The Broken System

THE BROKEN SYSTEM Written by Sherry Schlenke, M.Ed., and the Mother of a Boy, Now Deceased, who Suffered from the Disease of Addiction Daniel Montalbano, the son of The Addicts Mom founder Barbara Theodosiou, was a victim of the “Broken System” of our community mental health facilities and prisons. Dr. Harold Metzner of the University of Colorado uses the term “Broken System” to describe the failure of this nation’s mental health and prison systems to adequately meet the needs of the population of people who have a diagnosis of Co-Occurring Disorders: Serious Mental Illness (SMI) co-morbid with a Substance Use Disorder (SUD.) About The Addicts Mom In Barbara’s words: “I discovered within a six-month period that two of my sons were addicts. My first reaction was to become physically ill. I was completely lost in the sadness of addiction, feeling shock, fear, and confusion. As a woman of great personal and professional success, with a beautiful home and family, it appeared to others that I had it all. But, on the inside, I was broken and felt shattered into a million pieces. It was through my own brokenness that The Addicts Mom (TAM) was born. I knew deep inside that I was not the only mother who was suffering with her children; there had to be so many other moms going through the same horror that I was experiencing. I wanted to connect with those moms and create a forum where their pain and feelings could be shared with others who would be empathetic; a safe place where moms could “Share Without Shame” their experiences, their sorrows, their anguish and their fears of being the mother of a child with the disease of addiction.” TAM began as an online, grass-roots national and international support network, and has grown to over 70,000 members, from all across the country . Members meet online and in person to: educate, advocate, and act as liaisons between policy makers, mental health professionals, and families of those suffering from the disease of addiction. In local communities, TAM sponsors events dedicated to heighten awareness of the disease, to reduce the stigma of the disease, and to promote changes in the legal system affecting those with the disease. Through pledges from our generous donors, TAM is now able to offer treatment scholarships to the loved ones of our members. As drug use and subsequent imprisonment and death among our youth reach epidemic proportions, TAM is becoming a force for societal change. What is the Broken System? The first component of the “broken system” often begins in elementary school. Daniel was likely a child with undiagnosed High Functioning Autism, which is termed by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a Pervasive Developmental Disorder. He was cognitively gifted, therefore, it is probable that he had Asperger’s Syndrome. When Daniel entered the school system, he was very misunderstood. A handsome boy, with huge luminous dark brown eyes, Daniel was shy and a bit fearful. Brilliant, but socially awkward, Daniel was bullied and ostracized; he was bullied at the bus stop in the morning, he was bullied at school, and he was bullied on the bus home. Adults other than his mother were either unaware or unsympathetic. Barbara once witnessed a teacher ignore a bullying incident on the playground in which Daniel was the victim. Further, because he lacked coping mechanisms for his social and emotional problems, Daniel acted out in class. Barbara speaks of how Daniel could be “annoying, repeating a phrase over and over, louder and louder, pestering people, getting in their face, disregarding their personal space.”  People with autism suffer from “Theory of Mind,” in which they are completely unaware of the perceptions and feelings of others’. According to Stephen M. Edelson, Ph.D., of the Autism Research Institute, “Theory of Mind refers to the notion that many autistic individuals do not understand that other people have their own plans, thoughts, and points of view. Furthermore, it appears that they have difficulty understanding other people's beliefs, attitudes, and emotions.”  Thus, Daniel did not realize just how very inappropriate and annoying he acted. Nor did he understand when others reacted to him in a negative way. As he grew older, he developed feelings of anger and resentment, which is common among people diagnosed with autism, according to Dr. Harold Bursztain of Harvard Medical School. Bursztain states that these individuals are deficient in several social domains, including social reciprocity, and in developing and maintaining peer relationships. “They often experience severe social anxiety and depression, and these deficits lead to impairment in social-emotional functioning that can have detrimental effects on the quality of life.” Daniel also struggled with deficits in his gross motor skills, which is not uncommon in children with autism. Therefore, developing skills on the playing field as an alternative to popularity at school was problematic. Barbara decided to enroll him in youth football, but Daniel was clumsy and awkward. He sat on the bench in his uniform, anxiously waiting for the coach to call him into the game; a call that never came. At home, he trusted and felt an affinity to his younger sister, spending time with her friends, but he was never able to cultivate his own. Consequently, his resentment and anger grew, and he developed low self-esteem. As Daniel advanced through his school years, and continued to be a behavior problem in class, his teachers placed him in isolation, further distancing him from his peers. The parents of the other students complained that Daniel was too disruptive in class. He was disliked, mocked, and ostracized by his peers. According to Bursztain, among the autistic population, behaviorally, “deficits in emotion regulation manifest as problems with impulse (usually anger) control, aggression, and often negative peer interactions.” Substance abuse is not unusual in these individuals; Daniel’s progression to substance use is predictable. He told his mother that he began using drugs at the tender age of 13 as a way to escape the reality of his painful life. Barbara, as any loving mother would, felt devastated by this news.   Daniel was not referred for educational or psychological evaluation by the school staff, nor did they implement behavior modification, conflict resolution strategies, or promote positive peer interactions. The school system was indeed “broken” in Daniel’s case. As a diligent mother, Barbara had observed in Daniel several ritualistic behaviors, in addition to the difficulties at school, so she consulted a child psychiatrist when Daniel was 13. Unfortunately, Daniel was mis-diagnosed with the relatively benign, highly treatable disorder of ADHD, which has a high co-morbidity rate with autism. By this time, Daniel was also experiencing auditory hallucinations, which may indicate a thought disorder. His SMI symptoms were exacerbated by his drug use. Heavy drug use causes mood swings, depression and anxiety. Co-occurring conditions are often very difficult to diagnose because the two conditions are intertwined, making it difficult to determine which condition is causing each symptom. The mis-diagnosis of ADHD was also due in part to the reluctance of the professional to “label” a young boy with a psychiatric diagnosis. Barbara followed the recommended treatment options, which included therapy. Because Daniel’s problems at school continued to escalate, Barbara removed him, and he finished his General Educational Development (GED) high school equivalency through the local community college. Being completely distanced from his peer group, however, exacerbated his social deficits. Further, his continued substance use resulted in an increase in symptoms of a psychological disorder. At the age of 16, Daniel was admitted to a psychiatric hospital; Barbara was hopeful for an accurate diagnosis and treatment program. He did not improve, however, and he continued to use drugs after his release. Daniel also spent 1 year of his life in a state-run psychiatric hospital. He remained fairly stable for a brief time after his release, but he always reverted to his drug use. Was this mental health system also “broken” for Daniel? We will never know. Daniel began to compose poems and short, satirical essays, as an outlet for his troubled thoughts and his frustrations. Today, when Barbara reads Daniel’s work, she realizes the extent of his desperation and unhappiness. He leaves an insightful body of written work and paintings, the subject of which is always a troubled young person, a faulty society, and in his later essays, Salvation through Christ. This author, in my capacity as an English teacher, met with Daniel several times. I found him to be brilliant as he carried a dog-eared copy of Shakespeare’s Macbeth; he desired to complete a college degree, perhaps in English. However, I found him to be anxious, fearful and jumpy, with his eyes roaming the room whenever he heard the sound of someone approaching. Kind-hearted by nature, he offered me a blanket should the room be too chilly. Barbara tells us that he, although quite unfortunate himself, fed the homeless, while reading to them from his journal. The Broken System Escalates   Barbara and Daniel would soon discover that decisions regarding his welfare and mental health would be made by others who were often misguided and misinformed, and certainly ill-equipped to interact with Daniel’s unique personality and Co-Occurring Disorder. Now, the third component of the “broken system” evolved in his life. Daniel began living the vicious cycle common to all mentally ill and substance users, as he became a victim of the greater community mental health system combined with the prison system. The cycle for Daniel was: overdose, transport to an emergency Room, physician enacts Civil Commitment to the psychiatric unit for a 3-day stay, release to a treatment center, complete or leave treatment, become homeless, find a shelter, leave shelter, commit a petty crime (shop-lifting), public intoxication, loitering, arrested with excessive violence by the police, housed with felons, brutalized in jail, placed in isolation, and suffer over-all mistreatment by the “broken systems.”  A 3-day stay in a psychiatric unit is inadequate for an accurate assessment of the person’s functioning, and inadequate to implement a treatment plan that promotes a goal of recovery. The patients are so fragile when released from the hospital, with little to no gains in recovery from either disorder. Barbara reports that Daniel was subjected to Florida’s Civil Commitment laws perhaps 12-15 times per year. Daniel’s Psychiatric records read like the DSM-V: Obsessive Compulsive Disorder and Generalized Anxiety Disorder, Depression and possible Delusional Disorder involving paranoia, Bipolar Disorder, suicidal ideation, an unspecified mood disorder, stress-related trauma, rage, impulse control, feelings of worthlessness, hopelessness, and  personal failure, withdrawn and introverted, and substance-induced psychotic disorder. At some point in his cycle of addiction, Daniel was accurately diagnosed with a Co-Occurring Disorder of Mental Illness and Substance Use, although the exact diagnosis of the mental illness is still unclear due to the many years that Daniel used drugs, and the many evaluations by a variety of experts in overlapping fields of psychology, psychiatry, social work, and medicine. He was also determined to be eligible for disability benefits, as it seemed unlikely that he would ever remain stable long enough to maintain gainful employment. For Dr. Metzner, once the sufferers of SMI and SUD come to the attention of authorities, they experience first-hand the complete failure of the community mental health and prison systems. Tragically, in order to protect them from assault and brutalization by the other inmates, the mentally ill are often placed in isolation,as was the case with Daniel. For persons with serious mental illness, psychological stressors such as isolation can be as clinically distressing as physical torture, Metzner discusses. “They have no social interaction, often spend only three to five hours a week of recreation, they are alone the rest of the time in caged enclosures, and they have little, if any, educational, vocational, or other purposeful activities.”  Hence the term “stir crazy.” Psychological effects can include anxiety, depression, anger, cognitive disturbances, perceptual distortions, obsessive thoughts, paranoia, and psychosis. The person emerges from isolation completely defeated. Daniel, whose most serious crime was shoplifting, was devastated physically, emotionally, and mentally by his horrible experiences while incarcerated.  Further, even if not placed in isolation while in prison, while incarcerated, the person has little to no access to treatment, and little to no contact with professionals, physicians, therapy, or medication. In fact, research indicates that perhaps only 1/3 of our prisons offer any treatment for mentally ill prisoners. According to Dr. Metzner, their mental illness inevitably worsens when they are placed in isolation, and their substance use is not addressed. Stress, lack of meaningful social contact, and unstructured days can worsen their condition. How Serious is the problem of the broken system? Metzner’s research reveals some dismal statistics: 15 to 20 % of our prison population have SMI 60% of state correctional systems responding to a survey on inmate mental health reported that 15% or more of their inmate population had a diagnosed mental illness 30-35% of inmates in isolation across the nation are SMI 22 of 40 state correctional systems reported in a survey that they did not have an adequate mental health staff As TAM members are experiencing and reporting, when their children are released from prison, the cycle begins again. The cycle will end eventually: it will end in recovery, imprisonment for a lifetime, or death. Dr. Metzner advocates for systemic change as delineated by professional organizations. For example, the National Commission on Correctional Health Care (NCCHC) has crafted a series of guidelines for accommodating the mentally ill and or those with SUD in the prison system. Institutions are not required to implement the guidelines, but there are accreditation procedures should an institution wish to follow the recommendations. The American Psychiatric Association (APA), and the American Medical Association (AMA), have also created recommendations, but not formal guidelines for the institutions. Individual doctors are placed in an ethical dilemma because they know that the mistreatment of the mentally ill in prison is a human rights violation, as defined by the United Nations. Metzner states that iInstitutions can be sued if they are not meeting the standards, however, “class action suits filed by a large group of people are the only way to bring about change.” Unfortunately, all of the individual lawsuits must involve the same system, so in Daniel’s case, Barbara has little or no recourse. Further, Metzner writes that “individual suits result in settlements, with no press coverage, and no changes.”  Potential Solutions to the problem of the Broken System  Mental Health America (MHA), an advocacy group, reminds us that people with Mental Illness and Substance Use Disorders have basic Constitutional rights. They are an especially vulnerable population. The mentally ill who are involved in the criminal process must have access to community-based treatment aimed at recovery; such treatment is termed a Diversion Program and needs to be implemented before booking the person. MHA advocates for recovery-based, individualized treatment, delivered by an appropriately trained staff. Individual therapy, group therapy, structured educational, recreational, or life-skill-enhancing activities and other therapeutic interventions are needed, but there is not enough money, nor highly trained staff to provide these services. According to The Honorable Judge Steve Leifman, law enforcement and correctional officers have increasingly become the lone responders to people in crisis due to untreated mental illnesses. For example, “on any given day, the Miami-Dade County Jail houses approximately 1,200 individuals with SMI, which is approximately 17% of the total inmate population, and costs taxpayers more than $50 million annually. The County jail now serves as the largest psychiatric facility in the State of Florida.” This is a sad state of affairs and further enforces the “Broken System” theory for treatment of the mentally ill who commit crimes. There is some hopeful news, however, as communities across the nation are beginning to recognize the crucial need for better treatment of these poor unfortunate souls. For example, ten years ago, Miami implemented a program called the Eleventh Judicial Circuit Criminal Mental Health Project (CMHP.) The purpose is to divert nonviolent misdemeanor defendants with SMI or co-occurring SMI and SUD, from the criminal justice system into community-based treatment and support services. The program has expanded to serve defendants that have been arrested for less serious felonies. The program operates two components: a Crisis Intervention Team (CIT) training for law enforcement officers, and a component that serves individuals booked into the jail, and awaiting adjudication. According to Judge Leifman, all participants are provided with individualized transition planning including community-based treatment and support services. “The CMHP is proving to be an effective, cost-efficient solution to a community problem by eliminating gaps in services, and by creating productive and innovative relationships among all stakeholders who have an interest in the welfare and safety of one of our community’s most vulnerable populations.” The National Alliance on Mental Illness (NAMI) strives to increase awareness and understanding of the mentally ill through its partnership with the University of Memphis Crisis Intervention Training Program. Recognizing that law enforcement personnel need to be better trained to interact with persons with Co-Occurring Disorders, Crisis Intervention Training (CIT)—with a 40-hour curriculum—is the most comprehensive police officer mental health training program in the country. There are currently crisis intervention training programs in 45 states as well as the District of Columbia. For the CIT program to be effective in dealing with the mentally ill who commit a crime, law enforcement, mental heath and advocacy agencies must work together. The Gloucester, Massachusetts Police Department, through The Police Assisted Addiction and Recovery Initiative (P.A.A.R.I.) is now offering treatment as an alternative to prison for people with SUD with or without SMI. Through a letter writing campaign that targets community law enforcement organizations throughout our nation, TAM is actively promoting the P.A.A.R.I program. P.A.A.R.I. was started to support local police departments as they work with opioid addicts. Rather than “arrest our way out of the problem of drug addiction,” P.A.A.R.I. committed police departments:
  • Encourage opioid drug users to seek recovery
  • Help distribute life saving opioid blocking drugs to prevent and treat overdoses
  • Connect addicts with treatment programs and facilities
  • Provide resources to other police departments and communities that want to do more to fight the opioid addiction epidemic
The monetary cost of our “Broken System” is but one challenge. The human cost cannot be over-stated. Many changes must be implemented, according to Dr. Metzner. First, money for facilities, therapists, and physicians must be allocated. Then, those suffering from a Co-Occurring Disorder who commit petty crimes need to be housed in a special needs unit with access to treatment, therapy, medications, and community and social interactions. These type of programs are known as Integrated Therapy. According to Dr. Harold Koplewicz, Child and Adolescent Psychiatrist and President of the Child Mind Institute, “with an approach that treats the whole person, these programs not only include the psychological side of recovery, but also the physical side with diet, exercise and social aspects. Some key factors in an effective integrated treatment program can include education, case management, sessions on creating healthy relationships, Motivational Interviewing, counseling, and long-term community building and life skills courses.”  Experts from these special needs facilities or programs design individual re-entry programs to help the client transition back to society. As evidence demonstrates, re-entering society and maintaining sobriety are two challenging factors that may lead to relapse.  Daniel Montalbano: The End of his Heart-breaking Journey  In the summer of 2014, Daniel once again fell victim to the broken system. Transported to an ER because of an overdose, he was committed to a psychiatric unit. There, he became psychotic, due to withdrawal symptoms and an allergic reaction to the medication being used to treat him. While thrashing in his bed, Daniel accidentally struck a security guard and was charged with a felony. He was transported to jail, where he was housed with felons with extensive criminal records. He was assaulted and placed in isolation to protect him from the other inmates. Daniel was permitted to go to treatment off-property, but during an altercation instigated by another boy at the treatment center, Daniel was threatened by the staff with police intervention. He believed that he would be taken to prison for a probation violation, and once again be housed with the dangerous felons. Fearful, he fled the center, and was never again seen alive. He drowned in a canal just a few miles from his home. Daniel Montalbano was just 23 years old. Shockingly, the Coroner’s office failed to identify Daniel’s body for 10 days. His frantic mother and family and the entire TAM community had begun a nation-wide missing person search for Daniel, unaware that he was, in fact, lying in a steel drawer a few miles from home. Mistreated by the broken system throughout his lifetime, and mistreated once again in death, Barbara and those who loved him hope that Daniel finally found the peace that eluded him in life. Daniel Montalbano was an unfortunate victim of the “Broken System.”  Barbara is determined to continue her work as an advocate and spokesperson for the sufferers from addiction, as well as their families. “I do not wish for Daniel’s life to have been in vain. Daniel’s heart-breaking struggle is my inspiration to bring awareness to the topic of addiction, and the devastation that it brings upon families, and on the future of our country.” Sadly, the public is both unaware of and apathetic to the plight of those suffering from Co-Occurring Disorders, and the accompanying burden placed on their loved ones. Few lawmakers are willing to address these issues. There is little or no public support, therefore, elected officials have been reluctant to provide the funds and leadership needed to ensure that prisons have sufficient mental health resources, and that law enforcement personnel are adequately trained to interact with these sufferers. Grass-roots campaigns promoted by organizations like The Addicts Mom are the best hope to raise public awareness of addiction, and to lobby for funding. As Barbara stood strong and brave at the funeral of her precious boy, she reminded all of us that we must remain steadfast, we must stand strong and united, and we must follow Barbara's lead in our mission to educate society, to advocate for our children, to lobby for changes in the broken system, to promote prevention of substance use, and to secure treatment for our family members who are suffering from the deadly disease of addiction.   References:   Barbara Theodosiou, Founder, “The Addict’s Mom”, and Daniel’s loving mother.   Jeffrey Metzner, M.D. The Journal of the American Academy of Psychiatry and the Law, March 2010.   Phone Interview with Dr. Metzner on May 11, 2015.   Mental Health America Position Statement 56.   National Alliance for Mental Illness CIT Program.   Harold J. Bursztajn, MD Associate Clinical Professor of Psychiatry Co-founder, Program in Psychiatry and the Law. The Honorable Steve Leifman, Associate Administrative Judge, Criminal Division, Miami Florida. Gloucester, Massachusetts PAARI Program.   Harold Koplewicz, MD. Child and Adolescent Psychiatrist and President of the Child Mind Institute. Stephen M. Edelson, Ph.D., of the Autism Research Institute.