CONTEXT COUNTS IN CARING FOR CHEMICALLY DEPENDENT KIDS AND FAMILIES

By Andrew Malekoff©

Despite feeling blindsided, many of us now know that we are living in the midst of an unprecedented drug epidemic. According to the U.S. Department of Health and Human Services, since 1999, the rate of overdose deaths including prescription pain relievers, heroin and synthetic opioids such as fentanyl, nearly quadrupled.

In the intervening years, many steps have been taken to help save lives. These include improving prescribing practices and expanding access to medication-assisted treatment and the use of Naloxone. 

Medication-assisted treatment combines behavioral therapy and medications such as methadone or buprenorphine to treat opioid addiction. Through affordable, accessible and quality care people can recover and go on to live productive lives.

Naloxone is used to treat a narcotic overdose in an emergency situation by reversing the effects of opioids, including slowed breathing or loss of consciousness.

Notwithstanding the increased attention to lifesaving measures, there is relatively little focus on the devastating impact of addiction on children living in families where a parent is addicted to drugs or alcohol.

There are more than 8 million children under 18 years of age that are growing up in homes with alcohol and other drug-abusing parents. These young people are likely to become alcohol or drug abusers themselves without intervention.

Parental alcoholism and drug addiction influence the use of alcohol and other drugs in several ways. These include increased stress and decreased parental monitoring that contributes to adolescents’ joining peer groups that support drug use.

Children who grow up with an addicted parent learn to distrust to survive. When unpredictability dominates one’s life, he or she is likely to be wary, always sensing disappointment lurking nearby.

Children growing up with an addicted parent become uncomfortably accustomed to living with chaos, uncertainty and unpredictability. When a child grows up under these conditions, they learn to guess at what normal is.

Denial, secrecy, embarrassment and shame are common experiences of children who live with an addicted parent. Even seeking help outside of the family might in itself be seen as an act of betrayal, a step toward revealing the family secret. The stigma of addiction can leave chemically dependent persons and family members feeling utterly alone in the world.

Children who grow up with an addicted parent live with the unspoken mandate - don’t talk, don’t trust, don’t feel.

Growing up with an addicted family member leaves children with little hope that things will ever change. I am reminded of a parable about the small village on the edge of a river.

One day a villager saw a baby floating down the river. He jumped in the river and saved the baby. 

The next day he saw two babies floating down the river. He and another villager dived in and saved them. Each day that followed, more babies were found floating down the river. The villagers organized themselves, training teams of swimmers to rescue the babies. They were soon working around the clock.

Although they could not save all the babies, the rescue squad members felt good and were lauded for saving as many babies as they could. However, one day, one of the villagers asked: "Where are all these babies coming from? Why don't we organize a team to head upstream to find out who's throwing the babies into the river in the first place!"

Mobilizing resources to pull babies from the river, while neglecting the ones left behind makes no sense.

Published in Behavioral Health News, FALL (2) 2017 Issue, Volume 5, Number 2, p. 20

ANIMAL ASSISTED THERAPY FOR VULNERABLE YOUTH

By Andrew Malekoff©, Summer 2018

For almost two decades, my agency, North Shore Child & Family Guidance Center has been utilizing Animal Assisted Therapy (AAT) in outpatient mental health work with youths and their families, working in partnership with local canine and equine organizations.  An adjunct to traditional therapy, AAT relies on the human-animal bond in goal-directed interventions as an essential part of the therapeutic work. 

According to leading AAT expert Cynthia Chandler some of the reasons to include animals in therapy are:

1.     Consumers may be more motivated to attend and participate in therapy because of a desire to spend time with the therapy pet.

2.     Consumers may receive healing nurturance and affection through physical contact with the therapy pet.

3.     Consumers may experience genuine acceptance by the therapy pet.

4.     In many instances . . . consumers may be able to perform activities and achieve goals that would not otherwise be possible without the assistance of a therapy pet.

Following is an illustration of animal assisted group work using a therapy dog to build social competencies and self confidence in group members.

In a group that was composed of early adolescents who were identified as painfully shy or socially awkward, the group members were all drawn to the therapy dog Elvis, who was introduced as a new “group member.”

Everyone wanted to pet Elvis, a Basset Hound, and feed him treats. The norm in groups like this is to earn time with Elvis by taking steps forward in skill development. For example, speaking up and talking about one’s experiences in the previous week could earn time with Elvis. In addition, the work is metaphorical in the sense that the group members are directed to notice things about Elvis. 

For example, one group member says, “Elvis looks a little shy.” To which the worker asks, “How can you tell?” This ignites a process in which members begin to build their powers of observation and reading non-verbal cues, for example.

In animal assisted groups the group worker must work closely with a co-facilitator, the animal handler. The handler is like an interpreter who can teach about his or her dog. For example, “This is how Elvis will show you if he is a little shy and here is how you can approach him.” The group members transfer learning by observing and learning about and interacting with the animal. They can then practice without being hit over the head with it by being lectured to.

Success comes by noticing the animal or by failing to do so. For example, if an animal shies away, group members learn that maybe he needs some quiet time. In other words, the members discover that there are lessons learned from not having their wishes fulfilled all the time.

Having an animal handler as a co-leader is not very complicated since their role is circumscribed. The handler is an interpreter who loves to talk about the personality of his or her dog and its uniqueness. They can humanize how the dogs speak and keep appropriate boundaries (e.g. not rushing at someone socially). Using dogs are a little easier to arrange for logistically, but there are a growing number of settings that offer equine facilitated therapy, which add another dimension to group work for shy and awkward youths.

According to my North Shore Child & Family Guidance Center colleague social worker Lee Holtzman, Animal Assisted Therapy is a viable alternative to work with children and youths who have a history of trauma. Expanding research in the area of how trauma affects the brain has highlighted the role of adjunct therapies such as yoga and animal assisted therapy, for example, to help people safely regain the ability to feel their bodies and to uncover and release painful memories stored in the body.

Finally, two guidelines to keep in mind when planning to use animals are: (1) Seek parental permission. This is particularly relevant to culturally sensitive practice. There are certain cultures that may have strong attitudes towards human-animal interaction that might preclude practice with animals. In any case, engaging parents in the process is a must; and (2) Screen for proper credentialing and training. Carefully screen animals and handlers to be sure that they are properly trained and credentialed.

Published in the New York State Behavioral Health News, Summer issue 2017

DEPRESSION, SUICIDE, DISCRIMINATION AND PARITY

Depression, Suicide, Discrimination and Parity

By Andrew Malekoff© Summer, 2018

In the immediate aftermath of the suicides of Kate Spade and Anthony Bourdain Gov. Cuomo issued a press release about new funding to address the rising rate of suicide.

He stated: "Two high-profile suicides this week put mental illness front and center, but while those names were the ones in the press, every day there are thousands of New Yorkers who struggle with suicidal thoughts, and we must do everything we can to support them. Depression does not discriminate. It affects every part of society and people from all walks of life."

I applaud the Governor for bringing this matter to light. He stated, “Depression does not discriminate.” Nevertheless, health insurers that do not comply with federal parity law, denying timely access to care, do discriminate. When New York State government does not enforce this law, they aid and abet discrimination against the “thousands of New Yorkers,” who the Governor referred to as those “who struggle with suicidal thoughts”.

The difficulty people have accessing mental health and addiction care is not simply a matter of stigma. It is a matter of discrimination. This is a civil rights issue that an announcement of new funding alone will not solve.

On December 15, 2017, North Shore Child and Family Guidance Center held a press conference at its headquarters in Roslyn Heights and issued the results of a research study – Project Access that we conducted in collaboration with LIU Post Department of Social Work. 

In this year-long study, hundreds of Long Islanders were surveyed about their experiences attempting to obtain help for mental health and addiction problems.

Of the 650 Long Islanders who took part in the survey, almost half said that it was more difficult finding help for mental health or substance abuse problems than finding help for physical illnesses, nearly 40 percent said that their insurance company did not have an adequate number of providers and two-thirds said that their insurance company was not helpful to them in finding a suitable provider for themselves or a loved one.

NY State Senator Todd Kaminsky, who attended the December 15th press conference, stated that the findings were “Damning.”

In a bipartisan effort, Kaminsky and Senator Elaine Phillips wrote to the Department of Financial Services (DFS) on January 9, 2018 citing the Project Access study and requesting “a thorough investigation to determine why insurance companies are not being held accountable for network adequacy.” Network adequacy is the part of the federal parity law that states that health insurers who cover mental health and addiction care must have an adequate number of providers in their network. Many more people wrote directly to Gov. Cuomo, requesting the same.

Almost five months later Scott Fischer, Executive Deputy Superintendent for Insurance, a division of DFS, responded in writing to the Senators. Fischer wrote: “DFS’s review of the various networks has confirmed that each of the insurance companies in Long Island exceeds the standards for mental health and substance use providers, for the purpose of the commercial products sold outside of NYSOH.”

Translation: There is no problem. There is nothing more to do. This does not square with the results of Project Access.

Health insurers and government ignoring federal parity law is discrimination. When it comes to suicide prevention: access delayed, is access denied.

Discrimination deserves a place alongside stigma when the conversation turns to access to care.

It’s a matter of civil rights.

Long after the tragic deaths of Kate Spade and Anthony Bourdain fade from the front pages, the lack of compliance and enforcement of federal parity law will persist and the thousands of people that the Governor spoke of in hispress release will still be unable to access care.

Published in the New York State Behavioral Health News, Summer 2018 issue

WHAT IS TODAY'S AMERICA MAKING OUR CHILDREN SUSCEPTIBLE TO?

By Andrew Malekoff© June 22, 2018

There are a few great films that have lingered in my consciousness; images are seared in, memorable lines are indelible and feelings evoked are still close to the surface. 

The White Ribbon (2010) is one such film that has left a lasting residue. It depicts the residents of a northern German village, dominated by a baron, sometime before World War I.

Inhabitants of the village young and old are sliding down a slippery slope of moral decline. A number of men in leadership positions are despicable, especially in their treatment of women and children.

The cruelest scene of the movie was not one that showed physical violence, but verbal abuse towards a woman that served faithfully as caretaker and more for the town's widowed physician.

As for some of the children, although it is only suggested it appears that they are budding sociopaths that perform serial acts of meanness.

Movie reviewer Mike LaSalle wrote about the film, “No child is trained to become a martinet, and no one says anything about a master race. Rather, the kids, from their elders, get quiet lessons in moral absolutism, sternness, emotional violence and heartlessness.”

Weeks after seeing the film, I started thinking more deeply about the children in this pre-World War I town. I realized that they would become young adults during the time Hitler would rise to power.

They lived an incubator in which they adopted the brutality that they experienced, often against unsuspecting victims. They were being unwittingly primed for carrying out the atrocities that later came to characterize their future lives in Nazi Germany.

Seeing this film has led me to wonder about what the times we live in today are a prequel for.

As LaSalle remarked, “It didn't have to be Nazism that took hold a generation later. It might have been any ideology that encourages blind devotion that flatters people's vanity by telling them they're intelligent for not thinking and that they're virtuous for believing themselves better than their fellow citizens.”

The White Ribbon begs the question: What is today’s America making our children morally susceptible to?

Published in the Blank Slate Media in June 2018

SETTLING IN, CHICKEN-STYLE

By Andrew Malekoff©, July 2018

It’s a common refrain heard in classrooms and at dinner tables all across the country: “Why won’t you just sit still?” Sometimes, with kids who seem especially hyperactive, there is an all-too-quick leap to giving the “problem” a psychiatric label and pulling out a prescription pad.

Although I’m a clinical social worker by training, I find that alternative sources of knowledge (what some may refer to as old-fashioned common sense) sometimes fit best. Here’s an example:

I recall a meeting with my colleagues regarding a newly formed after-school program for teenagers. A shared frustration was getting things started on time. After some conversation, it became clear that the kids eventually settled down, but it always took more time than the adults deemed necessary.

One of the women, my longtime colleague Dr. Nellie Taylor-Walthrust, an alcohol and substance abuse counselor and pastor, asked her colleagues, “Did any of you ever live on a farm?” They all signaled that they hadn’t. She smiled knowingly and responded, “Well, I did. And when you grow up on a farm you notice certain things.”

She went on to explain, “I’ve been watching closely, and in the after-school program I’ve noticed certain behavior by a number of the youngsters each time they come to the group.

Whether they arrive early or after the group has already begun, they perform a certain ritual before connecting more consciously with what is going on in the group. It goes something like this: They move the chairs several times, place certain objects—coat, sweater, book bag—in a certain position on or near the chair, collect objects from their pockets or begin to crumple paper and place it in the waste basket, and so on. When confronted about their distracting behavior, they often reply, ‘Okay, just one minute,’ meaning that they hadn’t quite completed their settling-in process.

“After weeks of observation, I was reminded that I had seen chickens perform similar rituals before laying eggs. I often wondered why they didn’t simply walk in, lay their eggs, and walk out. But instead, they would survey the nest, scratch and peck some more, and sit down again.

This behavior continued until they felt settled in. When the process was interrupted, I observed, they would start the ritual all over again. Now, I’m not suggesting that some youngsters are like chickens, but there seems to be a similarity in their need to release a certain amount of energy in order to focus on the task before them.”

Nellie’s “down home” observations captured the essence of the young people’s waking moments. The milling process seemed to be a normal resistance brought on by the daily residue of feelings either about home or school, perhaps intended to sidestep the work at hand.

For most kids, milling is a natural and normal process to be respected and left alone, as opposed to a manifestation of a disorder or some form of pathology. The kids eventually settled down and attended to task, as did the chickens.

This tale of the chickens had a soothing effect on Nellie’s colleagues, whose patience increased as a result.

What does this story about restless kids and chickens preparing to lay eggs mean? Sometime a kid is just a kid. That’s not to say that, for some, careful examination, diagnosis and specialized care are necessary and should be sought.

But for the others? Well, sometime they’re just being chickens. I mean kids. 

Published in the Long Island Weekly in July 2018

THE LIVES OF BLACK MOTHERS AND BABIES

By Andrew Malekoff© May 2018

In a report issued by Nassau County’s Department of Health - Community Health Assessment and Community Health Improvement Plan (2016-2018) – there is no mention of maternal mortality or information on social and environmental risk factors for women and infants of color. Consequently, no initiatives to address maternal and infant mortality disparities are recommended, yet overall Nassau County health data indicates that it ranks at the top of all counties in New York State.

To address this “invisible injustice,” maternal and child health advocates convened at Hofstra University on March 23, 2018 for a Birth Equity Breakfast organized by the Nassau County Perinatal Services Network.

Birth equity refers to the assurance that all human beings have the best possible births, buttressed by careful attention to racial and social disparities. 

Keynoter Dr. Martine Hackett, assistant professor at Hofstra University’s School of Health Professions and Human Services, presented data from the NYS Department of Health that showed the disparate outcomes for Black mothers and babies as compared with their White counterparts.

Infant mortality refers to the death of children before their first birthdays, which is a key indicator of the overall health of a population. According to the United Nations International Children’s Fund (UNICEF), Japan is the number one ranked country for newborn survival, while the United States ranks only 22nd in the world.

Among the eye-opening data that Dr. Hackett cited are the differences between the infant mortality rates in contiguous communities in Nassau County. For example, in Roosevelt there were 11.1 infant deaths per 1,000 births from 2012-2014, while neighboring Merrick had zero deaths. Overall, in Nassau County the Black infant mortality rate is more than four times that of the White infant mortality rate and even higher than in New York City.

Dr. Joia Creer-Perry, President of the National Birth Equity Collaborative, spoke about the perception of Black mothers and the barriers to receiving holistic care by the health care system. If a woman is living under great stress she will have trouble carrying her baby to term. Premature birth to underweight babies is a leading cause of infant mortality.

Social justice activist and attorney Fred Brewington condemned the institutional racism prevalent in healthcare that has resulted in infant mortality figures today that are no different than they were almost a century ago.

Just weeks after the Birth Equity Breakfast, Tasha Portley, a nurse living in Tyler, Texas, spoke at a similar forum halfway across the U.S. In a report published in the April 16th edition of the Tyler Morning Telegraph, Portley stated that “Pregnant Black women often experience casually degrading remarks from White people when they seek maternal health care.”

Portley shared the story of a Black woman who had some difficulty acquiring a breast pump from a local social services agency and, in the process, was the target of demeaning remarks by an employee. Portley went on to say, “We are dying because we are Black and we are living in a country where there is inherent racism. It is systemic. It is the thread; it is the fiber of everything that exists.”

Dr. Hackett highlighted what needs to happen in order to turn the corner on disparities in Nassau County. Among her recommendations were to inform women after childbirth of warning signs for hemorrhage, embolism or infection, especially when there are preexisting conditions; to enhance service integration for women and infants; and to treat women of color with dignity, respect and culturally relevant care.

Bringing birth inequities to light is an important step forward. When this issue is not identified in Nassau County health data, people don’t know about it and it cannot be addressed. The breakfast concluded with the unveiling of the Birth Justice Warriors, an initiative envisioned by Dr. Hackett, to train birth advocates with the hope of ameliorating the birth inequities in Nassau County.

Published in the Long Island Weekly in May 2018

AMERICAN IN EVERY WAY EXCEPT ON PAPER

By Andrew Malekoff© April 2018

Imagine being American in every way except on paper and knowing that if you are the victim of violent crime you cannot report it out of fear of being deported. This is the sad reality for nearly 800,000 young immigrants who found hope in DACA. 

If you’ve heard the acronym but are not familiar with DACA, it refers to Deferred Action for Childhood Arrivals, a federal program that began in 2012 permitting any person who was brought into the U.S. before the age of 16 the temporary right to live, study and work legally in America, providing they meet certain criteria including no criminal record and attending in high school or college, or serving in the military.

According to the Pew Research Center, two-thirds of current DACA recipients are 25 or younger, many of whom were brought to the U.S. as children so they might escape persecution, violence and poverty for the promise of a better life.

One young immigrant, Rodrigo Trejo, shared his story with United We Dream, the largest immigrant youth-led organization in the country: “When I was in the 11th grade my step dad was deported to Mexico, but he had a conversation with me before he was sent back. He told me that I was going to have to be the man of the house because he didn’t think he was ever coming back. I didn’t know what he was trying to say at the time, until he passed away crossing the U.S border. He couldn’t bear to be away from his family.”

Although Rodrigo became depressed and dropped out of school he bounced back. He reenrolled and graduated at the age of 20. Soon thereafter he applied for DACA in order to continue his education. “I plan to continue my studies and want to help others who have the potential of becoming someone great but because of similar life circumstances, don’t believe in themselves,” he said.

On September 5, 2017, U.S. Attorney General (AG) Jeff Sessions pronounced, "I am here today to announce that the program known as DACA that was effectuated under the Obama administration is being rescinded [effective March 5, 2018].”

On January 9, 2018, four months after AG Session’s announcement, a U.S. District Judge temporarily blocked the Trump administration from ending DACA, thus allowing recipients to renew their protected status for two years, re-affirming their legal legitimacy to remain in the U.S. A subsequent appeal of the judge’s ruling to keep DACA going failed.

If DACA were to be permanently rescinded it would prevent young immigrants like Rodrigo from applying for deportation protections and work permits, exacerbating the isolation, uncertainty, hopelessness and terror that preceded DACA becoming law.

If you follow national news, there is a cat-and-mouse game being played with DACA recipients in our nation’s capital. Let’s not lose sight of the fact that what is at stake is the physical and emotional well-being of young people like Rodrigo who came to the U.S. as children by no fault of their own.

In addition to the shifting sentiments expressed by the president, there is an organized anti-immigrant movement underway in the U.S. led by groups such as the Federation for American Immigrant Reform (FAIR), Center for Immigration Studies and Numbers USA. These nativist groups advocate for white European power and political control, and paint undocumented immigrants with a broad criminalized brush.

The issue of immigration in the U.S. is much broader than DACA. Nevertheless, we need to stand up to protect these young people from being rounded up and sent away. If you believe in human rights, doing nothing is not an option.

Published in the Long Island Weekly in April 2018