DEPRESSION, SUICIDE, DISCRIMINATION AND PARITY

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.

Andrew Malekoff

This article was published in the NYS Behavioral Health News, Summer 2018

Andrew Malekoff is the Executive Director of North Shore Child & Family Guidance Center, which provides comprehensive mental health services for children from birth through 24 and their families. To find out more, visit www.northshorechildguidance.org. To read more about Project Access go to: https://www.northshorechildguidance.org/wp-content/uploads/2017/12/north-shore-project-access.pdf

KIDS IN CAVES AND KIDS IN CAGES

By Andrew Malekoff© July 12, 2018

The daring cave rescue in Thailand was breathtaking. For a few moments the world stood still.

Skilled divers, medical personnel and others united and prevailed to save the lives of 12 children and their soccer coach.

It was a time when thoughts and prayers were a welcome sentiment, as opposed to the cliché often uttered by politicians in the aftermath of a school shooting.

Meanwhile, one of the more disturbing and divisive stories in recent memory—the forcible separation of thousands of migrant children from their parents after crossing the southern border into the United States—remains.

What makes the migrant children story disturbing is obvious. Although some people may be put off by the term “kids in cages,” the reality is that many of them are confined to chain-link pens that they are not permitted to leave.

Not so obvious are the nuances contained in the widely divergent and often politically motivated opinions about what brought them here in the first place.

Many believe the migrants were seeking asylum from violent gangs and terror.  Others say they were escaping poverty and looking for a free ticket into the U.S. Still others insist that the bulk of the children were brought here not by parents but by human traffickers posing as parents and that they haven’t been separated but put into protective custody.

Whatever the reason they undertook the arduous and dangerous journey, the result is the same: Who is welcome here and who is not have become political flashpoints in post-truth America.

The juxtaposition of migrant children trapped in cages and children trapped in caves symbolizes a troubling paradox: Some children count and some don’t.

Thailand is a well-known destination for forced labor and sex trafficking of children.  Yet we are not riveted to the plight of these children, whose daily peril is not as well-exposed as the kids in caves.

The kids in caves made for great reality TV. It evoked Survivor, the reality show where contestants are stranded in an isolated location and a lone survivor takes home a cash prize. Cave Rescue was more compelling must-see TV, with life and death at stake.

When the kids in the cave were losing oxygen, tanks of air were delivered to them. One man, a Thai Navy SEAL Saman Gunan, gave his life for the boys to breathe easier. These kids also had each other and a surrogate parent for emotional support. There were volunteers from around the world pitching in and well-wishers everywhere.

But what of the kids in cages who are experiencing inconsolable grief and a prolonged stress response that is likely to derail their healthy development for many years to come? Who is there to rescue them?

What they are missing cannot be found in a metal canister. What they long for is human touch and a sense of hope.

The daring rescue in Thailand was a blessing for its exhilarating outcome and for what it made us feel about ourselves, if only for a moment. We all cared together.

If only there was some way to sustain that feeling and good will toward all of God’s children.

Note: The following column will be appearing in Blank Slate Media.

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