decade. We aren’t addressing this systematically. We need to try.”  

The university has responded by adding four new mental health positions: two permanent counseling staff at Boynton Mental Health Clinic, and two temporary counseling positions at Student Counseling Services.

The Office for Student Affairs is committed to this issue,” Stangler said. “They moved up the hiring to help with wait times. It’s great to see a community-driven collaboration drive change.” 

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Nev Jones: First-episode psychosis programs help young people continue their lives

Nev Jones

Nev Jones

Few experts in first-episode psychosis have experienced the illness themselves. Nev Jones is an exception.

A decade ago, when she was a 25-year-old doctoral student, Jones began experiencing the subtle first signs of psychosis. Her experience searching for a mental health care provider who could help her knit the unraveling edges of her life back together ultimately led her to work a research scientist for the California Mental Health Services Oversight and Accountability Commission, a state entity charged with overseeing implementation of California’s Mental Health Services Act.

Jones, who has been diagnosed with schizophrenia, is a community psychologist, mental health services researcher and peer advocate who founded the Chicago Hearing Voices Network. She recently completed a post-doc fellowship at Stanford University. Her widely published research has primarily focused on psychosis across the age spectrum.

“I don’t know of a single other researcher doing work on early intervention in psychosis who has personal experience with psychosis,” Jones told me when we talked earlier this week from her home in Sacramento, California. “I am uniquely positioned, because I can bring together different perspectives and types of experiences in my work.”

Today Jones will be keynote speaker at a symposium on first-episode psychosis sponsored by the Minnesota Department of Human Services and held at the Earle Brown Heritage Center in Minneapolis.

MinnPost: Have you always been interested in mental health, or did your focus sharpen after your diagnosis?

Nev Jones: Several members of my family have been diagnosed with schizophrenia, so I was already naturally interested in mental health all the way going back to my teen years. As an undergraduate, I majored in philosophy of psychiatry. I was a first-year philosophy Ph.D. student in Chicago was when I was diagnosed with schizophrenia.

Several years after my diagnosis, I went back to graduate school in psychology. Right from the get-go I wanted to study early intervention because I had experienced it myself. I understood the difference this intervention made in my life. I understood the potential it had to alter the trajectory of young people’s lives.

I know now that after my symptoms began appearing, I was very lucky to end up in an early-intervention program.

MP: Really? Why was that?

NJ: After running into a lot of roadblocks, I was lucky to get connected to what at the time was one of only a handful of early-intervention, first-episode psychosis programs in the country.

But I didn’t get into that program as soon as I started experiencing symptoms. I had some pretty bad experiences at first, including multiple contacts with clinicians who didn’t realize what was going on with me. Some were so stigmatizing that I basically ran away. At some point I ended at a county-operated clinic, a quasi-hospital. The intake nurse there talked to my friend as if I was not there. She said, “I’m not the one who does the form assessments, but I can tell you right now that she’s a skitzo.” This nurse acted like I wasn’t there and couldn’t understand English. Here I am, a first-year doctoral student, and this person is acting like I have the capacity of a 5-year-old.

After my friends and I made dozens of calls, I finally learned about a first-episode psychosis program in Chicago. I called at 7:30 at night: I didn’t think anyone would be there. But the clinical director herself answered the phone. She was night-and-day different from anyone else I’d talked to so far. She was sweet and caring. I told her what was going on. She said she wanted me to come in as soon as possible, which was 8 a.m. the next morning.

The next morning I met with her and went through in-depth assessment. She was a specialist in early psychosis with all this experience working with young adults. She was not at all alarmed by me — or by my experiences. When I reported the same experiences to friends and other clinicians, they looked at me with horror. She didn’t ask the same heavy-handed questions I’d been getting.

MP: What kinds of symptoms were you experiencing?

NJ: Early psychosis symptoms can be very different from full-on psychosis symptoms. They are a lot subtler. I would feel certain stuff, like my hands were blending into the arms of a chair, or the ground was no longer solid. My thoughts were very confusing and jumbled. I had quasi-auditory hallucinations, but not stereotypical delusions or hallucinations. The other health-care folks kept asking me, “Are you hearing voices?” It was subtle, so I couldn’t say yes. My world felt very off, but I couldn’t put my finger on why.

Mainstream clinicians with no training in early psychosis don’t know what’s going on in cases like mine. They are trained in recognizing symptoms of full-on psychosis. With symptoms like mine, which are actually common in early-onset, they don’t know what to think. They might say the symptoms are signs of depression. Or they might think a young person is on drugs.

MP: How common is it that a young person experiencing psychosis for the first time is misdiagnosed?

NJ: There is something called the Pathways to Care literature that has looked at the experiences of youth and young people en route to finally getting into psychological treatment. They show up at ERs and get turned away or they get admitted to an ER and then told that they have depression. They get misdiagnosed and turned away more often than you would believe.

MP: What is the average age when people first experience psychosis?

NJ: I was in my mid 20s when my symptoms started. There is a general misconception about the average age of onset of psychosis. Many people think it usually starts in the late teens to early 20s. But the best epidemiological studies find that the average age of onset for women is late 20s to early 30s. Average age of onset is a bit earlier in men. So I was actually on the earlier side. Because of this general misconception about age on onset, some early-intervention programs cut off services at age 21 or 22, which is shortsighted.

MP: Why is early intervention so important in cases of psychosis? If a young person makes it through their first psychotic experience, can’t they just put off treatment until they are older?

NJ: It’s important because all of this damage can be done early on that impacts a young person’s entire life trajectory. And it is important that the intervention a young person receives is high quality. A young person’s care team needs to jump in as soon as possible and make sure to control or contain any damage that their psychosis may have caused in school and at work or with family and friendships.

After experiencing a first episode, if a young person is treated appropriately, they may continue to experience symptoms, but that doesn’t mean they can’t be successful in school or work or get married or find a life partner. The most important piece is not symptom reduction but functional recovery. That means vocational and social recovery. But that kind of support is typically absent from people’s experiences in mainstream care. In my opinion, that is really the most critical piece: making sure that people have as much support as possible from a treatment team to help maintain those friendships, those relationships with family, work and school. That way you can help people keep working toward future goals.

MP: In your opinion, what is the gold standard for treatment of first-episode psychosis? 

NJ: The ideal situation is a coordinated team where all clinicians are talking to each other and everybody is on the same page. That way care is integrated and includes a strong focus on educational and employment support and peer support and efforts to explore the young person’s experiences on their own terms and meet them where they’re at. Then people can get on with their lives.

MP: What is the life trajectory for people who are not treated promptly after their first episode of psychosis?

NJ: It’s very disheartening. The literature on people with psychosis suggests that between 75 to 90 percent end up unemployed, with low rates of marriage and romantic partnership. Only 10 to 15 percent of adults with schizophrenia are in a romantic relationship. If you look at the literature you will find that early intervention programs are absolutely crucial. They make a huge difference.

MP: Lawmakers agree with you on this point. The Federal Mental Health Block Grant Program has set aside federal funds for states to establish first-episode psychosis programs. Are many new programs up and operating?

NJ: This is the first time that every state has been asked to develop an early intervention plan. Many states, including Minnesota, have already started planning and developing them, but they weren’t instantly able to roll out interventions. The Minnesota State Legislature also set aside supplemental funds for this purpose.  

MP: Once more first-episode psychosis programs are established, what’s the next step?

NJ: Early intervention is an important building block, but it is not the end. If we have more ambitious goals for young people with psychosis, we need to go above and beyond. We need to improve individual long-term intervention. We need to significantly increase the capacity within external institutions like community colleges and universities to effectively work with youth once they have been through these first-episode psychosis programs. We need to be able to help them get back to society. Right now the burden is entirely on the clinical team.

For most underrepresented groups, there is this whole array of evidence-based research about the importance of increasing graduation rates, yet for young people with serious mental illness, none of these programs exist. My argument is that these programs already exist for other underrepresented groups. We know they work. We should also be providing them for young people with serious mental illness.

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Focus on elite performance makes eating disorders common among young athletes

When he joined the track and cross country teams back in high school, Richy Yin felt like he’d discovered the secret to good health.

“When I was younger, say between elementary and middle high school, I was a chubbier person,” Yin recalled. “I got teased for it a little bit, but when I started running, I stopped eating fast food and started losing weight. Everybody complimented me about how good I was looking. My times started getting better and better. I thought I was getting stronger.”

For the first few years, Yin was getting faster and stronger, but as his obsession with maintaining “race weight” grew, so did his unhealthy relationship with food and exercise. By the time he graduated from high school and moved on to competitive running, Yin’s life was governed by a rigid set of rules. Being the best runner possible required sacrifice, he figured. His life shrank to the point where the only things he thought about were the number of miles he ran each day — and avoiding a long list of “unhealthy” foods.

“It got to the where I’d stop going out with friends because they like to go out to eat, and going out to eat scared the crap out of me,” said Yin, 25. “Running didn’t even feel good anymore. It just felt like an obsession. If I didn’t get a run in every day, it felt like I had a monster on my back.” 

As pressure to compete at elite levels increases among young athletes, a growing number are suffering from eating disorders spawned from their rigorous training regimens, said Heather Gallivan, PsyD LP, clinical director at Melrose Center, an eating disorder treatment program based in St. Louis Park.

“The pressure to perform is so great,” Gallivan said. “And young athletes don’t always receive guidance about healthy eating habits and body-image issues. Amongst coaches, there can be this perception that a leaner athlete is going to perform better, when that may not actually be true.”

The ‘wheels started falling off’

A couple of weeks ago, Melrose sponsored a panel discussion about the link between eating disorders and sports. Yin, a Melrose graduate, was one of the speakers. He talked about how his eating disorder crept up on him as his athletic training and competition intensified.

“After high school I started training for my first marathon,” Yin said. “I went online to research training methods. What I read was that the lighter you are the faster you’ll be. So I stopped eating certain foods. My meals were getting smaller and smaller. I didn’t know I had an eating disorder.”

When he immediately began training for and ran a second marathon without taking a break to recover from the first, the “wheels started falling off,” Yin said. After running through painful bouts of shin splints, he was eventually diagnosed with a stress fracture. Being forced to take time off to heal from his injury drove Yin nearly to distraction.

When a concerned friend suggested he get evaluated for an eating disorder at Melrose, Yin went, and eventually “went through the motions” of an outpatient program, but took many more months of food limitations, purging and extreme overexercise — plus a second trip to Melrose — for Yin to finally accept the fact that his behavior put his health at risk long term. Forced vomiting after meals had thrown his electrolyte levels dangerously off balance, and he began passing out.

“One night,” Yin recalled, “I went out to eat with friends. Instead of having fun or talking, I couldn’t think about anything else but what I ate. I came home and found myself hugging the toilet bowl. I thought, ‘What am I doing? What’s happening to my life?’ All I could do was think about was what I ate and when I was going to run off the calories. It was a rock-bottom moment.” 

Common, growing problem

Yin isn’t alone, Gallivan said. According to a study of 1,445 Division 1 athletes conducted by the National Collegiate Athletic Association (NCAA), eating disorders are increasingly common among young competitors.

“One in four female athletes and one in 10 male athletes are at higher risk for anorexia than the general population,” Gallivan said. “More than a third of female athletes reported attitudes consistent with and symptoms that placed them at a higher risk of developing eating disorders. Fifty-eight percent of females and 38 percent of male athletes were at risk for vomiting, laxative, or diuretic abuse.”

Heather Gallivan

Heather Gallivan

And as the pressure to perform at top levels spreads to even younger athletes, Gallivan said that programs like Melrose are treating younger and younger clients.

“We treated a 10-year-old. He was a hockey player. He stated cutting out pop because his coach told the team to drop junk from their diets. Then he started cutting out more and more food until his diet became dangerously unbalanced. He ended up losing a lot of weight, so much that he wasn’t able to play hockey.”

It used to be that athletic-related eating disorders tended to center on sports that focused on physical appearance or enforced weight limits, like dance, gymnastics or wrestling, Gallivan said. But mounting performance pressure has caused the disorders to spread to other sports like hockey, basketball and track.

“There might not be as big a focus on weight in those sports, but there is a focus on performing at a high level,” she said. “And that might make an athlete do extreme things to their body. They might be a hockey player who thinks, ‘If I am smaller, maybe I’ll be a faster skater.’ ”

Competition, drive breeds disordered behavior

Because athletes like Yin are speaking out about their struggles with disordered eating, more and more coaches are paying attention to the their athletes’ relationship with food, Gallivan said. 

“I think there is growing awareness among athletic organizations, an encouragement for coaches to look at what is happening with their athletes, not just with eating disorders, but with their mental health in general,” she said. “It’s important to touch on healthy eating behaviors, but a coach needs to be careful not to take that too far.”

Taking things too far is an important distinction, Gallivan said, because competitive athletes tend to be particularly susceptible to messages that may encourage eating disorders.

“A lot of people who are successful at sports have personality traits similar to people with eating disorders,” she said.

Richy Yin, Daniel Ly and Josh Coval

Courtesy of Richy Yin
Left to right: Richy Yin, Daniel Ly and Josh Coval completed the Surf the Murph 50K race in 2015 at Murphy-Hanrehan Park in Savage.

Those personality traits include “an intense drive, perfectionism, a personality on the anxious end of the spectrum. In life, those traits can help you or they can hurt you, because you can take things too far. With the shift to kids younger and younger performing at high levels, their brains aren’t ready to process the information they are getting from coaches or parents about being healthy, and that can backfire and turn into an eating disorder.” 

Gallivan said that one key to avoiding eating disordered behavior among athletes is for coaches to “know their players as people, and treat them as people. Coaches should be on the lookout for changes in athlete behavior. Competitors need to know that not every day is going to be a good day and that’s OK.”

Focused on balance

Yin still runs almost every day, but he tries to be more balanced in his workouts and keep his over-exercising impulses in check.

That’s in line with the Melrose philosophy, Gallivan said:  “It’s not realistic to tell an athlete that they have to stop exercising. Our goal is through education to broaden their horizons and work with them on a plan of how to get their exercise in better balance so it doesn’t take over their life.”

Yin said that two years after completing eating-disorder treatment, he is now able to run for the sheer pleasure of the physical activity — not for the calories it will burn. As assistant track and cross country coach at Bloomington Kennedy High School, he tells his runners about his own struggles, and emphasizes the importance of balance and health in overall athletic performance.

“The head coach and I, our philosophy is, ‘You should enjoy doing what you’re doing,’ ” Yin said.  “After every hard workout, I say, ‘Make sure to eat something. You need the energy.’ ”

Energy is important to Yin because now that he has his eating disorder under control, he plans to stay healthy for the long haul.

“I want to be able to run for the next 50 years, so I know that what I do right now is going to matter in the future,” he said. “What I do to my body matters long term. I love running: I’m still racing, but it’s not taking over my life anymore.”

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Emily Johnson Piper: ‘I have a personal connection with people caring for the acutely mentally ill’

Human Services Commissioner Emily Johnson Piper

Human Services Commissioner Emily
Johnson Piper

In her role as commissioner of the Minnesota Department of Human Services, Lucinda Jesson was considered by state mental health activists to be a champion for the rights of Minnesotans facing mental illness. During her time in the position, the state made historic gains in funding for mental health programs. So when Jesson stepped down late last year and Gov. Mark Dayton picked his former general counsel, Emily Johnson Piper, as her replacement, the question on many people’s minds was: Would Piper continue in the same direction as her predecessor?

Piper, who worked in private law practice before entering state government in 2011 as general counsel for the Minnesota Department of Commerce, grew up in North Minneapolis. Her mother worked a nurse in number of Twin Cities mental health programs, and gave her a strong sense of the key role that mental health workers play in the overall health of the state.

Just three months on the job, Piper is excited about her new responsibilities and ready to share her plans for the future. The scope of her new role is expansive, but she feels confident that she will be able to move forward in advancing mental health supports for all Minnesotans.

Earlier this week I met Piper in her St. Paul office. We talked about the challenges of her new role, plans for the future, and about accomplishments she’s made in during her first weeks.

MinnPost: What led you to this role? What made it appeal to you?

Emily Johnson Piper: Through my whole life, I’ve been part a family that’s committed to public service, both personally and professionally. My grandma was the first woman to be president of the Minneapolis City Council. My mom serves on the Minneapolis City Council. I’ve had family members on the Hennepin County board and in the state Legislature, and so I grew up in a family that was very committed to serving our community. When I started in state service in 2011, I felt called to serve the state and the Dayton administration.

I’ve looked at every position that I’ve held during the entire time I’ve been in state service through this lens: How can I best serve the people of Minnesota? This job is so important. There is no other position in the governor’s Cabinet that can touch more people’s lives and serve the people of Minnesota, particularly the most vulnerable.

MP: Your mom worked as a mental health nurse. When you were growing up, did she tell you about her work?

EP: When I first started as commissioner, one of the first things I did was to go out to Anoka Metro Regional Treatment Center. I knew there were real challenges in that hospital, and that we were having really significant issues with patient care and employee safety there.

One of the reasons why I felt like I needed to go talk to the staff at Anoka was because of my mom. I remember as a kid her coming home and talking about being in a really physical environment with people dealing with mental health issues. She worked nights and weekends and every Christmas and every holiday through my childhood. So I have a personal connection with people caring for the acutely mentally ill in crisis. I felt a very strong connection to the people that work at Anoka in a large part because of my mother.  

MP: Your predecessor had a clear emphasis on working to improve mental health in Minnesota. Mental health advocates like Sue Abderholden of NAMI   say her support helped to make many advances for mentally ill Minnesotans. Are you going to continue to move in that direction?

EP: Absolutely. I feel like Commissioner Jesson’s leadership was instrumental in the gains that we’ve made in mental health and community-based mental health. My most immediate challenge is shoring up our safety-net services, many of them inpatient for some of the most acutely mentally ill in crisis. My most immediate focus and highest priority in the next several months will be to address some of the real crisis issues at Anoka and at St. Peter Security Hospital and at other facilities we operate.

MP: Do you feel like you still have the same strong bipartisan legislative support for advancing mental health issues that existed last session?

EP: Part of the challenge is always going to be that because this is not a budget year, there is significant pressure and varying priorities. But I’m hopeful that we have the legislative support that we need to advance our initiatives. The governor has released his bonding proposal and there’s $70 million there for Security Hospital and over $2 million for Anoka Metro Regional Treatment Center. Those are really significant needs and they’re very important improvements that we feel strongly we need to make to our facilities in order to provide the best care possible to patients and the safest environment to staff. 

MP: Tell me a more about what you see is needed at places like Security Hospital. 

EP: When I was general counsel to the governor, we were brought issues around workplace safety and challenges in caring for the patient population. One of the things that we — the governor’s chief of staff, me as general counsel and our policy adviser for health and human services — did was work with the staff from all different areas to establish a mediated, facilitated solution-finding process to address the challenges at Security Hospital.

That started in earnest in early September. Since that time, the hospital has formed five committees that are making recommendations to an oversight committee around what they think needs to change about their work environment and pathways to change for their work environment and their patient environment. It’s a consensus-based process. They are presenting recommendations to me and to the governor and to the Legislature on how they think solutions to those problems can be advanced.

One area where they have been very focused for the immediate future is around appropriate staffing for the patient population. They have made recommendations around increasing staffing in particular areas and trying to align Security Hospital’s staffing ratios with other like facilities across the country.

MP: So when you say, “appropriate” staffing, it’s really about getting the right number of staff?

EP: It’s not just the right number of staff. It’s the right kind. Do we have enough security counselors? Do we have enough recreational therapists that take people out to get exercise or do programming with them? Do they have enough treatment time? Do we have enough facilities-management people, based on the needs of that facility and the desire to provide the best care possible for patients?

MP: This ties into the larger mental health work force shortage in the state. That’s a big issue.

EP: There is a work force shortage across all of health care. We’re facing pressures at DHS — not only as a direct-care provider but also because we work so closely with community-based providers and nursing home facilities. We are hearing from all angles that there is a health-care work force shortage. That being said, I feel very strongly that we needed to staff up at places like Anoka. We had a job fair last Tuesday. We had over 50 vacancies and we had over 300 people attend the job fair. So there are positive signs that when you promote job vacancies and you incent people through hiring bonuses, through loan forgiveness, people will come work for you.

MP: Wages for mental health workers tend to be low, so that may be part of the worker shortage. 

EP: In places like Anoka, incentives historically have declined relative to the private sector. So we’re trying to find solutions within the collective bargaining contracts that we have now to try to alleviate some of those issues but also with an eye and awareness toward the issues as we go into future contract years.

MP: One concern that’s central for many people is the shortage of beds in the state for adolescents in mental health crisis. Do have plans to try to address that issue?

EP: We have some funding that’s going to be coming through the pipeline from last session. We also have issues with hospital-level care that young people need. The challenge is that with any really difficult challenge there aren’t any easy solutions and usually that involves using several tools in the toolbox. I was out in Willmar two weeks ago at our Child and Adolescent Behavioral Health Services trying to understand more about what the needs what the solutions are in the pipeline. I want to see if this will be adequate, or if we in fact need to add to the options for young people suffering from mental illness.

MP: How do you get a clear picture of the state of mental health in Minnesota? It is such a huge job with so many moving pieces.

EP: Since I became commissioner, I’ve worked with the Minnesota Hospital Association, with the Minnesota Medical Association, with NAMI and other advocacy groups to understand from them where they see the landscape because they really are the people on the front lines.

But I also think it’s really important to go to places and see how things are working there. I’ve talked to nurses and doctors. I’m also public guardian to about 2,000 people in the state of Minnesota. I’ve gone to visit the people that I’m guardian for to understand directly from them, to talk to them and look at where they live and how things are working for them. I want to see how the system’s actually working.

There’s a lot of humanity in human services. I feel very strongly that it’s incumbent upon me to see firsthand how the system’s working for the people in it and the people working in it. That is the only way to understand and make the best-informed decisions.

MP: So you are actually meeting face-to-face with patients?

EP: Yes. I’ve done a fair amount and I plan on continuing in that trajectory, going in and meeting with people in our facilities and in other not-state-run facilities and seeing from them how things are working. I was invited recently to go and shadow an emergency room and see the mental health patients coming in and understand what the challenges are from a front-line triage position how things are working and how they aren’t.

MP: Suicide rates are climbing in Minnesota. Is there anything that your department is doing or thinking about to deal with suicide in the state?

EP: One of the challenges for us as a safety-net service provider is to make sure that people have access to crisis services. Until we can get crisis services to the people who need them, we do have a greater risk of having higher adverse outcomes for our patients like suicide. So that’s part of what we’re trying to do in the direct care and treatment side. We’re trying to provide access to our crisis facilities for people who really, really need it.

MP: Rates of opioid addiction continue to climb in the state. What is your plan for addressing this issue?

EP: In the short term, one of the challenges I face is making sure that we are thoughtful and strategic about who’s at the table trying to come up with the solutions. We have state leadership that’s very engaged in substance-abuse strategy. But we want to make sure that all of the stakeholders and all of the people that can impact the situation are involved in coming up with a solution.

We have to ask ourselves: Are we engaging the Native American bands in the state? Are we engaging in the best possible way with the U.S. Attorney’s Office? With the courts? With county attorneys? With public defenders? Human Services doesn’t have all the answers, but we have a lot of levers that we can pull to move the dial in a thoughtful way. I think we’re trying, but I want to make sure we are doing it as strategically and thoughtfully and comprehensively as we can.

MP: The idea of working with the Native American bands is really important. Rates of opioid addiction are high in that population. Have your conversations been fruitful? 

EP: When I was at the governor’s office, I worked on a lot on tribal issues and this was a chief concern amongst many of the Native American bands in the state. They were concerned about opioid addiction and drugs coming in and off of their land and also the disparate impact that they are seeing in their people. It is a struggle, and my impression has always been that the tribal leadership from the bands that I’ve engaged with has been very interested in working together and partnering.

MP: Are there other mental health or addiction initiatives that you are particularly excited about?

EP: I’m really excited about the progress we’ve seen. I’ve been commissioner for three months. I’m excited about the progress we’ve made in the short term in direct care and treatment. I’m excited about the advancements we’ve made at Anoka Hospital in reducing the amount of mandated overtime that staff is being required to work. We are also proactively addressing patient care issues, both internally through better training and support to our employees but also externally, through partnership with the federal government to enter into a systems improvement agreement. That is going to provide us some external resources and external support to make sure we are providing the best treatment possible to our patients.

What else am I excited about? I’m excited about the recommendations of the Healthcare Financing Taskforce around increasing opportunities for people to access MinnesotaCare up to 275 percent of the federal poverty line. And lots of other recommendations: There are over 30 recommendations coming out of that task force. So I see that as very positive.

I was very excited about the job fair at Anoka because the challenges with hiring are so significant. It was exciting to see such a great turnout and exciting to fill a lot of the vacant positions, which were causing some of the mandated overtime and other challenges there.

MP: Anything else on the horizon?

EP: The governor’s bonding proposal is so focused: I believe DHS received more recommendations for funding for our facilities than any other state agency. And then he also recommended $20 million for early childhood facilities. I went to the YWCA a couple of weeks ago and saw the great advancements that they have made in their early childhood programs, thanks to resources from the state. Increasing funding for some of these really great early childhood learning centers that serve underprivileged kids is just really exciting for everyone. It’s a great opportunity that I hope the Legislature capitalizes on. 

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Mark Thomas: Research may identify relapse trigger in human brain

Some addicted people say that quitting is the easy part. What’s hard is saying sober. Relapse to drug use is common — the majority of people who have completed recovery programs eventually slide back to substance abuse one or more times. A number of factors can trigger relapse, including social cues, access to drugs or life stress.

A group of researchers at the University of Minnesota Medical School’s Department of Neuroscience has identified a potential target for preventing morphine relapse in mice. By pinpointing and manipulating this target in the brain using a method called optogenetics, researchers have been able to repress relapse behaviors in mice, blocking continued morphine use.

They hope that these findings will bring them closer to a treatment that will block relapse in humans.

The group’s research was published in January in the Proceedings of the National Academy of Sciences. The senior author was Mark Thomas, Ph.D., associate professor in the departments of neuroscience and psychology.

Thomas, a Minnesota native, has been at the University of Minnesota since 2003. His longtime interest in how the brain works led him to this field. When we met for coffee last week, he took time to explain his research and its potential application in human addiction.

MinnPost: How did you enter into this particular area of research?

Mark Thomas: I got interested in neuroscience because I am very interested in how experience shapes the brain. Initially I was interested in normal learning and how information is stored in the brain in normal, everyday memory. I was working on that as a graduate student, but it is a field that is really saturated with talent.

So I started getting interested in a very small literature that focuses on addiction as kind of a maladaptive form of learning. I began to get interested in the question of whether some of the same neural processes involved in normal learning could get corrupted and play a part in how drug experience shapes the brain in a way that leads to compulsive drug seeking. There was very little hard research on it. That seemed like a way to apply the experimental approaches I’d been using in this other field to a new field.

MP: Have you always used animals in your research?

MT: Yes. My initial interest was how the brain stores information. In order to study that, you have to land on a process where you can study individual brain cells and how the connections to other brain cells are changing, which is something that you can only do in a reduced preparation of some kind. So a lot of what we do now has to do with treating animals — mice — with drugs, and then taking the brain out, making a thin section through the brain and keeping that tissue alive for eight to 10 hours so we can study it. Then we can probe the function of neural pathways by stimulating and recording the neural responses.

MP: Why would you want to find that out? 

MT: I think there are traces of all life experiences that are stored in the brain. And so I wonder, “What is the signature of each experience?” If we knew more about how to track that in cases like addiction, we might be able to disrupt those signals so that they don’t control a person’s behavior.

MP: So you’d disrupt those signals through some kind of pharmacological means?

MT: This is a very good question. I think it’s most likely to be a combination of pharmacology and neural stimulation that turns out to be the useful anecdote to addiction-related brain plasticity. So it’s not likely to be a pill alone that does the trick.

MP: You’re searching for a treatment method?

MT: I have a long-term vision of the work that we’re doing. Right now we’ve really focused in on relapse. And that’s where it seems like the work that we’re doing in the lab could really help people in the most direct way. Because what we’re finding is that with the mice that are treated for chronic drugs, whether it’s morphine or other opioids or cocaine or amphetamines, their brains continue to respond differently to stimuli after chronic drug use, even in abstinence.

When I say “stimuli,” I mean drug exposure during abstinence or stress during abstinence or even exposure to the context or cues that were paired with the drug in the past. Those three different categories of stimuli create a brain change in the chronic-drug mice that doesn’t happen in drug-naive mice. If we could pinpoint and control the exact area of that change, we could prevent it from taking control of behavior. And that could really make a difference for people. 

So we’ve got a laser focus on the relapse part now.

MP: Can you explain how you recreate drug relapse in a mouse? Mice aren’t people, obviously, and I’m trying to imagine how a mouse would relapse to drug use.

MT: It’s amazing how the behavioral patterns of mice mirror that of people.

MP: So you’d be giving a mouse a regular does of morphine and then suddenly you cut off the morphine. And the mouse’s reaction is, “I’ll do anything for the morphine.”

MT: Initially, the mice will work for the morphine, but when they realize they can’t get it, they sort of give up. And then it is pretty difficult to tell the difference between a drug-treated mouse and a regular mouse.

The drug-treated mice may be miserable initially, but after they are all hanging out together for a time, eventually you can’t tell the difference unless you probe them with a stimulus that was paired with the drug in the past or the drug itself or stress of some sort.

Then the drug-treated mice respond differently. If given the opportunity under of any of those trigger conditions they’ll immediately go back to looking for the drug again. So that’s the relapse in mice. That’s why we call it relapse because it really does create what we interpret as craving — hard to know for certain — but under stress, the drug-treated mice will clearly go back to seeking the drug again and the drug-naive mice won’t.

MP: How is this research applicable to human addiction?

MT: We think there is a trigger in the brain that gets switched by chronic drug use. So far what we’ve been doing in this study is changing brain activity just prior to delivering a drug again after abstinence. That has blocked the relapse response in mice.

With people, presumably, you’re not usually going to know whether you are about to be stressed in life, which could lead to a susceptible period for relapse. So we have to think of something that happens just after that. The stress/relapse trigger gets flipped and then what? Then perhaps an addicted person realizes that they’re in a vulnerable state and they need some help. If they are in AA, they call their sponsor and get them to talk them down.

We feel like if we were able to identify the exact location of the brain change then we would be able to return the brain to an abstinence-like state.

But your question is, “How do we do that?”

MP: Right.

MT: So that’s what we’re now trying to figure out. By knowing more about what the relapse brain change is that’s triggered by stress in as specific terms as we can find out, we will have a better shot at trying to flip the switch back over to the “good” side. And how do we do that? We’re hoping to use neural stimulation and pharmacology in combination. But we don’t yet know the magic combination.

MP: There are a growing number of physicians who are interested in using pharmacological treatments for addiction.

MT: Yes. But I think the 12-step approach has its place. That, and other behavioral treatments for addiction will always play an important role. Pharmacology alone is not likely to correct everything with addiction. But it can help. No matter what we find, support networks are always going to be important for fighting addiction.

MP: Because triggers are always going to exist, and those triggers are often caused by human interaction.

MT:  Absolutely. What seems to me to be the most important or most likely opportunity that we have is this: There’s an addict who’s decided to quit. They’ve gone through treatment. They’re now clean. Those steps are always going to have to happen that way. We won’t prevent people from getting addicted in the first place. We won’t probably reverse the brain plasticity completely to the extent where they will never even have any cravings for a substance. It is probably going to be a lifelong issue.

Some people go through treatment and change their lives in a way where triggers just can’t touch them. But most people probably won’t be like that. The triggers will always be there so they can try to avoid the cues, the context they were in. But don’t get stressed? That’d be pretty hard. So having something that would be a tool to prop people up who get triggered before they go way back down and start compulsively using again, that’s where we’re headed.

MP: What about methadone? Doesn’t a drug like that work to keep people from compulsive use?

MT: From our point of view it’s not a very satisfying form of treatment, because it’s just sort of putting somebody in a holding pattern. You can taper down from addiction, which helps at that initial stage for sure. But people who taper off have the same relapse rates as those who quit cold turkey.

MP: So it’s not the greatest solution?

MT: It’s not the greatest solution. And I hear that it’s pretty common to use methadone and supplement that with other opioids.

MP: But won’t the combo you’re talking about still be a lifelong form of maintenance?  

MP: My hope is that this treatment would be time-limited. It would be a one-time deal that you would use when you’ve been triggered and you’re in a susceptible period for relapse. You could go into a clinic. At this point this is fantasy. When we’re doing research in the lab about how this would help people this is what we’re imagining.

MP: So you haven’t invented a prototype device that could deliver the electric stimulation?

MT: Not yet. Right now our study subjects are very small and they run around a lot. But the thing that makes us feel like this isn’t complete and utter fantasy is that kind of stimulation is a big deal in neuroscience these days, especially at the University of Minnesota. There is an initiative that’s funded by the state called the MnDrive Initiative on Brain Conditions. It is fostering private-public partnerships in neural stimulation. There’s a big focus on that.

I think it’s exciting to learn about the brain. I’m happy to have the opportunity to be doing that.

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‘Everything worked better when she was there’: Doulas help addicted moms build healthy families

Ashley loves her three children. She works hard to be a good mother, but because she is a methadone user, when she goes to the doctor or deals with other medical professionals, she’s hyperaware of being judged.

Take the midwife Ashley saw some months ago, before her youngest son was born in December.

“I felt judged by her and I didn’t like that,” said Ashley, who was addicted to opioid-based pain medication and briefly used heroin but now controls her addictions with methadone. (Ashley asked that we not use her last name in this article.) “The midwife didn’t know anything about what was going on with me. She didn’t know who I am or any of the good things I’m doing with my life. She just knew I was on methadone, and she seemed like she was against me because of that.”

It’s understandable that a medical professional might look askance at a pregnant woman struggling with opiate addiction. The highly addictive drug is toxic — not only to the mother, but also the fetus. Mothers who use opiates while pregnant face an increased risk of miscarriage and stillbirth. A large percentage of babies born to addicted mothers suffer physical and intellectual disabilities and dangerously low birthweight. Many are born addicted and experience painful neonatal abstinence syndrome (NAS), or withdrawal, during their first days and weeks of life.

Methadone, while an imperfect solution (some percentage of babies born to mothers on the drug still experience NAS), carries fewer risks for both baby and mother. But methadone-using mothers like Ashley often face discrimination when they interact with health-care workers. This means that many avoid getting the care that they and their babies need. And when it comes time to give birth, these moms sometimes report feeling frightened and powerless, leading to worse outcomes for both mother and child.

Joining forces

A unique partnership between Specialized Treatment Services (STS), a Twin Cities-based methadone clinic, and Everyday Miracles, a Minneapolis nonprofit dedicated to reducing health-care disparities for low-income mothers, aims to address this issue by supporting addicted mothers like Ashley through their pregnancies and births. Mothers who get the nonjudgmental support they need are less likely to use drugs and more likely to take care of themselves and their unborn children, resulting in better outcomes for all.

Everyday Miracles’ staff of doulas, or specially trained birth assistants and advocates, is a key element in this partnership. Doulas step in and help addicted mothers navigate the medical system, and guide them and their babies to the births they desire. 

“Whether it was at the doctor’s office or the hospital or seeing any type of care provider, our moms would come back with stories of how the second the provider found out they were on methadone they were treated poorly,” said Melissa Prudhomme, program director at STS’ location on Minneapolis’ Central Avenue. “They were dismissed, treated like they didn’t know what they were talking about or were just ‘less than.’ There is a lot of stigma around heroin use and methadone. And when a woman is pregnant at the same time, we were seeing a lot of people not being so nice to them.” 

Teaming with Everyday Miracles and adding doulas to the birth team helped get STS’ addicted moms heard, Prudhomme said: “This partnership gives them a voice, and that’s what they need.”

Casts of pregnant bellies decorate the walls

MinnPost photo by Andy Steiner
Casts of pregnant bellies decorate the walls of the
Minneapolis office of Everyday Miracles, a support program
for low-income women.

Everyday Miracles is focused on helping women who usually feel uneasy in their interactions with the medical system feel more confident and supported, said Melissa Gutierrez Nelson, Everyday Miracles’ marketing and program coordinator.  The program’s clients are all low-income women on Medicaid. Many are women of color who are single mothers.

“A lot of our moms say that they feel intimidated by hospital and clinic staff,” Nelson said. “This is the world we live in. Because she carries a feeling of authority and expertise, a doula is going to change the care that the client might get in a hospital or a clinic.”

That’s especially the case for moms on methadone, said doula Heidi Akpaette, who attended two of Ashley’s three births.  

“What I discovered as a doula for moms on methadone is the importance of the long-term relationship, of building that trust and being the one that is safe and supportive,” Akpaette said. “At the hospital, these moms feel condemned and zeroed out when staff finds out they are on methadone. It’s my job to support them while they are going through their births so they can have the same experience as anybody else.” 

Because Ashley had already established a strong relationship with Akpaette, she decided to let her know about her experience with the midwife.

“I told Heidi that my appointment with the midwife felt really awkward once she knew I was on methadone,” Ashley said. “So Heidi went with me to my next appointment. Everything worked better when she was there.” 

Akpaette said that she’s happy to be able to help ease the pregnancy and birth experience for her clients.  She thinks it’s all about relationship building: She establishes trust with clients like Ashley, and garners respect from medical professionals.

“I get to be the bridge between the mother and the health-care team,” Akpaette said. “I think that’s important for anybody, but I think it’s really important when you’re in a situation when you are a little more vulnerable — especially when you are in a situation where people are a little more predisposed to judge you without knowing you.”

Power source

Located in a large, sunny suite in the Waterbury Building in Northeast Minneapolis, Everyday Miracles offers cozy couches, a kitchen, a donation closet full of free baby supplies, a treatment room for a chiropractor, and a space for prenatal yoga classes.  Large, colorfully adorned casts of pregnant bellies decorate the wall.

When the partnership with STS was launched, all Everyday Miracles doulas were given the option to work with methadone-using moms. Interested doulas, independent contractors whose fees are paid through Medicare, were trained in the basics of addiction medicine and drug counseling by STS staff. Akpaette signed up.

“It’s been nice for doulas to have the option of working the methadone counselors to provide holistic care,” she said. “We’re not really trained in drug counseling, but we can get insights from STS staff and we can be the liaison for the hospital and health-care portion of the pregnancy.”

Akpaette said that the number of moms on methadone that she has worked with so far has been, “minimal, to be honest. I haven’t had tons and tons of clients in this situation, but enough to walk that journey.”

The journey Akpaette refers to is risky, Nelson said. Pregnant women on methadone are carefully monitored, with regular drug tests to confirm that they are staying sober. Women who keep abusing drugs during their pregnancies are at high risk of losing their children to child protection.   

“There are a lot of unknowns about what is going to happen with methadone and pregnancy,” Akpaette said. “They don’t know if the baby will end up in the NICU. They don’t know who is going to be at their birth and why. I want to help a mom in that situation be empowered to ask important questions so they can go into their birth having a clear understanding of how it is going to be different because of the methadone. Knowing that helps them feel more empowered.”

Future focused

Though she does lean on Akkpatee for support, Ashley is usually quite self-assured and confident, Nelson said.

“When she feels comfortable, Ashley is pretty well spoken and direct. Other clients, even with the presence of a doula, wouldn’t feel comfortable speaking out for themselves, but Ashley usually does.”

In Everyday Miracles, Ashley has found a place where she feels comfortable, a place that is consistent, warm and welcoming. When she brings her youngest child in for a visit, staffers coo and beam. Akpaette scoops up the infant and cuddles him, while he stares at her with calm, unblinking eyes.

“What I love about Ashley is she’s just a great example of the way Everyday Miracles works to create community,” Nelson said. “Heidi’s connection to her has kept her connected to us. These days, she’s a client who just pops in to say hello, who brings her baby. When she’s here, she does the dishes just to help out. She just is a lovely soul and we love her. I feel like this community is an extension of the support that Heidi’s been able to give her.”

Ashley needs all the support she can get: Addiction runs in her family. “I got an auntie that passed away because of it,” she said. “My mom had just been on the clinic. That’s how I started there.” She said her own addiction started with pain medication prescribed after her older brother died in a car accident. “It was really bad,” Ashley said, tearing up.  “That’s how I started. It was just all bad.”

Ashley said she knows it will be tough, but for the sake of her children, she is committed to staying off opioids for good. With the support of Everyday Miracles and STS, she thinks she has a good shot.

“The program director at STS was my counselor at the beginning,” she said. “I’ve known her for almost four years now. I told her if I ever feel like I would want to use again, I would go to them first for the support. I don’t feel like I need to use right now. If I did, I would just go to talk to her and she would talk me out of it. That ain’t what I want to do. I just keep myself around people who are more supportive and happy. That way I’ll stay clean.”

Prudhomme feels cautiously optimistic about the future for Ashley — and her children.  With a strong support network like the one that exists at Everyday Miracles, she may be able to find a life beyond addiction that she can build for herself.

“The women we send over to Everyday Miracles come back smiling, confident and feeling good about themselves,” Prudhomme said. “Nobody wants to say, ‘I’m pregnant and I have drug addiction.’ There is a lot of shame. We might have someone who doesn’t smile, who just appears to be very shy and rough around the edges. They go into Everyday Miracles, and they get nonjudgmental support from a group of women who just care about mom and baby. They come back a whole different person, one that can see a different life for themselves and their baby. It is pretty amazing to see.” 

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Attorneys report high rates of problem drinking, mental illness

The image of the wizened attorney, tie loosened and coat rumpled, slumped at the bar with cocktail (or two) in hand after a day in court has long been a trope of fiction. A new, large-scale study of the behavioral health of practicing attorneys conducted by the American Bar Association (ABA) and Hazelden Betty Ford Foundation found that stereotypes like these hold more than a kernel of truth.

The national study, which surveyed some 15,000 licensed attorneys from 19 states, found that 21 percent qualify as problem drinkers, 28 percent struggle with some level of depression and 19 percent demonstrate symptoms of anxiety. The study, co-authored by Patrick Krill, director of the Legal Professionals Program at Hazelden Betty Ford Foundation and Linda Albert, representative of the ABA Commission on Lawyer Assistance Programs, was published this month in the Journal of Addiction Medicine.

Krill said that the study, the first-ever national survey of attorneys’ behavioral health, points to some serious, deeply rooted problems in the legal profession and should be considered a call to action.

“These findings are worrisome for anyone who’s used an attorney or will hire an attorney in the future,” he said. “The profession has an obligation to take better care of its members to they can take better care of the public. It is common sense. You can’t have someone who is a problem drinker and is not in full control of his or her mental abilities in charge of handling key life issues.”

Last week, I spoke with Krill about his work, the study and the significance of its findings for the legal profession.

MinnPost: You run a treatment program at Hazelden Betty Ford that’s focused specifically on legal professionals. Why is there a need for that type of program?

Patrick Krill: This program is needed for two reasons. The first reason is that there is a much higher incidence of addiction in the legal profession than there is in the general population. This is a population that struggles with addiction at a significant level. The second reason this program is important is because attorneys have specific, unique challenges that they face in terms of recovery. Our program addresses that.

MP: How is legal professional program different from other recovery programs at Hazelden?

PK: The goal of this program is to help somebody who is going back to the practice of law be able to return to that environment and stay sober, which is not an easy thing to do, given that between one in five and one in three attorneys has an alcohol-use disorder. So when an attorney gets sober, he or she is going right back into an environment that can be incompatible to sobriety.

MP: How’s that?

Patrick Krill

Hazelden Betty Ford Foundation
Patrick Krill

PK: The mindset of attorneys tends to be one that is not consistent with recovery. Attorneys tend to be intellectual and live in their heads. They are not people who have an easy time admitting to vulnerability, taking advice or acknowledging that they are struggling with any type of problem. Successful recovery requires a willingness to be vulnerable. It is all about asking for help and saying, “I don’t have control over this addiction. I need help. Can you help me?”

But vulnerability like that is incompatible with the legal mindset. A lot of the key skills that attorneys are taught  — to analyze things, to question things, to be skeptical and rational — aren’t always part of a mindset that is consistent with recovery. When you go into a recovery program, you are asking a person to take a leap of faith. A person in recovery is told, “If you follow this program, you will get and stay sober,” and lawyers want to know, “Where’s the proof?” and, “What’s that theory based on? Is it grounded in any kind of evidence?” Lawyers are just are a more challenging group to bring around to the notion of recovery and how it is supposed to work.

MP: Then, once an attorney makes it through an addiction treatment program, he or she still has to go back to their law firm, where the same behaviors are still happening. Is the post-recovery experience particularly hard for attorneys? 

PK: Post treatment, staying sober is tough for anyone But it’s particularly tough for attorneys. It is an incredibly stressful profession, and it is also a professional environment where help-seeking is discouraged, where self-care is discouraged and dysfunctional coping mechanisms are normalized.  If you go back into a legal environment and you are in recovery and actually take time for self-care like you have been taught to do, you are going to be the odd one out.

MP: Can you tell me more about your survey?

PK: It was a huge undertaking. We partnered with the ABA to conduct a nationwide study of the current rates of substance use, depression and anxiety among licensed attorneys currently employed in the legal profession.

MP: Why did you feel it was important to conduct such a survey?

PK: The information just wasn’t out there. The previously available data was really limited. It was so limited that in my mind it was useless. It was completed in 1990, and it was based on a small sample of attorneys in one state on the West Coast. That one small survey was all the legal profession had to gauge the behavioral health of its members.

MP: How did you form your partnership with the ABA?

PK: I reached out to them several years ago. We had several conversations, they had lots of questions, and they eventually came on board. Then we began a partnership. We designed the survey instruments and, with the help of the ABA, we got 19 state bar associations to come on board to agree to send the study out to their members. This was a big project with a lot of moving pieces.

MP: How large was your survey?

PK: Approximately 15,000 lawyers took part in the study. In the end, we narrowed it down from there because we made the decision that the inclusion criteria needed to be that participants were be currently employed in the legal profession. Once we made that decision, we had to throw out 1,500 or so responses from people who were licensed attorneys but not currently employed in the legal profession. In the end, we had about we 13,000 responses. I wanted this survey to be a really persuasive study.

MP: Why had it been so long since anyone conducted a survey on behavioral health issues in the legal profession?

PK: I think there’s a general reluctance in the profession about confronting these issues in a meaningful and productive way. The fact that there hadn’t been a study on these issues in 25 years is telling. If you compare it to the medical profession, there have been a number of these types of studies done over the years, but the legal profession had just one small study and it was 25 years old. I don’t think that this is an accident. I think it is evidence of larger cultural issues in the profession.

MP: What findings stood out for you?

PK: The highlight of the research is simply the fact that the level of behavioral health issues among members of the legal profession is significant. These numbers are alarming and should be worrisome to anybody who ever needs to use the services of an attorney or has ever used the services of an attorney.

Our findings are compelling: Attorneys are struggling with mental health issues and substance abuse. I think that the profession needs to have a concerted response to these issues. The rate of problem drinking among attorneys in our survey is between 21 and 36 percent. Those numbers are completely unacceptable — that is nearly three times the rate of problem drinking in the general population. At a minimum, the levels of problem drinking should be in the same neighborhood as the general population and not multiplies of it.

The same goes for the level of depression and anxiety. These rates are also multiples higher than the rates in the general population.

MP: What should these numbers tell us?

PK: In my view, this really is a call to action. I think it is imperative that the profession responds. And the response should be broad. This isn’t something that just bar associations or lawyers’ assistance programs should be responsible for tackling: Law schools, lawyers and law firms also need to step up and help make change.

MP: What do you hope will be the long-term impact of your research?

PK: We have a lot riding on this. I don’t think we can let the numbers speak for themselves. This is an issue that needs to be addressed. We’ve brought it out into the spotlight with the publication of this study. There has to be a lot of efforts to keep it there.

MP: Though yours is only the second survey about attorneys’ behavioral health, many similar studies have been done in the medical profession. Why’s that?

PK: I think it’s due to a general public misconception about the role that attorneys play in our lives. People see these issues as more urgent or immediate with physicians than they are with attorneys.

MP: People might say that physicians hold their lives in their hands.

PK: I’d say this issue is just as significant in the legal profession. If an attorney is handling your very important legal matters, writing your will, keeping you out of jail, handling your family’s business, your life savings, these things are all central to your life.

The bottom line is that attorneys, like physicians, are also tasked with significant, important responsibilities. You would not like to work with an attorney who misses a court date or makes an important mistake in your legal documents as a result of their addiction or mental health problem. I would argue that the work attorneys do can also be a life-and-death matter.

MP: In some ways, your study paints a pretty grim picture.

PK: One point I want to make is that while this sounds like a lot of bad news — these are not good numbers, I know — I don’t want that to be the final judgment or disposition of this study. What this turns out to be is an opportunity for the legal profession to take meaningful actions and make some meaningful improvements in the area of attorney behavioral health. This change has to come from within the profession. This is an opportunity for the legal profession to create proactive, positive change. Once we get past this bitter pill, I hope we can move on to find solutions, and hopefully we will turn the corner.

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Out of the shadows: Mental Health Resources meets $1 million fundraising goal

Alexander Ramsey, Minnesota’s first territorial governor, lived a life of luxury and privilege. But a family history of serious mental illness meant that he also lived another, less public life, one of secrecy and shame.

Earlier this week, on a bitterly cold night, a group gathered at the historic Alexander Ramsey House in St. Paul’s Irvine Park to hear about the Ramsey family’s secret struggle with mental illness — and to celebrate the successful completion of Mental Health Resources’ (MHR) $1 million “Invisible No More” social capital campaign.

Though conditions are far better than they were in Ramsey’s day, still many people with serious and persistent mental illness live marginalized lives, shut out of mainstream society, said Kathy Gregersen, MHR executive director. Because of this harsh reality, the campaign’s theme was chosen to send a specific and clear message. 

“When we were developing this campaign,” Gregersen said, “we took a good, hard look at our clients. What we realized was that so much of the time they are not seen or heard. They are invisible in the community. This campaign was about changing that. It was our way of saying, ‘You are no longer invisible. We are here for you, and we always will be.’”

First major fundraising campaign

Founded more than 40 years ago in response to the closings of the state psychiatric hospitals, MHR provides a range of community-based services and supports for adults recovering from serious mental illness. The agency serves more than 6,000 clients and employs 210 staff members.

Mental Health Resources has never before run a large-scale fundraising campaign, said Jim Wyman, MHR board president, but a little over two years ago the board felt the time was right to turn to funders to expand the growing organization’s existing programs — and build new initiatives that would directly benefit their client base.

Jim Wyman

Courtesy of Mental Health Resources
Jim Wyman

“The agency has been extremely effective and successful at treating clients for a long time,” Wyman said. “That continues to this day. We saw opportunity for this campaign because we realized we that throughout our history have been so focused on doing the work that was in front of us that we were losing sight of how much we could add value to helping our clients through fundraising.”

The “Invisible No More” campaign focused on four key initiatives, which include:

• Expanding MHR’s integrated service approach to incorporate a holistic wellness model, including a specialized tobacco cessation program aimed at an audience of people with serious mental illness;

• Creating a dental program for MHR clients;

• Teaming with community partners to teach coping and resilience skills for children of adults with serious mental illness; and

• Expanding the organization’s ability to effectively collect data and produce outcomes from that data.

Education initiatives

The campaign, which officially launched in 2014, was slated to reach its fundraising goal in three years. But that time was cut significantly, thanks to support from a wide variety of Twin Cities-area funders, Wyman said: “We accomplished our goal in two years. The board was impressed with how quickly we were able to make it happen.”

In order to meet the campaign goals, MHR development staff needed to let funders know more about their programs, the people they serve, and their hopes for the future. The organization, which has long been considered a leader in community-based treatment for adults with mental illness, has gone through significant change since Gregersen came on board in 2009. That fact alone wasn’t known to many in the mental health community.

“What’s compelling about MHR is we’ve been around for 40 years, but since 2009 the agency has tripled in size, in terms of budget and the number of clients served,” said Jill Johnson, director of advancement. “This led us to pursuing this fundraising campaign, to serve this influx of new clients in a better way.” 

Kathy Gregersen

Courtesy of Mental Health Resources
Kathy Gregersen

And development staff also worked to tell the stories of MHR clients, to let potential funders know about the challenges clients face in their day-to-day lives.

“By and large, funders weren’t aware that there was this much of a health disparity between people with mental illness and those without,” Gregerson said. “Part of what we did was educate them and say, ‘This is who this population is. This is how we can improve their quality of life.’ I think that what changed things for us was letting funders know about how serious this disparity actually is.”

One startling disparity between people with serious and persistent mental illness and the general population is life expectancy, Gregerson said: “Our population, or people who have chronic mental illness, die on average 25 years earlier than the general population. That is a huge health disparity. Part of what we wanted to aim for with this campaign was to directly address areas where we could have an impact on this disparity. Our initiatives all focus on that.”

Work still to be done

At the Ramsey House tour, visitors, all funders who had supported the “Invisible No More” campaign, walked through the stately old structure as costumed guides from the Minnesota Historical Society told about the family’s secret struggles. Ramsey’s own father died by suicide, as did his brother, Justice. Ramsey himself frequently wrote of suffering from “the blues.” In 1875, his only surviving child, Marion, married Charles Furness, who later spent two decades of his life hospitalized for mental illness until he died in 1909. Marion’s daughters never married, and lived in the house until they died, donating it to the Minnesota Historical Society.

After the tour, visitors gathered in the parlor, and discussed what they’d learned. It was stark to see that, even with all their wealth and influence, the family seemed so restricted by their mental illness. They saw that, despite all the progress that has been made for people with mental illness, there is still work to be done.

Johnson looked around the assembled group and smiled, almost ruefully.

“It was a moment to sit back, celebrate our success and relax before launching into the next effort,” she said.  

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HealthMedical marijuana

Dr. David Thorson: Efficacy of medical cannabis treatment for intractable pain remains unclear

Chronic pain is a fact of life for millions of Americans. Though a host of pharmaceutical options exist for treating pain, there is a population whose near-constant suffering cannot be eased by readily available methods. This malady is common enough that it has even been given its own medical acronym: IP, for intractable pain.   

Some people believe that medical cannabis may provide pain relief for people with IP. In states like Minnesota that have legalized the use of cannabis for medical purposes, advocates have campaigned to get intractable pain added to the list of conditions that a physician can certify for access to legal medical marijuana.

In December, Minnesota Commissioner of Health Edward Ehlinger, M.D.added intractable pain to the list of nine qualifying conditions already allowed in the state’s medical cannabis program.

While some patients’ groups cheered the decision, Minnesota Medical Association (MMA) President David C. Thorson, M.D., issued a statement of his organization’s concerns about the move. The MMA stated support of and understanding for Ehlinger’s decision, but it advised caution as the certification process is defined.

“The MMA,” Thorson wrote in his statement, “remains concerned about the expanded use of medical cannabis, particularly for conditions such as intractable pain that are difficult to objectively certify. Treatment of severe and chronic pain deserves careful consideration and medical cannabis should never be a first-line therapy. Significant questions about the efficacy of medical cannabis remain and we continue to call for additional well-controlled studies. The MMA looks forward to further guidance from the health department regarding how intractable pain will be added to the state’s medical cannabis program and we will continue to provide education and information to Minnesota physicians who may be interested in participating in the program.”

Earlier this week, Thorson, a board-certified family physician at Entira Family Clinics in White Bear Lake, made time to talk with me about the nuanced position he and the MMA have taken on the issue. 

MinnPost: Can you tell me more about your feelings about the use of medical cannabis for intractable pain?

David Thorson, M.D.: My position on the issue depends on which hat I’m wearing for this interview.

MP: That’s a good point. Which hat would you like to wear? 

DT: I’ll put on my MMA hat first. Historically, the MMA has worked with the state Legislature and the commissioner of health to help guide and support their decisions. And that is the role we are playing in this issue. We want to help the commissioner make sure that the medical marijuana certification process in Minnesota is one that is most aligned with the current science and medical evidence. We want the state’s regulations to allow for the distribution of medical marijuana in a way that enables research to continue to take place. We want to find out if medical marijuana is truly helpful in the treatment of pain. So far, the science behind that claim is not clear.

David C. Thorson, M.D.

David C. Thorson, M.D.

The addition of medical marijuana as a treatment for intractable pain causes more problems than its use for other medical concerns. There is less evidence about medical marijuana and intractable pain. There is more research-based evidence of its efficacy in the treatment of other diseases. That lack of certainty makes it difficult for a physician to find out what needs to be done to certify a patient as having intractable pain in order to qualify for medical marijuana.

As an association, we were supportive of the commissioner when he felt he needed to make this certification. But the commissioner’s medical advisory committee recommended not adding intractable pain to the list of conditions qualifying for medical marijuana because there isn’t yet evidence to support its use in those cases.

This put the commissioner in a very difficult position. There is a subset of patients out there with intractable pain that may be helped with medical marijuana, and he felt that in order to be humane he needed to include them.

MP: Now, put on your physician’s hat. What do you think about this decision? Was it a good idea to add intractable pain to the list of qualifying conditions for medical cannabis?

DT: As a physician who is in the practice of primary care and has patients who have asked to be certified for medical marijuana based on medically defined illnesses, I believe that intractable pain is going to have a difficult certification process. We’ll have to wait to see what the details of the state rules are.

I do know that intractable pain is going to be more difficult to identify than other illnesses because of the subjective nature of the disease. At this point, a physician can’t order a test that says, definitively, “This person has intractable pain.” There isn’t a scientific, evidence-based measurement for it.  So much depends on how the rules are written. How exactly are they going to define chronic and intractable pain? It is a much more nebulous diagnosis.  

MP: What do you see as the downside of using medical marijuana for intractable pain?

DT: Marijuana has an addictive side. We have to be willing to accept the fact that addiction is a reality and is possible in patients who are taking marijuana. Of course, addiction is a reality with the use of certain medicines in the treatment of chronic pain. And we have to realize that often people who are using marijuana could also be using other drugs as well. I think there are people who will try and use the intractable pain diagnosis as a way of getting medical marijuana and then legalize their potential abuse and addiction.

I’m not saying that everyone who has intractable pain will become addicted. But I am saying that there are people out there who will try and work the system as a way to get medical marijuana.

MP: And you think that there isn’t yet enough scientific evidence to support the use of medical marijuana for intractable pain?

DT: Not yet. If we’re trying to say, “This is a medical use for a drug for people who have an illness that does not respond to anything else,” we have to stay true to that definition.

Because of the illegal nature of marijuana, its effects on certain diseases haven’t yet been fully studied in this United States. In other parts of the word where the research has been done, there is less evidence that medical marijuana has been helpful with treating intractable pain. We have to take that into account. 

And pain remains hard to measure. Intractable pain is more subjective than many other diseases. That doesn’t make it less real. It’s just more subjective. I’d like to be able to measure it, to identify it more clearly in a patient before I can certify them for treatment.

MP: Do you have other concerns about medical cannabis and pain treatment? 

DT: As a physician, another thing I worry about is the whole business model of medical marijuana. We hear about the costs of producing medical marijuana and we know that at least some of the cost is related to the number of patients who have been certified for its use. On some levels there is a need to have more patients certified so that the cost for the drugs can come down.

Is that a reason to expand the number of diagnoses that qualify for medical marijuana in order to get more patients? Or is the motivation the fact that it is proven to help patients with these diseases?

One perspective might be that in order to end up at a price that will allow medical marijuana to be cost effective to produce, there needs to be more patients out there who are using the product. Therefore if there aren’t enough patients with the current diagnoses that grant them access to medical marijuana, producers need to expand those diagnoses and increase the pool of potential patents.

MP: But isn’t that a classic supply-and-demand scenario?

DT: I think it’s a combination. There is a pressure to increase the number of qualifying diagnoses so we can have more potential patients. While the business model is based around keeping costs down, the fallout of having more patients is the risk of more addiction and less scientific evidence. I think that is a valid concern.

MP: Finding a safe and non-addictive treatment for pain is a big issue. Addiction to opiate-based pain medications is a major issue in Minnesota and around the country. But people really do suffer from pain and need relief. Is there another treatment option on the horizon?

DT: There has been a lot of transition over the last 20 years. In the old model of treatment, the point was to treat pain to the point where people weren’t having pain anymore. Now more physicians and health-care providers are coming around to the idea that in life some level of pain is inevitable. In that approach, physicians are helping people learn to live with pain, to identify pain generators and deal with those pain generators rather than just treating the pain.

Some physicians are taking the perspective that pain has some benefits. It helps the body adapt and adjust and guard and protect. It’s learning how to live with your pain rather than having your life be limited by your pain.

If you look at other parts of the world you can see that the treatment of pain is done differently. In Eastern cultures, for instance, physicians use acupuncture to mediate pain in surgery.

MP: It sounds like you are struggling with the fact that it is so hard to measure and identify intractable pain. Am I right?

DT: Yes. I think adding intractable pain is a difficult direction to be going in because when you do that, then you put physicians in the position of having to certify these illnesses themselves. In my own practice, I see how difficult it is to certify and verify the current illnesses that have some scientific background that supports the use of medical marijuana. Adding another, less evidence-based disease to the list only makes it harder.

Intractable pain aside, the discomfort that many physicians have with this medical cannabis certification process in general is real. If you look at the number of patients that have been certified for medical marijuana use so far, I think it’s still less than 1,000 people in the entire state. So you can see the reluctance on the part of physicians.

At the MMA, we are not opposing medical marijuana in general. I’ve actually certified some of my patients for medical marijuana. I am not against the certification process.

MP: What have you certified your patients for?

DT: It has been it for muscle spasms from severe multiple sclerosis and for Crohn’s disease.

MP: Would you certify a patient for intractable pain?

DT: The intractable pain diagnosis is more nebulous. It isn’t available yet. I haven’t seen the rules. Right now I feel uncomfortable and concerned about how they are going to be able to define this as a medical condition, so I’m not certain how I would I could recommend a certification. 

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New support group is launched for siblings of medically complex kids

When Kelly Mussehl was growing up, she’d sometimes feel frustrated that her younger brother Andrew was getting most of her parents’ attention.

In some ways, this imbalance was inevitable, because Andrew, who was born when Kelly was 4 years old, had a severe form of spina bifida, and needed 24-hour medical support. Still, even though she loved Andrew and understood that he needed extra care to thrive,  there were days when the young Mussehl felt like she was living under a serious attention deficit.  

“It’s a long time ago now, so it’s hard to remember the details all that clearly,” said Mussehl, 34. “But I asked my mom the other day if I acted out when I was younger, and she said I did because I didn’t know how to express my feelings and emotions when my brother was getting all the attention.”

As she reached elementary age, Mussehl began to understand that her life was different from other kids’ lives.

“When I was younger, I just thought that the way my family had to adapt to my brother being sick and having all those people in the house helping him was the norm,” she said. “As I started going to my friends’ houses, I saw that other people didn’t have all that kind of stuff going on. ” The realization made Mussehl feel isolated. 

“I didn’t know any other kids who were in the same situation,” she said.

Siblings need support

Mussehl’s experience is not unusual, said Monica Handlos, MSW, LICSW, a clinical social worker at Pediatric Home Service (PHS), a Roseville-based for-profit agency that provides medical home-care services for some 4,000 children.

Kids who have siblings with complex medical issues like Andrew’s often face many of the same concerns as Mussehl did, she said. Addressing those issues can be complicated: A medically complex sibling has more obviously pressing needs, and even with the most loving parents, a typically developing kid can feel relegated to the background.

Because of these very real concerns, Handlos is launching a new support group for able-bodied kids ages 6-11 with medically complex siblings. The “small, intimate” group of 4-6 children will begin meeting for 12 weeks at PHS starting March 3.

“Kids with medically complex siblings need a support group, because it is possible — though not guaranteed — that it could feel quite isolating for a kid to see all the services and attention that their sibling is receiving,” Handlos said. An able-bodied sibling may wonder, “‘Why does my family look different from little Jenny’s family?’ A group like this helps build support within the community and limits that isolation for the child — and their parents.”

This sibling support group is a new direction for PHS, which has for the last quarter century focused on helping children whose complex medical conditions used to mean that they would require long-term hospital care have the option of being cared for at home. The agency’s focus has always been on the medically complex child, not on their family members. With this support group, the program is branching out to able-bodied siblings and parents.

“Our motto has always been ‘Taking care of the child,’ ” Handlos said. “That’s always been our focus. This new service is about taking care of the child’s family members as well.” Only children will attend the support group meetings, but at the end of each session, there will be a special debriefing time set aside for parents.

“The kids will stay and play with each other,” Handlos said (a social work intern will supervise), “and I will meet separately with the parents. We’ll discuss what I worked on with the children and what reactions parents should look for. Each support group session will always include a ‘feeling of the day’ with an activity. We’ll provide normalcy to a variety of feelings. We’ll also discuss feelings about having a brother or sister with complex needs. We’ll break that all down for the parents.”

A friend in need

Mussehl continued to feel isolated from her peers until one day, when she was in fourth grade, a new girl came to her school.

“Her sister had had a stroke at a young age,” Mussehl recalled. “She understood what I was going through with my brother in a way that the other kids didn’t. She and I became best friends and a support team for each other. She let me know her information and I let her know mine. That was the only thing I had. There were no other support groups available for me, even in the hospital world. If I didn’t have my friend, I would’ve been alone.” 

One of the major stressors in Mussehl’s childhood was the fact that her parents needed to spend time apart while Andrew underwent major medical treatments. “Every time my brother got sick and had to go to the hospital, we basically had to have a split family,” she recalled. “My mom stayed with my brother and my dad took care of me.” The situation was tough, because even though she knew her brother needed special care and attention, and even though her dad was a warm, comforting presence, Mussehl still missed her mom. But there was no other option for her family.

Today, Mussehl, works as a licensed respiratory therapist at PHS. (“My brother inspired me to be become a respiratory therapist,” she said.)  She thinks a support group for kids in her situation would have made her growing up years much easier. Though she had her friend to lean on for support, “I would’ve liked to have more information about how to be able to cope with these issues and be able to communicate better with my parents so they could help me deal with feelings as they came up,” she said.

Mussehl’s work brings her into homes that feel much like hers did when she was growing up.

“I always feel so sympathetic toward the family, especially the siblings,” she said. “I have the empathy of knowing what those kids are going through, of having new equipment and supplies being brought into their house. I feel for the parents, too.” No one expects that their parenting journey will take such a turn.

Group participants’ siblings do not have to be PHS clients, Handlos said. And the medically complex siblings don’t need to have as severe a disability as Mussehl’s brother. “We have a large population in our own client base that would be a good fit for the program,” she said, “but it will be open to any child with a medically complex sibling.”

These days, other sibling support group programs exist in Minnesota, but this is PHS’ first attempt. Handlos feels confident that the group will take off, and hopes to eventually expand the program’s support-group offerings to a “full-hour parent group and also a group for older kids.”

The support groups might help create a network of caregivers, of people who love their medically complex children and siblings, but who also need help and support to live happy, healthy lives. Caring for a child with serious medical needs is hard: It’s OK for parents and siblings to feel jealous or frustrated or even angry.

“What I worry about is not the acting-out behaviors that people might see or witness,” Handlos said. “I worry about the internalization. With these groups, I want to help children and parents express their feelings and get in tune with how they are feeling. I want them to find the support they so desperately need.” 

Shared responsibility

As Mussehl grew older, she accepted her familial attention imbalance as a fact of life.

“Because of my brother’s needs, he will always get that full-on undivided attention,” she said. “He needs that. I don’t. As I got older, I got more proud of him and less jealous. When I was in high school, I played basketball. When he came to the games, I was proud. I liked to introduce him to my friends.”

These days, Mussehl is married and long out of her parents’ house. She and her brother are close; he still lives at home, and when her parents need extra help, she steps in. It feels good to help — and to spend time with her little brother.

“When my parents are out of town, I’m the primary caretaker,” Mussehl said. “My parents have been so wonderful with him: It’s hard to fill those shoes. Sometimes it is worrisome stepping up to the plate, but at the end of the day, I feel like I’m responsible for him, too.”  

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Moving pictures: Basilica Mental Health Film Festival aims to spark discussion, understanding

The idea of hosting a mental health film festival at the Basilica of St. Mary happened organically, almost on a whim.

The massive, landmark Catholic co-cathedral, home to some 12,000 members from 56 ZIP codes, has had a mental health ministry for nearly a decade now, said Janet Grove, Basilica ministry coordinator. The 30-member ministry was founded by a group of parishioners who have family members with mental illness or live with mental illness themselves. They work together to educate the church community about mental illness and confront misconceptions about people who live with a mental health diagnosis. 

The decision to host the festival was spontaneous, Grove recalled: “At one of our meetings, we were talking about outreach, and a few of the group members came up with the idea of hosting a film festival. Without much hesitation, we all said, ‘Let’s just try it.’ Turns out it’s been a really good fit for us. It’s one the highlights of our congregation’s mental health work.”

Grove said that the festival has maintained that same natural, community-driven feeling in the four years since its founding: That’s one of its appeals.

“The festival has really come out of the committee and their desires,” she said. Films are selected in part to spark conversation about mental health topics. “The post-film discussions are really what’s so incredible. We’ve seen such different perspectives on all of the films. Nobody’s afraid to say, ‘I didn’t like that at all.’ And that’s so important.”

Discussion helps break down barriers and misconceptions about mental illness, Grove said. A few years ago, when the theme was “‘Children, Youth and Young Adults with Mental Illness,’ the festival staged a revival of the 1980 film “Ordinary People.”

“After all these years, the film still really holds up,” Grow said. “After the film, the discussion centered around whether Mary Tyler Moore’s character was a good mother or not. Some people thought she was spot on, that she did what was best for her son. And others said, ‘How could she behave like that?’ That led to a great discussion about mental illness in a family.”

Selection process

This year’s festival theme is “Mental Illness and the Arts.” Each year, in preparation, Grove, an avid film buff, searches for contenders, and then selects around 10 films for a group of committee members to screen and rank.

“Usually I get about four or so people who are interested in watching the movies and taking notes and telling me what they feel about it,” Grove said. Grove and her family also review the films.

Films are selected for their content and connection to the year’s theme. Just because the films are screened in a church doesn’t mean that they have to be squeaky clean.

“We have shown R-rated films,” Grove said. “We are not afraid of that. Two years ago, for instance, we watched ‘Silver Linings Playbook.’ We selected the film because it felt like a strong portrayal of young adults and their experience with mental illness. The committee members agreed that it was a good choice.”

The festival always kicks off with a documentary, followed by three feature films of varying vintage. Documentaries are an important part of the mix, Grove said, because they get viewers thinking about a topic in a different way and help to introduce the year’s theme. Feature films expand on the theme — and get viewers to think about the topic from unique perspectives.

"Love & Mercy" director Bill Pohlad

Roadside Attractions
“Love & Mercy” director Bill Pohlad

It’s especially exciting when someone who has been intimately involved in the making of a film is able to appear at the festival. This year, Minnesota native Bill Pohlad will introduce his film “Love and Mercy” about Beach Boy Brian Wilson and his struggles with mental illness. Pohlad will also lead a post-film discussion.

“Bill is member of the Basilica,” Grove said. “When I approached him, he was more than willing to take part in the festival.”

The festival’s featured documentary is “Brushes With Life: Art, Artists and Mental Illness.” The film’s director, Philip Brubaker, and producer, Deirdre Haj, will lead a post-film discussion, along with representatives from Vail Place, Interact, NAMI Minnesota and the Basilica’s Mental Health Ministry.

“The film was made by a filmmaker who is an artist and who suffered a tremendous bout with depression,” Grove said. “In the film, he follows eight artists who all went through the same hospital. The hospital decided to create a gallery that features artwork from patients in the hospital.”

Other films featured include “Iris,” starring Jim Broadbent, Judy Densch and Kate Winslet, about writer Iris Murdoch’s struggle with early-onset Alzheimer’s, and “The Soloist,” starring Jamie Foxx, Robert Downey Jr. and Catherine Keener.

“It’s the true story of a friendship between a Los Angeles Times news writer and a gifted musician who had a mental health break and has become homeless,” Grove said. “The friendship that that developed between these two men fits nicely with the Basilica’s overall mission and our dedication to ending homelessness.” 

2016 Mental Health Film Festival lineup

All films are screened at the Basilica of St. Mary, 1600 Hennepin Ave. Minneapolis. All are free and open to the public. 

  • Thursday, Feb. 4, 6 p.m. “Brushes With Life: Art, Artists and Mental Illness” (2008). Post-film discussion led by director Philip Brubaker and producer Deirdre Haj.
  • Thursday, Feb. 11, 6 p.m. “Love and Mercy” (2015). Introduction and post-film discussion led by director Bill Pohlad.
  • Thursday, Feb. 18, 6 p.m. “Iris” (2001). Featuring a post-film discussion.
  • Thursday, Feb. 25, 6 p.m. “The Soloist” (2009). Featuring a post-film discussion.
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Macalester student helps his dad fight PTSD-fueled night terrors with mobile technology

For a big part of Tyler Skluzacek’s childhood, his dad, Patrick, couldn’t sleep. A veteran who had served in Iraq from 2005 to 2006, Patrick was awakened most nights by night terrors, intense, violent dreams that are a common symptom of PTSD.

At first, Skluzacek didn’t know his dad couldn’t sleep. But the truth eventually became impossible to ignore.

“I was a kid, and our house was just big enough for me not to hear it,” Skluzacek recalled. “But as high school turned into college I noticed that my dad was really sluggish, tired, irritable, cranky. He eventually told me that he was having a hard time sleeping at night due to flashbacks of things that happened in Iraq.”

The whole family felt the impact of the elder Skluzacek’s sleep deprivation.

“Straight up, my dad was insufferable,” Skluzacek said. “He tried every pill in the book. He tried the VA-sanctioned therapies. They didn’t seem to work very well for him. He was frustrated and exhausted, and it took a pretty heavy toll on all of us. He wasn’t sleeping —and we all had to deal with a man that wasn’t sleeping.”

Skluzacek, who left his hometown of New Prague to attend Macalester College in St. Paul, assumed that his father would likely have a hard time sleeping for the rest of his life. But a little part of him always held out hope that some day he would be able to help his dad get the rest he needed.

Putting coding skills to use

It wasn’t clear how Skluzacek, a computer science, applied math and statistics triple major, would ever be able to help his dad. But then he was given an opportunity to focus his impressive coding skills on the problem.

In September 2015, Skluzacek heard about Hackathon for Health, an event held by the nonprofit HackDC in which coders, developers and medical professionals were invited to come together in the nation’s capital to develop ways that mobile technology could be used to help veterans cope with PTSD.

The event’s theme immediately appealed to Skluzacek.  “I thought, ‘I’ll show up and see what I can do.’ ”

When he arrived at the event, Skluzacek quickly realized that if he wanted to create something that would actually help veterans like his dad, he needed to jump in and learn everything he could about PTSD research in order to create the most useful technology.

Tyler Skluzacek

David Turner/Macalester College
Tyler Skluzacek

The 36-hour event was held “in a giant gymnasium,” Skluzacek recalled, “with tables set up in the middle. On the outside there were booths with technology companies, veterans’ associations, psychiatrists from the VA. If you wanted to go to the next level, you had to get your booty out of your chair and talk to these psychiatrists. A lot of people at the hackathon would not go talk to the psychiatrists, but my team spent a lot of time talking to the them and reading research papers about stress indicators that we could use in our project.”

The team learned that it’s not the night terrors themselves that take a toll on veterans; it’s the fragmented sleep the terrors create. After talking with researchers, Skluzacek and his team landed on the idea of inventing a smartwatch app that could detect and interrupt the terror without fully waking the sleeper.

“These watches have just enough technology on them to track when a night terror is happening,” Skluzacek said. “We can do heart rate, body temp, sounds, movements — and out of all of these we can get a pretty good idea of when a night terror is happening. Then the watch steps in and sends a stimulus to interrupt the night terror, but not fully wake the user.”

myBivy is born

The hacathon was intense — “Over the 36 hours, I got a total of one hour of sleep each night,” Skluzacek recalled, “but by the end, we were actually able to create a semi-functional glue-and-paperclips prototype.” 

Skluzacek’s team, dubbed “The Cure,” won the event’s “Best Mobile Application for Clinicians” category. Their prototype, now known as myBivy, (for bivouac, or the light-weight, portable shelter used by soldiers), took home a $1,500 prize, or $300 each when divided by the five members of the team.

“That’s not that much,” Skluzacek said, “but it’s a lot for a college student who doesn’t have much money.” 

Still, $300 isn’t enough to go from prototype to reality. The team knew it needed more money if they wanted to make their idea fly. They calculated the amount needed to get started and landed on $1,200 to $1,500. “We needed to buy one of every smartwatch,” Skluzacek explained.

So they launched a Kickstarter campaign. Skluzacek’s pitch was very DIY: “I set up a camera stand and talked for five minutes about why our watch was cool, and how we needed money to develop it, and lo and behold, KARE 11 covered us.”  

The local TV news report was picked up around the world. “All of the sudden there was a media flood,” Skluzacek said. Stories were written about myBivy in “USA Today,” “Huffingon Post” and “Gizmodo,” among others.

All the attention worked wonders for the fundraising campaign. “The $1,200 turned into $26,000,” Skluzacek said, and with the infusion of funds, work has begun on the app in earnest. “We still don’t have the money to do a lot of things, but there is a lot of expectation about this app now. Before, it was just about my dad and his Army buddies. Now it needs a mass release or,” he laughs quietly, “there will be mass outrage.” 

Next step: clinical testing and development

The outrage will come from sleep-deprived veterans eager to try out myBivy, which Skluzacek is testing on his father.

The device works like this: “It is tethered to a smartphone,” Skluzacek said. Over several days and nights of wear, “The watch collects a whole bunch of data images. It does calculations and determines if and when the user is having a night terror.”

The technology will run on just about any smartwatch, including the Apple watch or the Samsung watch. “It will run on a Fitbit as well,” Skluzacek said.

“If myBivy detects that the wearer is having a night terror, at first it is going to intervene very softly,” Skluzacek said. “That may not be enough to take you out of your terror, but over time the app will determine the level of interruption that is needed and then adjust to that.”

Skluzacek’s father is a heavy-sleeping mechanic who’s often unaware of loud noises, so his watch had to be adjusted to the point where “he is almost jackhammered on his wrist in the middle of the night,” Skluzacek said. “But it takes him out of a night terror.”

In November, Skluzacek and his team participated in an event in Minneapolis called Mobcon, where inventors and developers bring in their ideas and pitch them to an audience of potential investors.

“There were CEOs, developers of massive apps,” Skluzacek said. “They all got to vote on the ideas. I presented my idea to 500 people. They voted and said that myBivy was the best app here. I won $20,000 in developer credits and $5,000 in legal credits.

Skluzacek still has to finish up his senior year, but now myBivy’s development is moving quickly. “By March, we want to be in clinical testing,” he said. “We are looking at an overall release in May or June.” 

While he stresses that myBivy is really more of a “cheater hack” or a band-aid than a cure — and that veterans with PTSD should continue to seek other therapies for the disorder while using his app — Skluzacek said that the myBivy prototype has been “wildly helpful,” for his own father: “He’s used it for three months now. His buddies are already outraged. They are seeing my dad healthy and full of energy. They want one, too. But I just can’t give it out to everyone. I have to make sure it is tested first.” 

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addiction recovery

Stand-up guy: Mark Lundholm uses humor to fight addiction

People who’ve been in recovery can recite their “rock-bottom” story, the point in their journey with addiction when they hit their lowest point ever and realized they had to turn their life around.

These tales — a staple of AA meetings — can be harrowing. Some people cry and shamefully admit their transgressions. Others recount their stories in an exhausted, dull tone. Emotions run the gamut, but hardly anyone tries to get a laugh out of their rock-bottom story.

Hardly anyone that is, except Mark Lundholm. In his shows, the comedian and recovering addict likes to use his lowest-of-the-low-point story for comic effect.

“In 1988, at my lowest point, I put a gun in my mouth and pulled the trigger,” Lundholm recounted. “The gun didn’t go off. It jammed. My first thought was, ‘I suck at everything.’ ”

Lundholm knows that some people will not see the humor in a story like that, but he believes that those who do will gain a special understanding of the desperate struggles addicted people face. He also knows that the ability to reveal the humor in life’s darkest moments is a special skill, one that he has been sharing with audiences for the last quarter century, ever since turned his back on decades of heavy drug and alcohol abuse.

“Comedy is relative to the bottom,” Lundholm said. “The lower you’ve been, the funnier the laugh has to be. Dark humor is a nice reminder that we all live on the edge of insanity.”

Professional funny guy

Lundholm, a self-described former “street guy,” had no experience in comedy before he was put on psychiatric hold and into court-ordered rehab. After getting sober, he used his natural sense of humor (“I come from a big family,” he said. “If you weren’t funny, you don’t get to talk. If you don’t talk fast, you don’t eat.”) to perform a volunteer comedy routine for inmates at San Quentin State Prison. After that, Lundholm decided the stand-up life was for him, and once he’d earned enough money at odd jobs to buy a car, he began traveling the country, doing one-nighters in any comedy club that would take him.

“I’d drive, sleep in my car, do the gig,” he said. “The routine was like drinking or doing dope. The addiction became comedy instead of meth or cocaine.”

These days, Lundholm is still addicted to comedy, though he no longer has to sleep in his car. He headlines at clubs around the country, doing routines that speak to “normies”— or people who haven’t experienced addiction — as well as people in active recovery.

“I always had the jail, addiction, recovery lane covered in comedy,” Lundholm said. “It took me a while to write ‘normy’ stuff where I could relate to a couple who just had a baby and came out to the comedy club for their first time out since they’d gotten a sitter. But I do that now. My comedy is recovery specific, but normy friendly. Anybody can go.”

That’s good to know, because Lundholm will be at the House of Comedy at the Mall of America tonight, performing with his friend and fellow recovering addict Kurtis Matthews. For the last two years, they have toured the country with their addiction-humor show “The Addicts Comedy Tour.” The show, which attracts an enthusiastic audience of people hungry for Lundholm and Matthews’ unique brand of humor, kicks off at 7 p.m.

“Most of the people who come see us are rabid because they are addicted to what feels good,” Lundholm said. “There are people who will drive five hours to see this show. In Minneapolis, we’ll have people in the audience who have driven all the way from Wisconsin, Nebraska, Michigan. They’ll probably have seen the show before. We get a ton of repeaters.”

Some of Lundholm’s fan base comes from the recovery-humor DVDs he distributes through the Hazelden Betty Ford Foundation.

“I’ve got very specific clinical DVDs,” he said. “I’ve also got comedy.”

‘Laughter inspires trust’

Though Lundholm makes a living laughing about his — and others’ — struggles with addiction, he also is clear about his serious commitment to helping people climb up from rock bottom and back into the daylight. In his mind, addition is a form of mental illness. There’s no shame in that fact, he said, but acknowledging the link inspires people to do the work that’s needed to recover.

“People who talk about ‘mental health and addiction’ are being redundant,” Lundholm said. “Addiction is a mental illness, period.” Just admit it and work through it, he said. Laughing at his own very real struggles with drugs and alcohol doesn’t diminish them; it just opens up the conversation and gets people talking about their own recovery. 

“Laughter inspires trust,” Lundholm said. “People will laugh hard at my shows because they trust me. I’m not making fun of anybody.” 

Lundholm might not be making fun of anybody, but that doesn’t mean that his humor is all rainbows and unicorns, either. He likes to walk the line between dark and light, exposing the brutal side of addiction with a wry smile.

“The comedy that I enjoy is a lot darker and not for everybody,” he said. “It’s PG-plus. There’s no swearing. My comedy highlights where you’re hurt and tries to help you fix it. If you don’t think I’m funny it’s because you’re broken,” he laughed. “It’s a mental health thing.”

Or maybe it’s because you’re too normy. Lundholm makes fun at the language gaps that exist between people who intimately understand addiction and those who live in the bright, shiny world without cravings and abuse.

“When normal people hear the word ‘accessory,’ ” Lundholm said, “they think ‘belts or seat-warmers on the Lexus?’ I think ‘three months.’ When normal people hear the word ‘blackout,’ they think ‘no electricity.’ I think ‘age 11.’ ”

Hopes to help others

Lundholm believes that humor has been the tool that’s allowed him to stay sober for so many years. He’s been bitterly, deeply addicted and close to death, and he’d do anything to never be back down there again. He shares his gift of humor with others in the hopes that it will keep them from going down that same road. If they do get stuck the way he did, he hopes laughter will help lift them out.

“I think that the power that be or the universe or the happy accident has allowed us to laugh at what we’re afraid of so we don’t run smack back into it,” Lundholm said. “It’s like a pothole in the road: If you hit one while you’re not paying attention you are going to damage your car. But, if I can avoid the pothole, I can tell the next person where that pothole is so they can avoid it. But if they don’t listen to me and get stuck anyway, we can laugh together about being in the pothole and figure out a way to get out.”  

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Mental Health

Melissa Heinen: Community commitment is key to suicide reduction

Last week, I attended a forum held by a coalition of neighbors who live near St. Paul’s Smith Avenue High Bridge. The group gathered to discuss ways that community members can build connectedness between individuals in order to help prevent suicides on the landmark structure.

One of the speakers invited to the event, which was attended by some 60 people, was Melissa Heinen, suicide prevention coordinator for the Minnesota Department of Health.

Heinen, a Minnesota native with a background in nursing, public health and accident reduction, spoke to the group in an accessible, knowledgeable manner. She outlined basic strategies for suicide reduction, safe responses to suicide deaths and talked about how the community should reclaim the bridge as a beautiful landmark, a place for walking, sightseeing and photo taking.

A few days ago, I talked to Heinen about her strong commitment to reducing suicide deaths. Heinen also outlined recommended strategies for responding to such incidents in schools.

MinnPost: How did you get interested in this kind of work?

Melissa Heinen: My brother-in-law died by suicide in the summer of 2001. Prior to that I hadn’t done much work in the area of suicide. I’m a nurse. But after my brother-in-law’s death, I became interested in suicide prevention.

For a time, after my brother-in-law’s death, I lived in New Hampshire, where I worked on reducing overdose poisoning. I also was on a survivor speakers’ bureau, sharing my story to help others who are responding to suicide.

MP: What are your job responsibilities at the Department of Health? 

MH: I have three roles. One is to assist other agencies and communities in implementing the state Suicide Prevention Plan [PDF]. That’s a big piece of what I do. I’ve been meeting with the Department of Human Services and the Minnesota Department of Education to make sure that they think about suicide prevention when they are thinking about overall community health. The second piece is overseeing and implementing community grants and making sure that they are going where they need to go for suicide prevention. The  third piece is providing community technical assistance for suicide prevention.

MP: How do you assist communities in implementing the state Suicide Prevention Plan?

MH: One of the ways I do that is by going to events like the West Side community gathering last week. When a community wants to get together to talk about the impact of suicide, sometimes they come to us to find out how we can help. A big part of what I’m doing at meetings like is trying to create local community capacity, to educate individual community members and inspire them to take further action so that eventually we will have a team of community “experts” who can educate others about preventing suicide.

MP: You said you give out grant funds to community organizations. Can you give me an example of one of your grantees?

MH: We have provided a grant to Suicide Awareness Voices of Education (SAVE) so that they can run a training program for journalism schools and members of the local media. The training will help them better understand how to avoid promoting contagion with post-suicide stories.

MP: When a school experiences a suicide, how can your office assist them?

Melissa Heinen

Courtesy of Melissa Heinen
Melissa Heinen

MH: A school in that situation might want to schedule a day focused on suicide prevention. I could help the school respond in the case of a student suicide. I’d have to be invited by the school, though. I can’t just show up: We don’t have the capacity to do that. And it really only works when you’re invited.

Some schools have invited us to help out in these cases, and I think we’ve been able to help. But our presence is not the end-all-be-all at these events. The most successful interventions take a community approach. We might be there, but our job is to keep a low profile, to introduce community members to the supports that are available for them and then let them take the lead.

It’s important that organizations take a coordinated approach in these cases, that they have consistent messaging about what happened and that they maintain control over how that message is communicated.

MP: How can more people get trained in suicide prevention strategies?

MH: This last spring, in partnership with DHS, MDE and NAMI Minnesota, we hosted two trainings on postvention, or ways to respond to suicide without creating contagion in the community. We trained 30 people in one day. In that group there were about 16 people who were train-the-trainers so they could go forward after the workshop and train other people.

There have also been a series of postvention trainings going on throughout the state. We started out working with schools. This is an area we know. Youth are more impulsive and responsive to an immediate crisis. Because of where they are developmentally they can over identify with someone who died by suicide. We’ve also done trainings specifically for tribal communities so they could use this information within the tribes. We want trainers who know how to be present and supportive after a suicide in a culturally responsible way.

MP: Why is postvention important when a young person dies by suicide? 

MH: Based on surveys of youth, we know that if someone experiences the suicide of a loved one, they are at increased risk of suicide themselves. And it’s not just close friends or family members: We used to think that if a young person’s close friend or relative died by suicide, it increased their thoughts of suicide. Research has showed us that a young person doesn’t even have to really know the kid who died to be at increased risk of suicide. If the kid who died went to the same school, that could be enough to increase a young person’s thoughts of suicide. Contagion can be that strong.

MP: Suicide prevention experts have told me that it is better to downplay a suicide, to limit dramatic public memorial services or symbolic tree plantings. Why is that?

MH: This is especially true in schools. We know youth act more impulsively. They are more likely to experience a mental health crisis on the day of a suicide attempt. And also young people are developmentally more likely to over identify with someone who has died by suicide. Say a young person is a soccer player and the kid who died was also a soccer player. If that kid is struggling with mental illness, she might think, “We’re similar. This is something I should think about.”

If there’s a big memorial at the school and the kid who died gets celebrated in front of their peers, a person who’s feeling like no one cares or notices them might feel like suicide is a way to really get noticed.

MP: So how do you handle that? Is it emotionally healthy to ignore a death or brush it under the rug?

MH: One of my roles is helping schools understand that they can still acknowledge the suicide death of a student but they can do it in a way that doesn’t increase contagion. I don’t recommend memorials or posters, but a school can put out a roll of white butcher paper and have kids write memories of the peer who died on that. Then school officials can roll up the paper and bring it to the family at the funeral. That’s a way to acknowledge the loss, but also a way to put some closure on it. From there you can move on, restart the kids and help move them forward.

We want the school to support students in their grief. We want to acknowledge the life that was lost. But we don’t want to make the way in which they died the focus of the event. We don’t want to make one death more shameful than the other.

It doesn’t matter how a student died: Their name doesn’t have to be on a bench. We don’t want to make the family feel like the school doesn’t care, but if a student dies by cancer or car crash, that usually doesn’t create contagion. We want to acknowledge the death without making it a permanent thing. You don’t want memorials that make suicide seem like a valid choice. When you’re feeling like your life sucks, if you walk by that memorial every day and you remember that that kid died by suicide, it normalizes it as an option. We don’t want to do that.

Posteveniton guidelines even recommend talking to the clergy before the funeral and making sure that no one says something like, “Now he is at peace and in a better place.” If I’m struggling with thoughts of suicide and I hear how my loved one is now peaceful and in a better place, that isn’t helpful to me as an individual.

We understand that this is a tough thing for people to balance and work through.

MP: Lately, I’ve seen more obituaries that are open and honest about a person’s struggle with mental illness and ultimate suicide. How do you feel about that?

MH: It makes sense to talk about the struggle with mental illness and say it is a risk factor for suicide. Doing that is different than having a reminder that this person killed him or herself. Wearing green ribbons to acknowledge mental illness is different from memorializing or glorifying how a person took their life. It’s a nuance and no one has mastered it yet. We have to balance destigmatizing mental illness with not making suicide seem like a valid option. It’s a complex thing.

It’s not an easy thing, but we have to be so careful about all of our communications around suicide. Everything makes a difference. Research has shown that even neutral reporting on suicide may increase the risk of suicide in a community.

MP: Are there Minnesota schools or communities that you think have done a particularly good job at responding to suicide?

MH: The Jed Foundation has a suicide-prevention model for college campuses. St. Cloud State has received the Jed Campus seal. I’d like to see other universities take hold of this approach and follow St. Cloud’s lead. 

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Lexi Reed Holtum: 2015 saw advances in opioid overdose fight, but much more can be done

Oxycodone pills

Oxycodone pills, a type of opioid

Lexi Reed Holtum, executive director of the Steve Rummler Hope Foundation, is walking a fine line. While she wants to tout the successes her organization achieved in 2015, she also wants to make it clear that the problem of opioid addiction and overdose remains serious and significant in the state.

“In no way is Minnesota out of the weeds on this on this issue,” Holtum said. “Every other day in this state someone dies from an overdose of a prescribed drug. Every four days someone dies from an overdose of heroin or an illicit opioid.”

Here’s where the fine line comes in: While it is important not to lose sight of the seriousness of the issue, Holtum thinks it is also important to acknowledge that in 2015 several important advances were made in the fight against opiate addiction and overdose.

“We still have a long way to go,” she said.  “But we shouldn’t forget that he we have come so far in our fight.” 

Appropriation makes Naloxone available

Holtum considers the 2014 passage of Steve’s Law, legislation providing immunity from prosecution for individuals who report an illicit opiate overdose, to be one of her foundation’s biggest accomplishments. In 2015, advocates went back to the state Legislature and lobbied for appropriation funding to support training and distribution of kits containing the powerful anti-overdose drug Noloxone.

“We were granted $290,000 to be used to get Naloxone into the state’s EMS regions,” Holtum said. “This is something we have worked really hard on.”

Opiate overdoses usually happen at home, not in a hospital. In order for lives to be saved, the people who first arrive at the scene of an overdose must be equipped with the tools needed to save a life.

The appropriation funding made it possible for the Rummler Foundation — named after Holtum’s fiancé, Steve Rummler, who died of a heroin overdose in 2011 — to distribute Naloxone kits to a number of the state’s financially strapped first-responder organizations, including rural volunteer firefighters, ambulance services and police departments.

“We wanted to make sure that our first-responder entities who are already stretched could get kick-started so that they didn’t have to figure out how to buy this lifesaving drug,” Holtum said. “In the appropriation, 80 percent of the funding dollars go to buy Naloxone. The Rummler Foundation can now provide Naloxone free of charge or at low cost to qualifying agencies.”

In 2015, response to this Naloxone distribution campaign was enthusiastic, Holtum reported. Agencies from across the state applied for the kits, and the foundation was able to provide them. 

“We’ve been successful in rolling out that campaign to make sure our first responders have the tools they need to save lives,” Holtum said. “We are getting reports back that ambulance crews and law enforcement are saving a lot of lives. We are proud to support our state’s first responders so they can have the ability to get out there and be the heroes they want to be.”

Trainings offered

In order to save a life with Naloxone, it is best if a first responder is trained in its proper use. Holtum said that in 2015, the Rummler Foundation sponsored free training sessions around the state. The trainings were developed by Paul Satterlee, M.D., Rummler Foundation medical director.

“We developed a standardized training for first responders,” Holtum explained. “Out of the eight regions in the state, so far five of them have signed contracts with the Minnesota Department of Health to get funding dollars for the trainings.”

Lexi Reed Holtum

Steve Rummler Hope Foundation
Lexi Reed Holtum

The campaign’s impact has been broad, Holtum said. 

“Since September/October 2014, our Overdose Prevention Program has distributed over 1,200 Naloxone kits. In addition to this, we have trained over 1,500 individuals on how to save a life with Naloxone. Several of the individuals we trained are also trained trainers, so they are working within their own agencies to continue to train others in the correct use of Naloxone.” 

If used correctly, Naloxone is significantly effective at reversing opiate overdose. So effective, Holtum said, that the drug — and training in its use — should become as ubiquitous as CPR trainings.

“Dr. Satterlee says that 90 percent of the time you will be successful in saving a life with Naloxone,” Holtum said. “In contrast, CPR is only 40 percent successful in saving a life.”

In 2015, the Rummler Foundation also supported the state’s prescription monitoring program, hoping to limit the number of prescriptions issued for these highly addictive drug through a prescriber education program offered for medical students, practicing physicians and other perscribers. The program is offered in collaboration with the Minnesota Medical Association and the University of Minnesota School of Medicine. 

The lectures are available free of charge.  

Hospital, treatment facility partnerships

In 2015, the Rummler Foundation formed distribution partnerships with several area hospitals, including Abbott Northwestern Hospital, Hennepin County Medical Center, Mercy Hospital and United Hospital.  The partnership agreements make it possible for the foundation to distribute Naloxone kits that that hospital staff can pass on to family members of patients who may be at risk of opioid overdose. The kits are provided free and with no questions asked.

Even when first responders are trained and stocked with Naloxone, most people who overdose are found by friends and family members.

“The demographic that is doing the most rescues in opioid overdoses is the friends and family members,” Holtum said.  “We need to provide them with the tools they need to save their loved ones.”

In 2015, the Rummler Foundation also formed similar distribution partnerships with treatment facilities around the state, including Hazelden Betty Ford, St. Paul Sober Living, The Retreat and RS Eden.

Steve Rummler Hope Foundation
In 2014, the most commonly dispensed controlled substance prescription in Minnesota was hydrocodone/acetaminophen, with over 1.4 million prescriptions and 74 million units sold.

It is important that Naloxone kits are available in these programs as well, Holtum said, because “One of the things we know to be true for opioid users is that after even the slightest period of abstinence, when you use again you are at a much higher risk of overdosing. Your tolerance for the drugs drops so quickly.” 

Because of this issue, it is key for treatment facilities to keep Naloxone kits on hand, she said.

“In a treatment and sober living facility, if someone relapses they are at high risk of overdosing. These facilities all need to have Naloxone on site so their staff can act quickly to save a life. We are proud of these four facilities for taking the lead.”

What still needs to be done

Again the fine line: These advances, while significant, are just a scratch on the surface of what continues to be a huge problem nationwide.

“In 2014,” the most recent date accurate numbers are available, “we had a total of 47,055 drug overdose deaths nationally,” Holtum said. “Of those, 61 percent were opioid-related deaths. That means that that year we had a total of 28,647 opioid overdose deaths in our country. The problem is still growing. There was an increase of 14 percent nationally in 2014.”

In the Twin Cities metro area, some the Rummler Foundation’s work may be paying off. Holtum said that in 2014 Hennepin County saw a decrease in the number of opioid overdose deaths (the number of deaths in Ramsey County increased slightly). But, in rural areas of the state, the number of deaths from opioid overdose continues to rise.

Steve Rummler Hope Foundation

“In Minnesota, people outstate are twice as likely to overdose and die of an overdose of opioids than they are in the metro area,” Holtum said. “We need to make sure that not only are we focusing on the metro area but we are also reaching rural Minnesota.”

While she believes that Minnesota has “one of the strongest laws around opioid overdose deaths and Naloxone,” Holtum said, it is important not to get too caught up in self-congratulation. “There is much yet to be done. We all need to support the work that is being done to save lives.

“As a nation, we really need to continue to take action to prevent opioid overdose deaths,” Holtum said. “The way we can do that is through the things we’ve already talked about. We have to change our prescribing practices and we have to provide Naloxone to every individual who is at risk for opioid overdose. We have to keep doing what we’re doing — and we have to do even more.”

On Sunday, Jan. 17, at 6 p.m., the Steve Rummler Hope Foundation will host its fourth annual Night of Music fundraiser at Tuttle’s Eat Bowl Play at 107 Shady Oak Road in Hopkins. For more information, go here.

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Mental Health

Alison Aubrecht: Peer support program takes a deaf-centric approach to mental health

It’s hard enough to find a qualified therapist, but imagine being deaf and looking for a mental health professional who: 1) speaks your language (ASL); and 2) understands the intricacies of deaf culture. Not an easy task.

With the help of interpreters, hearing therapists often work with deaf, deafblind or hard of hearing patients, but the presence of a stranger in the treatment room can be awkward, to say the least. In Minnesota, there only a few therapists who are either deaf or hearing but fluent in ASL. Waiting lists to see them can be months long.

In recognition of these concerns, two years ago the Minnesota Department of Human Services’ Deaf and Hard of Hearing Services Division established a Certified Peer Support Specialist Program. The program is like other peer support specialist programs around the state, except for one big difference: The peer support specialists on the team are all deaf or hard of hearing people who have experience with mental illness. They’ve been trained to provide support and guidance to their peers.

The program’s supervisor is Alison Aubrecht, a licensed professional clinical counselor who also happens to be deaf. Her primary language is ASL. Enthusiastic and committed about her work, Aubrecht oversees a group of busy peer support specialists.

“At this time our seven peers meet with approximately 25-30 people per year,” Aubrecht said. “They have an average of 3-5 individuals on their caseloads at any given time.”

A Minnesota native and Gallaudet University graduate, Aubrecht lived and worked in other parts of the country before coming back to her home state.

“I returned to Minnesota,” she said, “in part because my family is here and in part because Minnesota has pretty amazing services and opportunities for deaf, deafblind, and hard of hearing people.”

This week, Aubrecht and I “talked” through a series of emails — our language barriers (I don’t speak ASL) made this the easiest way for us to communicate. She told me about Minnesota’s Deaf Peer Support Specialist Program, about mental health issues in the deaf community, and about her personal commitment to social justice.

MinnPost: Can you tell me more about the Deaf Certified Peer Support Specialist Program?

Alison Aubrecht: Certainly. Our program was officially launched in March 2014, with a total of four deaf certified peer support specialists (we now have seven). Our program is a state grant contracted with Consumer Directions, Inc., a contract that is managed by the Director of the Minnesota Deaf and Hard of Hearing Service Division Mental Health Program. Our specialists work with deaf, deafblind, and hard of hearing individuals across Minnesota. The certified peer support specialist group was trained using a modified (with permission) version of the Appalachian Consulting Group Peer Specialist Training curriculum. Modifications were made to ensure that the training would be culturally and linguistically affirmative, or accessible to American Sign Language (ASL) users.

MP: Tell me more about your peer support specialists. What kind of background do they have? What draws them to this work?

AA: All of our support specialists are deaf. They come from a variety of walks of life. All have struggled with mental health challenges and have agreed to share their experiences with folks who are currently struggling with mental health barriers. For the most part, they are drawn to the work out of a desire to use their own life challenges to help others.

MP: Are certified peer support specialists paid for their work?

AA: Yes, our specialists are paid for their work through a state grant. They are paid an hourly rate, based on their time with their peers.

MP: How are team members trained?

AA: Trainings are provided by co-facilitators: myself and Dori Richards, who also works as a certified peer support specialist. We provide a weeklong, 40-hour training based on the Appalachian Consulting Group Peer Specialist Training curriculum. Trainings are generally hosted once or twice a year.

MP: Why is it important that deaf, deafblind and hard of hearing people have specially trained support specialists?

Alison Aubrecht

Alison Aubrecht

AA: One of the foundations of peer support is the belief that people benefit from working with others who have experienced similar challenges. There’s this gut-level connection and mutual understanding. The same is true for other layers of a person’s identity — deaf, deafblind, and hard of hearing people are more able to form that connection with one another because of their shared experiences and understanding, not only of deaf people and deaf culture, but beyond that — the experience of a deaf, deafblind, and hard of hearing person struggling to navigate the mental health system.

MP: What are some of the unique issues that arise when deaf people are seeking mental health care?

AA: The biggest issue is probably the availability of accessible support. We believe that direct communication access is ideal, but most providers across the board (i.e. therapists, social workers, group home staff, treatment center staff, psychiatrists, etc.) don’t use ASL. So the next challenge becomes: Are they willing to provide qualified interpreters? And working with interpreters comes with its own set of challenges, as some are not trained to work in mental health settings.

As a result of communication barriers, deaf people are sometimes misdiagnosed, or don’t receive adequate treatment. Other times they may not have support where they need it — an example would be accessible AA meetings following discharge from a treatment program. So that leads to higher risk of relapse, whether relating to substance abuse or mental health symptoms. That’s one of the reasons the Deaf Certified Peer Support Program is so beneficial—our specialists have the potential to become that bridge, to provide that support and supplement the work of providers or temporarily fill gaps in services.

MP: Is it important for a deaf person to be treated by a mental health professional who is also deaf?  Can a hearing mental health professional be trained to assist people who are deaf, deafblind and hard of hearing?

AA: The National Association of the Deaf has a position statement on this topic. But if you’re asking me personally, my sense is that deaf people, like anyone else, should have options for mental health resources. Often deaf people relate more with deaf providers. This relates back to what I shared earlier regarding shared experiences. The larger issue, however, is ensuring that the provider is fluent in American Sign Language, if that’s how the person communicates. Hearing mental health professionals can be and are trained to work with deaf, deafblind, and hard of hearing individuals. Again, there needs to be emphasis placed on fluency and understanding of cultural nuances.

A short video explaining the Minnesota Deaf CPSS Program. Click on the “CC” icon to view with subtitles.

MP: Do deaf, deafblind and hard of hearing people have a hard time finding qualified mental health care?

AA: Absolutely yes. Minnesota is one of the better states in terms of providing quality mental health care to deaf, deafblind, and hard of hearing people. We have many wonderful programs and providers, including the Department of Human Services’ Deaf and Hard of Hearing Services Division Mental Health Program. Minnesota also has the only chemical dependency program tailored to this population: the MN Chemical Dependency Program for Deaf and Hard of Hearing Individuals. However, there are still challenges. Most services are specific to the Twin Cities and less accessible statewide. Most of these services are also specific to adults.

MP: How is mental illness acknowledged in the deaf community?

AA: There’s still quite a bit of a stigma. It isn’t discussed much, and there’s a level of insensitivity among community members at times, but that trend has been shifting in recent years. We are hoping that this program will contribute to removing stigma, and we have seen a really positive impact coming out of our peer specialists sharing openly their struggles and their accomplishments.

MP: What drew you to your work?

AA: I have a particular interest in social justice work. I see life through a social justice lens. Part of that lens is creating space for people to tell their own stories, because they often know best (lived experiences). As a trained therapist, I feel that same lens needs to be applied to people that I work with. I feel that people with mental health challenges have a wealth of wisdom and empathy beyond what many of us ever learn from books, and this program — for me — seemed like the perfect opportunity to combine my mental health training with creating space for people with lived experiences to work with others who have similar needs.

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Mental health legislative update: 2015 achievements acknowledged, 2016 ambitions outlined

Legislatively at least, 2015 was a good year for Minnesotans with mental illness. The most visible achievements were at the Capitol, where a bipartisan group of lawmakers approved $46 million in new funding for mental health initiatives — the most money invested in mental health care in state history.

Last month, in acknowledgement of this achievement, Minnesota was recognized as a national leader in mental health investment in “State Mental Health Legislation: Trends, Themes and Effective Practices,” an annual report released by the National Alliance on Mental Illness (NAMI).  The report singled out three states — Minnesota, New York and Virginia — as showing the strongest commitment to improving mental health legislation.

Sue Abderholden, NAMI Minnesota executive director, said that this acknowledgement is an important recognition of the hard work that has gone on in the state to advance the rights of Minnesotans living with mental illness.

“Nationally, people look to Minnesota and our work here as exemplary,” she said. “Sometimes mental health activists in this state think about what we have yet to achieve and they get frustrated, but when you look at what’s happening in Minnesota vs. what’s happening around the country, we are doing very well. We should celebrate that we are moving forward with so many important mental health programs.” 

Part of the state’s success may have to do with the fact that Abderholden has been in her position for so long.

“The average length of stay for a NAMI executive director is 18 months,” she said. “I’ve been in this job for 14 years. Longevity helps with progress.”

But it’s not all her doing, Abderholden stressed. Not by a long shot: Minnesota’s success in advancing the rights of people with mental illness can be credited to the strong support of state lawmakers.

“In 2015, we had a governor and a [Department of Human Services] commissioner who were committed to increasing funding for mental health,” she said. “As you look around the country, mental health gains depend greatly on the people in the governor’s spot and the commissioner’s spot. If you have someone in those positions who wants to move forward on mental health, positive change is going to happen.”

Sue Abderholden

Courtesy of NAMI-MN
Sue Abderholden

For states with less legislative support for mental health initiatives, progress is going to be slow, Abderholden said. Without support at the top, local activists will be stymied in their attempts to advance mental health care.

“Around the country, NAMI has many great executive directors,” she said. “But if they live in a state that continues to cut funding, they are not going to see much progress on their initiatives.”

And it doesn’t hurt that Abderholden is willing to make herself a thorn in the side of decision makers.

“I’m a pretty vocal person,” she said. “I always try to make sure that we’re on people’s radar for good — and bad — things. There is a lot of implementation that has to happen for the things that we have passed. But I don’t want to lose sight of the needs that are still out there. It’s all about striking a balance between thanking and urging.”

2016 legislative goals

It remains to be seen whether Emily Johnson Piper, the state’s new DHS commissioner, will have a strong focus on mental health, Abderholden said. Her predecessor, Lucinda Jesson, made mental health initiatives a cornerstone of her administration.

“She has a lot of pressure on her this year,” Abderholden said of Piper. “I don’t see anyone backing away from the mental health work that we’ve invested in so far. But it is too soon to tell whether mental health will be as big a priority for her as it was for Commissioner Jesson.”

Abderholden said that she and the staff at NAMI Minnesota don’t have huge legislative ambitions for 2016.

“We know it is going to be a very short session,” she said. “We don’t have huge goals.” 

That said, NAMI Minnesota has selected several legislative initiatives for the year, including expanding subsidized child care to parents with serious mental illness so their children can be cared for while they receive psychological treatment.

“When a mental health professional believes that it is essential for a person to go to intensive therapy, but they don’t have anyone to watch their young children, what is their choice?” Abderholden asked. “We’ve had families who’ve left their young kids alone so a parent can go to therapy. It is important to take care of your mental health, but it is also important to take care of your children. If a parent is not doing well, it is not good for the children. We’d like to be able to help these families out.”

De-escalation training program

Another legislative initiative supported by NAMI Minnesota would provide increased funding to help the state’s police officers undergo Crisis Intervention Training (CIT), a program that offers de-escalation techniques that officers can use when working with people in the midst of a mental health crisis. This training is offered by a number of agencies including Minneapolis’ Barbara Schneider Foundation

In some schools, children with severe mental illness have been secluded or restrained, Abderholden said. Yet another 2016 NAMI Minnesota legislative initiative promotes funding to help schools and school districts develop alternative ways of working with children with “high, complex” needs.

“In cases like these, regular training isn’t doing enough,” Abderholden said. “What schools need is funding to bring in experts who can work with children and educators so schools don’t have to resort to techniques like restraint and seclusion.”

Initiatives designed to help increase the state’s mental health work force will also be on NAMI Minnesota’s radar, Abderholden said.

And while one of the biggest legislative victories of 2015 was passage of Minnesota’s First Episode Psychosis (FEP) program (MN SF 1458) supplementing federal dollars to support evidence-based FEP programs, Abdderholden added that in the coming year, her agency will continue to push for more funding for similar initiatives.

“This is just too important an issue,” she said. “There is always more that can be done.” 

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U of M student survey reports that mental health concerns are up, binge drinking is down

The 2015 College Student Health Survey, a comprehensive study conducted since 1995 by the University of Minnesota’s Boynton Health Service, found that the number of University of Minnesota students reporting a mental health diagnosis in their lifetime has increased by 33 percent since the last time the survey was conducted in 2013. The rate of students reporting a diagnosis of two or more mental health conditions was also up — by 23 percent.

Some of this increase may be due to a heightened sense of comfort with talking about mental illness, said Dave Golden, Boynton’s director of public health and communications. When people feel more comfortable discussing mental illness, he said, they may be more likely to seek help — and with help often comes a diagnosis. 

“As a society, we are becoming more comfortable with discussing mental illness and reaching out for assistance,” Golden said. “That’s a positive change.” But that can’t be reason enough for the increased rates of mental illness among University of Minnesota students, he said: “We also have some evidence that there simply might be more mental illness out there in the world as well.”

Gary Christenson, M.D., Boynton’s chief medical officer, said that changing societal attitudes about mental illness is shifting the way we look at emotional health. Young people are especially impacted by this shift.

“Decreased stigma may mean increased willingness to seek out help,” Christenson said. “That may play a role in increasing those numbers of diagnosed mental illness. Here on campus, we’ve worked hard at stigma-reduction campaigns. We’ve also worked hard at educating everyone here about the multiple mental health resources available. All of those efforts may be contributing to some of those numbers.” 

The most frequently reported mental health conditions among U of M students are depression (21 percent lifetime diagnosis) and anxiety (22 percent lifetime diagnosis).

Dave Golden

Courtesy of Boynton Health Service
Dave Golden

Female respondents reported being diagnosed with depression at a higher rate than males. Students were asked if they were taking prescription medication for their mental health conditions. A little over 12 percent — with females at a higher rate than males — said they were currently taking medication for mental health conditions.

Many U of M students reported that stress plays a significant role in their lives. Nearly a third of students — 34.7 percent — reported that their stress levels felt hard to manage.

Christenson said that increased levels of stress may be part of the larger shift at the university toward a more academically accomplished student body.

“It is more competitive to get accepted to the university than ever,” Christenson said. “That may be a variable in the increase in stress for students here. But it also may mean that we are attracting a more resilient student body.”

Help available

The university offers many options to help students cope with mental health concerns, Golden said.

A first stop for many stressed scholars may be Boynton’s Mental Health Clinic, which is staffed by a team of 24 psychiatrists, licensed psychologists and licensed independent clinical social workers. Services at the Mental Health Clinic include individual, couples, and group counseling and psychotherapy and medication management and assessment. Urgent mental health consultation and care is also available, as well as a 24-hour crisis line with optional texting services.  

A new option that was created to help students cope with the stress of college life is a student-run program called de-stress.  In this program, trained student volunteers offer free 45-minute counseling sessions designed to help students cope with common life stressors.

Gary Christenson

Courtesy of Boynton Health Service
Gary Christenson

“We have about 25 of students who meet with other students one-on-one and talk to them about stress management,” Golden explained. Though the de-stress team are all volunteers, he added: “These jobs aren’t open to just anyone. A lot of people apply, we interview for the positions, and we only pick the very best candidates.”

The program, which was launched last year, has been popular. “Students can sign up online for sessions,” he said. “It is an opportunity for them to talk about their stress before it becomes unmanageable. We fill up all of our appointments.”

Another option is an online therapy program called SilverCloud. Students can turn to this automated program to get mental health assessments and treatment suggestions. “There are professionals behind the program, guiding the answers,” Christenson said.

And there is also the ever-popular PAWS (Pet Away Worry and Stress) program, where volunteers bring therapy animals to campus so students can experience the calming effect of interaction with animals.

“Not every resource is a perfect fit for everybody,” Christenson said. “But there are many, many good options available.”

Drug and alcohol use

The College Student Health Survey also found that U of M students reported a slight decrease in rates of binge drinking  and an increase in marijuana use. Rates of tobacco use continue to decline among students.

“Alcohol remains a problem on campus,” Golden said. “We’ve got over a third of students that are still engaging in high-risk drinking. That’s a lot of students. The good news is that the rates are coming down rather than going up. That’s really positive.” 

Added Christenson: “We’re happy that binge drinking is going down on campus, but we readily acknowledge that we still have work to be done in that area.” 

Golden credits public-health campaigns with some of the decline in binge drinking at the university. He said that Boynton officials plan to continue — and beef up — existing efforts to cut drinking rates through public education and activism.

“We’re going to continue to do what we do now,” Golden said. “And we are going to do more. We want to reach even more students. They know the impact of alcohol abuse. They know the negative consequences. We’ve focused a lot of our efforts on some direct-education stuff. We’ve also done something with policy: There is no alcohol advertising allowed on campus. But we also need support from the community at large. This is something we are going to keep on working on.” 

Rates of marijuana use on campus have gone up and down over the years, Christenson said. There is currently no active campaign at the university to address the effects of pot on academic performance, but there are plans in the works to educate students about the potentially negative side effects of the drug.  

The survey found that U of M students are more likely to have used marijuana in the last 30 days than they are to have used tobacco. Many students believe that smoking pot use is less harmful than drinking alcohol.

“Marijuana use is a significant concern for us because it is not conducive to good studying,” Christenson said. “When used regularly, marijuana blunts motivation, which is contrary to the goals of student life. It’s our goal to help students have the best experience possible while they are at the university. We want them to understand that substance use can have a negative impact on their academic life.” 

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Patrick Dale: New day-treatment program addresses increasing adolescent mental health needs

Kids these days. According to Patrick Dale, CEO of Headway Emotional Health Services, a Richfield-based provider of emotional health services for children, adults and families, the number of teens in need of mental health care is on the rise in Minnesota. And the number of programs that offer day-treatment services for them has shrunk.

“Young people are facing an increasing number of life stressors,” Dale said. The emotional fallout from those adverse childhood experiences manifests itself in a number of mental health issues: “At Headway, we see kids who are dealing with a wide range of issues that also affect adults, including depression, anxiety, ADHD and bipolar disorder. Kids and families need help, and they are willing to go to great lengths to get it.”

Headway, originally called Storefront Youth Action, and then The Storefront Group, was founded in 1970 by a group of suburban parents who wanted to help children and families in crisis in their communities. In its 40-year history, the program has grown to include a number of offerings. One central focus is adolescents; Headway’s Hopkins-based day-treatment program offers young people with mental health issues an opportunity to seek therapy while continuing to take high school classes.

This fall, in response to what they see as a growing need for adolescent mental health treatment, Headway expanded its offerings for teens when it opened a new day-treatment program in Brooklyn Center. The new program, like its sister location in Hopkins, will offer comprehensive mental health care and education for up to 40 children ages 12-18.

“The population is definitely there,” Dale said. “The response to this new program has been enthusiastic, and we’re excited to have another opportunity to help families.”

Just days before Headway’s Brooklyn Center branch opened, I met Dale at the Hopkins day-treatment program. He was excited to tell me about Headway’s mission and history.

MinnPost: You’re expanding Headway’s day-treatment programs for adolescents. Why?

Patrick Dale: The demand for services for kids in this age group has been growing over a four-or-five-year period. And in the last few years a few of the programs that work with teens have closed due to budget issues. Today, Headway is one of just two or three programs that work with kids in early adolescence through high school age. There just aren’t a lot of day-treatment options available in the state for kids ages 12-18.

The impact of these shortages has been seen at other programs, too. Take Prairie Care. They offer a hospital setting for kids aged 18 and younger. Before they opened in 2009, there was a lack of facilities offering that type of service. From Day One, Prairie Care’s utilization rate has been something like 99.6 percent. Fairview has also had an increase in demand. Kids are getting transported to different cities, different states to find secure psychiatric services: There is that level of demand at the crisis end.

MP: Is some of this increased demand for services due to an increasing comfort around talking about mental health?

PD: The perception of the need for this kind of treatment has certainly changed over the last five years. Children’s mental health has become a topic that people are more aware of and more willing to talk about. Parents and other adults are starting to look for treatment alternatives for kids who are struggling with mental health issues. We’re not ignoring things as much as we used to anymore.

But the increase in adolescents seeking mental health care may also have to do with changes in the adult population. The majority of adolescents experiencing mental health issues these days are mirroring what’s going on with adults.

It’s great that as a society we’re finally talking about mental illness. This increased awareness gives us a language to use to describe what is going on in people’s minds. When I was in school, kids who struggled were called “weird” or “dumb.” They were isolated in a special class.

MP: The news has been scary lately. Do concerns about terrorism and security impact the mental health of teens?

Patrick Dale

Patrick Dale

PD: I think there are challenges in the world that leave some kids feeling overwhelmed or lacking in the coping skills that they need to survive. Some kids can hear about the bad things that happen in the world, like incidents of terrorism where people get killed, and they’re resilient. They can say, “The likelihood of that coming to my neighborhood is low. I’ll move on.” But other kids become really concerned about what would they do if something like that happened in their world. They lose the ability to deal with it rationally.

In the ‘50s, during the Cold War, adults would say, “Those are evil people who live far away from us.” There was the threat that someday those bad people might come here and do something bad, but it was a more abstract threat. Some kids were scared, but there was a belief back then — whether it was realistic or not — that there were things you could do to prevent something bad from happening to you. Now the treat comes from inside. Cultivating that feeling of distance doesn’t always work anymore. Safety is something kids today take seriously.

MP: What symptoms do teens exhibit when they are experiencing a mental health crisis?

PD: These feelings take on many forms. They go by many names. But they tend to manifest themselves in an overall failure to adequately participate in life. A kid might become withdrawn, end relationships, find new friends, shut down or completely separate from others. They become less verbal, less social, they have a decrease in the amount of time they spend on the activities that they used to enjoy. Sometimes, they might go in the other direction and get hyperactive.

MP: What is the Headway model of day treatment?

PD: For us, education and therapy are tied inextricably together. There are day-treatment models where the kid goes to their regular school or an alternative learning center in the morning, and then buses from school to a separate program where they get therapeutic services in the afternoon or evening. At Headway, school and therapy are tied together with the intention that as kids address their mental health issues, they can also work on developing their academic skills.

MP: Are there teens whose mental illness is so severe that it is becomes impossible for them to go to school?

PD: In a perfect world, the answer to that would be “No.” It is age appropriate and essential for kids to be educated. But sometimes, in rare instances, there are times when mental- or physical-health issues interrupt a child’s ability to learn.

MP: Can you tell me more about your new Brooklyn Center program?

PD: It is a sister program, identical to the program we’re running in Hopkins. It serves kids of the same ages. We have the same education program, the same structure, the same schedule. We located in Brooklyn Center because we want to provide a resource in a part of Hennepin County where there are a limited number of options available for kids with mental illness.

Capacity in our Hopkins program is 40. They’ve been operating at 40-45 students for the last two years. The Brooklyn Center program is also designed for 40 students. The assumption was that we would start with enrollment in the low teens. Due to strong demand, we started in the low 20s. The need for the program and the choice of location seems to have borne out.

MP: What brought you to Headway?  

PD: Some people might say that I’ve always been here! I’ve worked at Headway in one form or another for 30 years. That’s my whole career. I earned my bachelor’s degree in social work from the University of Wisconsin-Eau Claire, and then I did my internship at a chemical dependency program.

Because my family has an extensive history with chemical dependency, I always had an interest in working with adolescents and young adults in crisis. I was aware of a program known as Way 12. I knew about it because my brother had been a resident there when I was growing up. I began looking for work in the spring of my senior year in college and found out there was an opening there. I got the job. I graduated college on Saturday and started work on Monday. Way 12 was a program operated by Headway. I’ve been here my whole career.

I was lucky to find a place that shares my values. I’ve never felt the need to go someplace else for work. I have been lucky enough to be able to move up in the organization and become one of the voices that determine how we are going to treat people here — both employees and clients.

MP: What are your goals for the rest of your career?

PD: I want to work myself out of a job. In a perfect world, Headway will provide support and services that will help each client be able to move on and live their life to the highest level they can achieve. I think that in the majority of cases we are able to do that.  

I have no plans to go anywhere else. I never felt like leaving was going to provide me any better opportunities than staying would. I’m proud of my decision to stay here. This job has met all of the goals I was hoping work would offer me. 

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Culturally specific treatment center knows that one approach doesn’t work for all

When Peter Hayden, Ph.D., went through addiction treatment more than 40 years ago, he was told that if he wanted his sobriety to stick, he needed to distance himself from his community.

“It was like ‘Mission Impossible,’ ” Hayden said with an ironic smile. “They told me I had to disavow my culture and my people in order to not get ‘caught,’ in order to stay sober long term.” 

For Hayden, who is African-American, creating this kind of exclusive space for sobriety meant moving out of his neighborhood and distancing himself from family and friends.

“For seven years, I lived in a different community than the one I was raised in,” he said. “I dated different people than I had dated before. Not that I didn’t love these people that I became connected to, but where was my culture? Deep inside I felt alone.”

Hayden, who had the financial and emotional resources needed to resettle in a different part of town, has been able to find sobriety and stay sober for more than four decades. But from the beginning of his recovery journey, he knew that for many members of the African-American community, this “distance and disavow” approach to sobriety just wasn’t an option. And for those who could afford to make such a drastic move, Hayden understood all too well that the feelings of isolation that such a change could stir up might be enough to drive a person back to addiction.

So, with the support of his friend, colleague and co-founder Henry Sullivan, Hayden launched Turning Point, a culturally specific drug-and-alcohol rehabilitation program headquartered in his childhood neighborhood of North Minneapolis. Turning Point’s first incarnation was a halfway house, located in a run-down former physician’s home/office, at 1523 Emerson Avenue North in Minneapolis.   

“We wanted to be in the center of the community,” Hayden recalls. He turned the building, which had earlier served as a halfway house for the Native American community, into a co-ed rehab program with beds for 16 people. 

“It was a raggedy building,” Hayden said. “We had squirrels in the attic, cockroaches in the kitchen. But it was not what the building looked like on the outside that mattered. What mattered was what was going on inside.”

Expansive programming

What was going on inside Turning Point was an experiment: a community-based treatment center designed to serve low-income African-Americans. After a few bumpy early years, the program began to take off, and Hayden (Sullivan had moved to the role of “silent partner”) worked to expand Turning Point’s services, moving beyond a singular focus on addiction treatment to a more expansive approach that addresses the varied needs of the program’s clientele.

Today, as Turning Point nears its 40th anniversary, the program is headquarted in an expansive, welcoming building at 1500 Golden Valley Road. Designed 18 years ago specifically for Turning Point, the building features corporate offices and meeting spaces as well as residential rooms for as many as 24 in-patient clients. Turning Point’s housing division also operates two low-income apartment buildings in the neighborhood for program graduates. And Turning Point’s original halfway house, now known as Ms. Bea’s House, has been converted into group residential housing with 32 beds.

“We are in the heart of North Minneapolis,” Hayden said. “We are serving the people I saw every day as I was growing up. We want this place to feel comfortable, to feel like a place that people can walk into and feel at home and safe and ready to work on their sobriety. At the same time it’s quiet and clean and professional, just like a Hazelden.”

Turning Point's first location at 1523 Emerson Avenue North.

Courtesy of Turning Point, Inc.
Turning Point’s first location at 1523 Emerson Avenue North: “We had squirrels in the attic, cockroaches in the kitchen.”

Because they believe that substance abuse in the African-American community is tied up with other, larger societal problems like poverty and racism, Turning Point staff has built an expansive program that offers assistance to clients that goes well beyond the basic 12-step model. While achieving and maintaining sobriety remains a central goal, Turning Point also offers a wide range of services for clients, including marriage and family counseling, legal assistance, job training, health insurance guidance and housing referrals.

“We understand the community and the people who live here,” said Elizabeth Reed, Turning Point chief operating officer. “We’ve developed all of our programs specifically to meet our clients’ needs.” When a person comes to Turning Point seeking chemical dependency counseling, staff knows to look beneath the surface for the underlying roots of the problem, she said.

“A person might come to us to work on their chemical dependency problem, but if they don’t have housing, if they don’t have education, if they don’t have health care, they aren’t going to get sober. We understand that it is all connected. By providing all of these things in our programming, we are able to take that individual and not only help them overcome addition but also make sure that once they leave here they are not going right back to where they started.” 

Turning Point is committed to supporting its clients over the long haul, Reed said.

“Our objective is to stay connected with anyone who comes in for at least three to five years. You have to stay connected, to be a family. That’s the tradition of the African-American community, that connection. We often talk about that village. So what we’ve done at Turning Point is create a village where anyone that walks in our door knows that they have somewhere to go for the rest of their lives.”

Reed came to Turning Point 15 years ago after a long corporate career at US West. Hayden believes that her steady, strategic guidance has helped the organization remain relevant and effective in a changing world.

“We started as a grassroots organization,” Hayden said. “What Liz has helped us to do with her leadership is to move us up from our humble beginnings into the national playing field. But we still manage to remain an institution where people can feel comfortable. Now we have generations of people who say, ‘I was in that program, my father was in that program, my cousin was in that program.’ It’s a legacy. When people walk by, they don’t say, ‘What is that building?’ They say, ‘That building is serving our community.’ ”

Best practices

This fall, Turning Point was the subject of a yearlong best practices report conducted in partnership with the University of Minnesota’s Program in Health Disparities Research team and funded by the Office for Business and Community Economic Development’s Community Health Initiative.

The report found that Turning Point’s culturally specific approach to drug treatment is an effective model for members of the low-income African-American community. Other programs interested reaching this community may want to model their programs after Turning Point’s multifaceted, culturally focused approach, the report’s authors said.

Darryl A. Peal, executive director of the University of Minnesota’s Office for Business and Community Economic Development, said one aspect of the Turning Point program that was found to be particularly effective is its culturally sensitive “whole person” approach to addiction treatment.

“It is important that there are culturally specific treatment approaches,” Peal said. “The once-size-fits-all remedy doesn’t always work for everyone. What may work for an upper-middle-class suburban person who is chemically dependent may not work the same for someone who is part of the urban poor. Turning Point understands that.”

After nearly 40 years of success treating members of Minneapolis’ African-American community, Turning Point is now starting gain national recognition, said Angela Reed, Turning Point’s director of support services. The U of M’s best practice report helps to bolster that reputation.

“We know we are an important resource to people in the local community,” she said. “We also want to be of assistance to the national addiction community.”

Elizabeth Reed and Hayden both emphasize that 40 years in, Turning Point continues to refine and shape its treatment methods and service offerings to meet changing client needs. The program has served some 24,000 people over four decades, and they are committed to serving many more.

“The community changes, and so do we,” Hayden said. He does not want Turning Point to rest on its laurels. “Even almost 40 years in, we’re still starting to grow. A pineapple tree just grows to one height, then after about 12 years, it just sprouts straight up. That’s where we’re at right now. We’re positioned for growth.” 

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Clare Housing’s apartments for low-income people with HIV/AIDS make inroads into the community

Not all that long ago, it was hard to find a community willing to welcome a new apartment building for low-income people living with HIV/AIDS.

“Back in 2005, when we built our first building, it was a long, contentious process,” said Doug Peterson, executive director of Clare Housing, a nonprofit dedicated to providing affordable and supportive housing options for people with HIV/AIDS. “For a number of reasons, that first neighborhood was not particularly supportive of us moving in.” A decade ago, Perterson said, “there was still a sense of fear and misinformation out there that we had to work hard to get around.”

But, thanks in part to the efforts of organizations like Clare Housing, cultural attitudes about HIV/AIDS and the people it impacts have changed. Last week, when the nonprofit opened Clare Terrace, its third building for low-income people living with HIV/AIDS, neighbors and city leaders in Robbinsdale enthusiastically packed the open house.

“Robbinsdale has been unbelievably supportive of having this project in their community,” Peterson said. “I would say 50 percent of the visitors at our open house last week were folks from the community and the city. The support and welcome has just been so overwhelming.”  

This shift from community resistance to overwhelming support is significant, Peterson said, especially considering the fact that the face of HIV/AIDS has shifted, from a disease that initially struck mainly white, gay men to one that disproportionately affects poor people of color, many of whom cope with mental illness and addiction.

“Fifty percent of the folks we serve have mental illness,” said Michele Boyer, Clare Housing director of programs. “And approximately 60 percent have a substance-use disorder, either binge use or full-fledged addiction. This is very much a part of the community we serve at Clare.”

The mental illness and addiction connection

The strong connection between HIV/AIDS and drug use or mental illness exists because both conditions can increase a person’s likelihood of risk-taking behaviors.

“If somebody has a meth or crack cocaine addiction, those are stimulants that also can be highly sexualizing,” Boyer said. “If folks are using those drugs, they are more likely to want to be sexual and less likely to think about safer-sex practices when they are high. Alcohol has the same effect.” 

And serious and persistent mental illness also puts some individuals at risk of unsafe activities, Boyer said: “It increases a person’s risk of self-harming behaviors. And when you add that to poverty and homelessness, the risk of contracting HIV just gets higher and higher.”

Mood-altering substances, which are often used to help people escape from harsh realities like poverty, racism or homophobia, limit users’ ability to behave in a rational of self-protecting manner, Boyer said. And even though state needle-exchange programs have been an effective way of limiting the spread of HIV/AIDS to IV drug users, Boyer still blames drugs and alcohol for a large percentage of infections.

“Male-to-male sex remains the highest mode of transmission in the state,” she said, “but many of those transmissions occurred when a man was drunk or high. That fact isn’t reflected in the data.”

Expansion plans

Clare Housing develops, owns and manages eight residential programs in the Twin Cities for low-income people with HIV/AIDS. Three of the buildings (Clare Apartments in Northeast, Clare Midtown in South Minneapolis and Clare Terrace in Robbinsdale) are new construction; a fourth project is planned to break ground next year on Lowry and 2nd Street NE in Northeast with a scheduled July 2017 opening.

And next year, Clare Housing will expand services into St. Paul, when it partners with Project for Pride in Living (PPL) to provide supportive services to 10 units in its Hamline Station building on University and Hamline Avenues.

“PPL invited us to be part of this project,” Peterson said. “We will have 10 units there for long-term homeless people with HIV/AIDS.” 

Peterson said that Clare Housing works to construct welcoming buildings that fit into the neighborhood.

“One of the things we pride ourselves on in the design of our buildings,” he said. “If someone drove by one of our buildings, they’d see that they look just like any other market-rate building in the community. They’re welcoming places for the community, residents and staff. We want them to be a home environment.”

Clare Terrace amenities

Clare Terrace, which features 460-square-foot studio apartments, had more than 120 applicants for the building’s 36 units, Peterson said: “There are three people for every one unit available. That mirrors the statewide affordable-housing situation.”

The building will fill gradually, with 12 residents scheduled to move in in December, 12 in January and 12 in February.

Like other Clare Housing buildings, Clare Terrace will be staffed with a full-time supportive-services manger and 24-hour resident assistants who will provide assistance to residents.

Residents at other Clare buildings have an option for full home-care services like nursing care, cleaning, laundry service and congregate dining, but Clare Terrace residents are able to live more independently. The building will feature a large community room and kitchen for residents and guests.

“We may host Sunday brunches,” Peterson said, “or events where people can gather and watch the Vikings or the Packers.”

Clare Terrace residents will administer and take their own HIV medications, though in certain cases staff will be available to help them remember to keep on top of their pills and stay connected to health-care providers. “We do think that we will have some clients who will want to have prompts and reminders via phone calls our staff,” Boyer said. “We will do that. Staff will also coordinate transportation to clinic visits.”

At the top, a sober floor

One feature that sets Clare Terrace apart from other Clare Housing buildings is the building’s top floor. Designated a sober floor, it will be leased only to residents committed to living drug-and-alcohol-free lives.  

“The top floor has been designated a sober floor for folks who wish to live in a place where everyone else who lives there is working on recovery issues,” Boyer said. “This was a popular option with residents.”  

But the entire building will not ban alcohol.

“Alcohol is a legal substance,” Boyer said. “It is not illegal for our clients to have it in their apartments. We want to work with people where they are at. We are a housing-first organization.” The difference, at Clare Terrace, Boyer explained, is in the keys. “For folks who lease on the sober floor, their fob only takes them to the sober floor. People who lease on other floors cannot access the sober floor from the stairwell.”

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Groups focused on mental health and addiction honored with Circle of Excellence awards

At the 2015 Commissioner’s Circle of Excellence Awards last week, then-Minnesota Department of Human Services Commissioner Lucinda Jesson honored seven Minnesota-based human services programs for their outstanding contributions to the lives of their clients.

Three of the programs honored — Ecumen Awakenings, Pregnant Native American’s Opioid Addiction Services and Zumbro Valley Health Center — focus on serving people with mental health and addiction.  (Other honorees included Southern Prairie Community Care; Kid Connection; Community Action Duluth; and Central Converting, Inc.

Jesson, who left DHS last week for a seat on the Minnesota Court of Appeals, said that traveling around the state to learn about the work of the different programs honored was “one of the very best things about being commissioner.”

She said that the programs and services the organizations provided had real, everyday impact on the lives of human services clients, including “the ability to remain independent, the chance to keep families together, the opportunity for better employment. It is a great calling to help our fellow Minnesotans live dignified and fulfilling lives and it is important that these exceptional efforts are applauded, their stories are told and ideas shared.”

The organizations “exemplify all of the great human services work happening across Minnesota,” Jesson said.

On Monday, I spoke with representatives from the three mental-health-and-addiction-focused honorees. They told me about their organizations’ unique histories and missions.

Ecumen Awakenings

In the not-so-distant past, nursing home patients with dementia were routinely physically restrained in their wheelchairs and beds. The rationale behind this protocol was that by limiting residents’ movements, caregivers were keeping them from harming themselves. The use of restraints eventually faded after the public objected to the idea of confining elderly people against their will.

Ecumen Awakenings

Courtesy of Minnesota Department of Human Services
Left to right: Project Director Maria Reyes, Ecumen Senior Director of Quality Improvement, and Resource Utilization Shelley Matthes, DHS Commissioner Lucinda Jesson, Ecumen Chief Operating Officer Shelley Kendrick and Awakenings Quality Improvement Nurse Sonya DeSmith.

While the use of physical restraints fell out of favor, many facilities chose to restrain elderly patients with dementia in a different way: through the use of potent antipsychotic medications. Assisting a person with dementia can be challenging; on antipsychotics, elderly patients often become passive, unresponsive and easy to control.

Starting in 2010, Ecumen, a Shoreview-based nonprofit that owns and operates senior-housing facilities in Minnesota, Idaho, Nebraska, North Dakota, Tennessee, Michigan and Wisconsin, changed its approach to caring for residents with dementia. Over a number of years, it has reduced or eliminated the use of antipsychotic medications in their memory-care facilities, instead relying on nonpharmacological and biomedical approaches. This new approach to care is known as Ecumen Awakenings.

“The problem of these medications was very much like the era when we used to physically restrain people in their wheelchairs and their beds,” said Maria Reyes RN, Acumen Awakenings program director. “We weren’t trying to be mean. It was out of a place of concern. But we learned that didn’t work, and we’ve found a better way to care for people.”

Last week Ecumen was honored by DHS for its Awakenings program, which, Reyes explained, was named for “the actual experience of when we first started to reduce medication for patients in a small pilot study. We saw that people were waking out of their drug-induced stupors and coming back into life. ”

Ecumen Awakenings

Today, instead of using drugs to calm residents with dementia, Ecumen staff employ individualized care strategies designed to engage and entertain.

“The strategies vary from individual to individual,” Reyes explained. “We are trying to learn who the client is, what their likes and dislikes are, what their historical patterns are, what hobbies they enjoy. As you start to provide things in lieu of medication, you start to find things that are of meaning.”

This approach, which is now standard in all Ecumen facilities, has been found to make life better for both patients and caregivers, she said: “When you know better, you do better. And that’s the approach we have chosen.”

Pregnant Native American’s Opioid Addiction Services Collaboration

Minnesota’s opioid addiction crisis has taken a particularly fierce hold on the state’s Native American population. The subgroup within that population that has been hit the hardest of all is mothers, said Amy Langenfeld, a certified nurse midwife who works at Minneapolis’ Indian Health Board.

Langenfeld and many of her colleagues in other agencies have seen too many pregnant Native women who are addicted to opiates lose their babies to adoption — or even to death. Four years ago, a group of care providers came together to build a coalition designed to give addicted Native American mothers the support they need to beat opioid addiction, give birth to their children and bring them home.

 “We are working on the front lines in the trenches,” Langenfeld said. “Over the years, we have built connections with each other. We are people who are passionate about caring for the pregnant addict, particularly those facing opioid addiction. We’ve built a collaborative effort that traditional organizations aren’t able to do. We’ve stepped outside of traditional boundaries, and that’s what’s made us so effective.”

Opioid Addiction Services Collaboration

Courtesy of Minnesota Department of Human Services
Left to right: DHS Commissioner Lucinda Jesson; Amy Langenfeld, Indian Health Board of Minneapolis; Erika Jensen, Hennepin County’s Project CHILD; Tamara Harvanko, Hennepin County Medical Center; and Dr. Gavin Bart, Hennepin County Medical Center’s Addiction Medicine Program.

The group, which calls itself a “collaboration” because of its nonhierarchical, all-hands-on-deck approach, has seen significant success with the mothers it has served.

“I’m the entry point,” Langenfeld said. “I’ve had 68 women who’ve come to me as opioid addicts when they are pregnant. Since we started this collaboration, there have been just two women out of those 68 who have not taken their babies home from the hospital because of continued opioid use. I think that’s a significant number. That’s the piece I want to make sure we get out there.” 

Much of that success should be attributed to the Collaboration’s unique focus on the needs of the mothers, Langenfeld said.

“So often programs like these are focused solely on the baby. Through our work, we have learned that by caring for the mother with honor and respect, you save not only the mother — but also the baby and the family.”

Pregnant Native American’s Opioid Addiction Services Collaboration

Being selected as one of the seven state honorees was exciting for members of her group, Langenfeld said. For the last 4½ years, they have been so focused on individual cases that they have not been aware of their work’s larger impact.

“When you have your head down and are working so hard in a tiny little office in a tiny little community clinic, you get to see individual lives change; that’s very rewarding and that’s what we’re all about,” Langenfeld said, “but then to have the state recognize our work as a group is a huge honor. It’s nice to know that someone out there is paying attention to all the work we’ve been doing. It encourages us to keep going.”

Zumbro Valley Health Center

For nearly 50 years, the Rochester-based Zumbro Valley Health Center has been providing services for people with serious and persistent mental illness. Though the organization had been known for providing compassionate care to the region’s vulnerable population, administrators and staff wanted to provide wrap-around, integrated care for their clients. 

“We saw that our clientele had several overlapping health issues,” said Sean Rice Zumbro Valley Health Center marketing and development director. A client in treatment for a mental health issue may also have a serious dental issue or a concern related to their physical health, he explained: “We were seeing a lot of people who weren’t getting all of the treatments they needed simply because they had to travel to too many different places to get them.” 

Zumbro Valley Health Center

Courtesy of Minnesota Department of Human Services
Human Services Commissioner Lucinda Jesson and Lt. Gov. Tina Smith, standing, talk with Jenna Benson, left, and Jessie Meyer, right, from Zumbro Valley Health Center at the 2015 Commissioner’s Circle of Excellence Awards ceremony.

Beginning in 2011, Zumbro Valley Health Center began focusing on integration, offering clients services beyond mental health. The center first signed an agreement with Genoa Pharmacy, creating an opportunity for clients to have psychiatrists’ prescriptions filled in clinic. (“Psychiatrists were writing scripts but we weren’t seeing if clients were having those scripts filled,” Rice said.) Then, in 2012, they teamed with Apple Tree Dental to provide in-clinic dental care. And in 2013, Zumbro launched a primary care clinic on site.

This integrated approach provides Zumbro clients with an opportunity to care for all aspects of their health in one place, Rice said. And Center staff can work together to provide the best quality of care. 

“Now we can have a primary-care nurse, a psychiatrist, a therapist, a chemical health counselor, a case manager, all talking together about Jane Doe and her treatment. That’s the unique piece. It is the truly integrated approach to patient care that we were aiming for.”

Zumbro Valley Health Center

Last week, Zumbro Valley Health Center was recognized by DHS for its approach, which has seen significant increases in patient satisfaction and continuity of care.

“The recognition was important,” Rice said. It is a key public acknowledgement of something that staff and clients of Zumbro Valley Health Center have already discovered: “When we have multidisciplinary teams all talking with one another, care improves, and patients feel better.” 

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Loan-forgiveness program encourages mental health professionals to work in underserved areas

In parts of rural and urban Minnesota, trained mental health professionals — including psychologists, social workers, marriage and family therapists, and licensed clinical counselors — are few and far between. Patients seeking assistance for mental health needs sometimes must wait months or travel hundreds of miles for an appointment.

A new state-sponsored option aims to slowly chip away at this shortage. Beginning this year, mental health professionals have been added to the Minnesota Loan Forgiveness Program, which was developed to ease the debt burden of health-care workers and encourage them to work in an underserved area of the state. This means that a cohort of recent mental health graduates willing to work for three to four years in one of the state’s designated Health Professional Shortage Areas will receive funding to pay off an average of 60 percent of their college and graduate-school loans.

Applicants had to apply for this new program, and some 15 recipients — from a mix of mental health professions — will be chosen for fiscal year 2016. 

“Over the last couple of years there’s been a lot of reporting on the looming health-professional shortage,” said Will Wilson, supervisor of the Minnesota Department of Health’s Primary Care Financial and Technical Assistance Unit of the Office of Rural Health and Primary Care. “Basically we have more patients and fewer practitioners. A number of people,” at the State Legislature and at workforce and education task force meetings, “have been thinking about strategies to address these shortages.”

Loan forgiveness was one of the more popular strategies that was raised at these meetings, Wilson said. Mental health workers, who are usually required to complete college and graduate degrees, are often underpaid, especially in rural areas of the state.

“The mental health worker shortage in those areas is especially significant,” Wilson said. When you combine lower pay with higher educational requirements, it makes it hard to attract workers. “That’s why mental health workers were added to the program this year.”

Legislative focus on mental health

Before mental health professionals were added, Wilson said that the Minnesota Loan Forgiveness Program budget was just $740,000 per year: “It wasn’t very much at all. We only had 15 or 16 recipients total for all professions.” But in the 2015 legislative session, after state lawmakers made significant increases in mental health funding, the budget swelled. “It was a big year in the legislature for mental health initiatives,” Wilson said, “Now we’ve been budgeted for $3.25 million per year for all professions in the program.”

With relatively short notice of the expanded funds, Wilson and his colleagues scrambled to let people know about the new program.

“We tried to blanket all of the schools that graduate people in mental health programs,” Wilson said, adding that the program is staffed by himself just two other colleagues. “We also reached out to the associations, the boards, everybody who has a stake in it and could help us get the world out. We told as many people as we could, using our tiny little bullhorn. We got a pretty good response, about 20 applications. So it will be competitive. It was more than we expected for the first go-around. It shows the demand is there.” 

Applications for 2016 are being reviewed now and awards will be announced in the next couple of weeks. Applications for fiscal year 2017 are being accepted until Jan. 4, 2016.

First talk, and now action

At the Legislature, there’s been talk of trying to increase the number of mental health workers in shortage areas for years, said Sue Abderholden, NAMI Minnesota‘s executive director:  “We’ve been working on this issue since 2013. Basically we never had a real plan before. People would talk about it, but nothing was ever done.” 

Adding mental health graduates to the loan forgiveness program is a good first step toward increasing access to mental health services across the state, Abderholden said: “If you want to build a mental health system, you need people to run it. So this is an important piece.”

State Sen. Greg Clausen

State Sen. Greg Clausen

Sen. Greg Clausen, DFL-Apple Valley, was an advocate for the program. “I was a principal at Rosemount High School,” he said “I saw far too many cases where a student needed mental health counseling and they were unable to get an appointment in a timely matter.”

The shortage of mental health workers in urban and outstate areas, Clausen said, “is pretty dramatic. This is a real problem that we need to address. We need to bolster the work force.” 

And loan-forgiveness program recipients tend to stay in the community, Clausen said. “From the studies we’ve seen, it looks like almost 80 percent will stay. That’s a good number.”

One element of the program that Abderholden wants to make sure doesn’t get pushed to the side in coming years is an initiative focused on attracting diverse applicants to the loan-forgiveness program. It is key — in rural and urban areas — that patients see health-care professionals who reflect their cultural experiences and backgrounds.

“Our original hope was there would be separate set-aside money to work on diversity,” Abderholden said. “It ended up being folded in. We’re OK with that, but we just want to make sure that our outreach efforts into communities of color and immigrant communities continue to be strong.” 

How the program works

To be approved for the Minnesota Loan Forgiveness Program, Wilson said that applicants must be graduates of mental health training programs. And, most importantly, he added: “they need to have debt. Otherwise the incentive doesn’t work. They need to be licensed already or be recent graduates. We give preference to recent graduates because often they are usually younger and looking for a community to practice in. There is a better chance with somebody who’s just starting out that they’ll move somewhere and make a life for themselves in the community.”

The central feature of the program involves an agreement that award recipients will work in an underserved community for a minimum of three years. A fourth year of service is optional, Wilson said. The hope is that after their years of service, they will stay, because they have a made a home for themselves in the community.

Total awards vary, depending on profession and debt size. Wilson explained that the average award for psychologists, who face a higher debt burden post graduation, is $12,000 per year, to be used to pay off educational debt. The average award for licensed social workers and marriage and family therapists is $7,000 a year, he said.

Payments go directly to the award recipient. “We give the professional the award, they work in an underserved community and at the end of the year they give us their bank statements to show that they used the money to pay back their loans,” Wilson said. “After four years on average the loan recipient will have 60 percent of their loans paid off.” 

If an award recipient moves away from an underserved area, he or she is no longer eligible for the program.

“If they leave for any reason, there is a penalty,” Wilson said. “They have to pay all the money back plus interest. But it is rare for someone to leave because we select the best people, people who are committed to serving the underserved.”

Life in the field

Working as a mental health professional in an underserved community is not for everyone. There are reasons communities like these are underserved, including lower pay for workers, community poverty, rural isolation and complicated social problems in communities. For medical professionals, it takes a true commitment to service to look beyond “easier,” sometimes higher-paying work and head to where the need is greater.

“It takes a certain type of person to want to go out and work in a rural area,” Wilson said. “The same can be said for some communities in the metro area.”

In underserved urban areas, mental health professionals may be working with “people with more acute needs,” Wilson said. “That can be very challenging.” 

That said, the new program has proved popular among recent graduates.  “We’ve already had more applications than we can fund,” Wilson said.

As word of the program has spread, the next round of applications has attracted even more interest. 

Sue Abderholden

Courtesy of NAMI-MN
Sue Abderholden

“We might get 40 applications this cycle,” Wilson said. He and his colleagues will use the same standards to review applicants for the next fiscal year. With such a significant sum at stake, the bar has been set high.

“We are looking for people who are committed to helping the underserved. This means that they have demonstrated that commitment through their academic history. We want people to show how they are culturally competent and are the best of the best.”

With each year, as more and more recipients are added to the pool, the number of available mental health professionals practicing in shortage areas will increase.

Award recipients won’t have a hard time finding a job. “If they are going into an underserved area, they’ll have people stumbling over themselves to hire them,” Wilson said. “The demand is so great.”  

Abderholden cautions that while she believes programs like this one are a good first step, there is still much more work to be done if we want to make sure that all Minnesotans have access to high-quality mental health care.

“Every new person in these fields is a new person,” she said. “And that’s good. Clearly they are needed. Part of our work is to make sure that mental-health graduates know that this program exists for them. If they do, we think it will continue to grow. It is a good thing. But it’s not going to fix everything in the next year or two. We have to look at this as a long-term strategy.” 

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Opioid abuseopioids

Statewide billboard campaign aimed to spread positive message about reversing opiate overdose

If you’ve driven just about anywhere in Minnesota in the last month, you’ve probably seen a billboard featuring a picture of a smiling, clean-cut person that read, “The Greatest Side Effect? Life. Carry Naloxone. Reverse An Overdose.”

The monthlong statewide campaign, sponsored by the Minneapolis-based Steve Rummler Hope Foundation, was designed to educate the public about Naloxone, a powerful drug that can reverse the potentially fatal effects of an opiate overdose. Naloxone is also known as Narcan.

The Rummler Foundation was named for Steve Rummler, an Eden Prairie man who died in 2011 from a heroin overdose. Rummler’s addiction started in 2005 after he was prescribed an opiate-based pain medicine for chronic back pain. After completing one in-patient addiction-treatment program and one pain-management program, Rummler turned to heroin when his painkiller prescriptions ran out.

The Rummler Foundation has been the driving force behind Steve’s Law, a Good Samaritan law that was passed by the Minnesota State Legislature in 2014. Steve’s Law provides people who alert authorities in the case of an opiate overdose with protection from drug charges. 

“Over 70 percent of the time, there is a witness to an overdose,” said Lexi Reed Holtum, Rummler Foundation vice president. Thanks to Steve’s Law, Holtum explained, “people in Minnesota acting in good faith can call 911 to report an overdose — even if there is drugs or drug paraphernalia on scene. They will receive limited immunity from prosecution if they are calling to save someone’s life.”

Spread the word

An anonymous donor gave the Rummler Foundation enough money to run the billboards for 30 days in 40 locations across the state, Hotum said. The cost ran somewhere between $150,000 and $250,000.  

“It was a generous donation,” she added. “This is somebody who feels this issue is incredibly important. They made a huge gift to us so we could put up this campaign. They felt it was important to educate the public about the issue.”

The campaign’s developers hoped that the billboards would have several effects. Increasing awareness about Naloxone and Steve’s Law were central, Holtum said, but they also banked on other corollary benefits.  

“We didn’t want to limit this campaign,” Holtum said, explaining why the billboards’ messages may have seemed vague to some viewers. “We wanted to raise questions, to get more people talking about opiate overdose, and we thought that was a good way to do it.” The clean-cut folks on the signs? Real people who’d survived an opiate overdose, thanks to Naloxone, Holtum explained: “We wanted to show that people with addiction look just like everyone else. We hoped these images would help make the stigma around addiction disappear, that they would help people focus on the powerful, positive things that can happen when somebody’s life is saved.”

Jazmin posing in front of a billboard featuring her image.

Courtesy of the Steve Rummler Hope Foundation
Jazmin posing in front of a billboard featuring her image.

The foundation also used the billboards to promote an Indegogo crowdfunding campaign focused on collecting donations to help fund and purchase Naloxone “rescue kits.” The Rummler Foundation’s kits, which contain doses of Naloxone, a breathing barrier device, an instruction card, alcohol wipes and gloves, are distributed to people who spend time around individuals at risk of opioid overdose, including friends and loved ones, staff at sober living homes and treatment facilities, church congregations, and colleges and community organizations. The Rummler Foundation assembles and distributes the kits statewide out of hospitals and emergency departments. They cost around $25 each to distribute, Holtum said.    

“We had a huge stretch goal with the Indegogo campaign,” Holtum said. “We thought, ‘Let’s see if we can raise $50,000.’ We knew this would be a far-reaching goal.” At the end of the campaign, the foundation had raised 19 percent of their goal, but Hotum said: “We still consider that to be a success because we had many people talking about the rescue kits and what it is we’re trying to do with them.” 

Positive response, but more work to be done

Response to the campaign has been positive, Holtum said. The billboards inspired important conversations about opiate addiction and overdose — which was just what the ads’ creators had hoped for all along. 

“We had some terrific responses,” she said. “We had individual people reaching out to us, sharing their personal stores of not only lives saved because of Steve’s Law but also lives lost because of overdose. We had a really good amount of people responding and starting to have conversations around the topic.”

The more people who talk about addiction and overdose, the better, said Holtum. She was engaged to Rummler when he died, and launched the foundation with his parents. Steve’s mother, Judy Rummler, is the foundation’s president.  

“We were very happy with the conversations that this billboard campaign started,” Holtum said. “We know that it had an impact. Was it enough? It’s hard to say yes, because there’s always more to do.”

Holtum talks about their being “more to do” because she believes that, despite the work of organizations like her own, the opioid-addiction crisis is still going strong in the state. Public-service campaigns help raise awareness about the dangers of opioids, she said, but the drugs are just so addictive and readily available that stemming the tide can sometimes feel impossible. Opioid addiction is a problem in every part of the state.  

Take the town of Eden Prairie, for instance. “I live in Eden Prairie,” Holtum said. “Steve and I lived in Eden Prairie when he overdosed and died. Last month we ran this campaign. We had so many successes: We contributed to important conversations and maybe even to lives saved. But last month in Eden Prairie we also had three opiate overdoses. Two people died. One life was saved. That’s not enough.”

Holtum is passionate about the topic. It’s clear she’s in it for the long haul, committed to saving lives and changing attitudes about addiction. She took a deep breath and continued: “It’s a hard topic to talk about because no matter how many successes we have, there is still so much more to be done. There are so many more lives to save. Addiction is a nondiscriminatory, equal-opportunity disease that crosses all social and economic levels. It’s a brain disorder that can be deadly. And we have to treat it that way.”

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Piper Meyer-Kalos: Prompt, focused treatment after psychosis is key to individual resilience

There was a point in our history when once a person experienced an episode of psychosis they were considered damaged goods. Often heavily medicated, they were isolated from society, locked away in psychiatric institutions, or, at best, encouraged to quit work or school and stay at home.

Things aren’t that bad these days, but the current system of care in the United States for people with schizophrenia could use some improvement, said Piper Meyer-Kalos, Ph.D., executive director of the Minnesota Center for Chemical and Mental Health at the University of Minnesota.

For the past six years, Meyer-Kalos has been part of the psychosocial development team of the Recovery After Initial Schizophrenia Episode (RAISE) project, a federally funded study that investigated best practices for treating people after their first psychotic episode.

Recently, increasing emphasis has been placed on the promise of prompt treatment after first psychotic episode. The RAISE project, which focused on intensive treatment to help people with schizophrenia get back to normal life, recently published the results of their research in the American Journal of Psychiatry. The study found that lower doses of drugs, combined with intensive therapy and individual resiliency programs, produced better results over a two-year period than the treatment methods most commonly used in the United States. 

Recently, I spoke with Meyer-Kalos. She told me about her research — and about her belief that people who have experienced psychosis can go on to live happy, productive lives.

MinnPost: You are part of a team that has recently published intriguing research focused on treatment methods for people who’ve experienced first-episode psychosis. Can you tell me more about your work?

Piper Meyer-Kalos: The project that I’ve been working on started in the United States in 2009. I’m part of a team headed by John Kane from the Feinstein Institute for Medical Research at Long Island Jewish Medical Center. Our research wrapped up in 2014 and we’ve been analyzing our results for about a year.

The research was focused on developing effective intensive treatment methods for people who have experienced first-episode psychosis. Across our borders in Canada and Europe they’ve been talking about the importance of this form of intensive treatment for first-episode psychosis for some time. In the U.S., we were a little behind, though some American programs have developed this form of treatment organically, popping up in cities around the U.S. This trial was an effort to establish best practices for this model of treatment.

Developing a new model of treatment for first-episode psychosis is important because what we are finding out is that the earlier that you address treatment for people who have experienced their first episode of psychosis the better their overall outcome can be. The earlier people are treated, the better the chance they have to change the trajectory of their illness and improve the quality of their lives.

MP: How does this intensive model of treatment work?

PMK: Our treatment model, which we call NAVIGATE, combines family education, individual therapy, supportive employment and education and medication therapy. It’s an intentional combination of these psychosocial rehabilitation models.

Piper Meyer-Kalos

Piper Meyer-Kalos

It’s a team-based approach. We believe that it’s really important that these therapies are used together. We think having all options available to the patient and then working together with the patient to maximize engagement is what works the best and gets the best outcomes.

If we address patient needs with a team-based approach, we can better address the patient’s immediate and ongoing needs and help them get on with their lives. After a psychotic episode, people want to get back to work and school and their friends and families. The hope is that this treatment will help them avoid having to go on disability and step away from life. We want to help change that trajectory so that they can more fully recover from psychosis.

MP: How is this approach different from the way psychosis is commonly treated in the United States?

PMK: In the U.S., the typical treatment model is that people who have had episodes of psychosis are offered several different types of treatment in separate locations. So they’ll see a prescriber to get their medication. Then they’ll see someone else for case management. Then maybe, if they’re lucky, they can participate in group therapy or individual therapy. But they usually have to go somewhere else to access that.

Because these treatment options are so spread out, people often have a hard time actually getting access to all the types of services they need to get better. Sometimes a person who might be just coming out of the hospital might get lined up with a prescriber, but the other services are much more inaccessible. Then it takes time to get all the services in place.

MP: So how was your trial designed?

PMK: It was a cluster-randomized trial that was offered at a number of community-based treatment centers in over 20 states across the U.S. that serve people with serious and persistent mental illness. We randomized our study by site, not by individual people at each site. Half of the sites in the study used the NAVIGATE approach to treatment. The other half used what we called “community care,” or the existing treatment that was available at that site. A total of 404 people were enrolled in the study.

There was a strict criterion for participation in the study. It had to be the subject’s first episode of psychosis. They also had to have less than six months of lifetime exposure to an antipsychotic medication. We wanted to work with people who had little exposure to medication treatment. We wanted to get them early on to see if we intervene at an early level can we make a bigger impact.

 MP: How did your NAVIGATE teams work with patients?

PMK: The NAVIGATE teams consisted of a project director, a family education specialist, a prescriber — either a psychiatrist or a nurse practitioner — a supportive- employment specialist, and what we call a “resiliency specialist.”

When people came into the clinic, they were greeted by every member of the team. Then they got orientation about all the components of the program. After that, based on their needs, patients would see some team members more than others. It was a very flexible model. We focused on the things that the clients told us were most important in their lives. If a client wanted to go back to school and work, for instance, that was our main focus. The treatment was client-driven.

 MP: Why was the team approach central to the NAVIGATE model?

PMK: The NAVIGATE team-centered approach really improves the quality of care and allows providers to focus on the individual. When we worked as a team, we were constantly looking at ways to collaborate and piggyback, ways to make the treatment program work best for the individual patient. We had weekly team meetings. In those meetings we would talk about ways we could support patients in their recovery. We also had treatment-team meetings in which the client, their family members and their team members met together so we could talk about new about ways to support the client in their treatment and healing.

 MP: What were your study’s central findings?

PMK: We’ve only just begun to really dig into this data. The research that was published in the American Journal of Psychiatry included the major outcomes of our study. We found that people in the NAVIGATE program stayed in treatment longer. They had a greater percentage of time in work and school. Our most important outcome was that study participants reported greater improvement in their quality of life. They also had a lower number of symptoms than subjects treated in the traditional programs.

MP: How did you get interested in this kind of research?

PMK: My research and work has centered on developing psychosocial treatments for people with schizophrenia. I’ve done work in manualized treatments and developing trainings for providers.

I’ve always worked with people with multiple episodes of psychosis. It became really interesting to me when the opportunity presented itself to be part of this research. My colleague was able to become part of the group that was developing NAVIGATE, and he invited me to join him. I was really interested in emphasizing recovery and resiliency.

I’ve also done a lot of work in positive psychology and what that approach might do in the treatment and recovery of this population.

MP: What role do you think positive psychology can play in the treatment of schizophrenia?

PMK: Most of the research that is out there about schizophrenia has always focused on questions like, “How do we help people work with their deficits or the areas that they need to improve in their lives?” What I think is so interesting about positive psychology is that instead of focusing on deficits we talk about how we can enhance people’s existing positive qualities. Focusing on people’s positive qualities becomes just as important as remediating their deficits.

MP: Talk of “deficits” does seem like it carries a feeling of shame. Is that why some people avoid seeking treatment for mental illnesses like schizophrenia?

PMK: The stigma that still exists around metal illness places a lot of pressure on people who have been diagnosed with a major mental illness. They think, “If I am diagnosed with this mental illness, then I won’t be able to do X, Y and Z.” The self-protective impulse would be to say, “I must not have this mental illness, I must not seek help for it, because I can still do X, Y and Z.” 

Eventually, with the right treatment, people with schizophrenia can come to a point where they realize, “This illness is something that I can manage and still continue to live my life. It’s part of who I am, but it doesn’t define who I am. It’s one piece that makes me who I am.” That response can be a result of this kind of treatment.

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