DISCUSSION As of 7/6/12 1. Outline Background What’s happening now The treatment landscape Options Next steps Proposal: Two options (private and public)

DISCUSSIONAs of 7/6/12

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Outline• Background• What’s happening now• The treatment landscape• Options• Next steps

Proposal: Two options (private and public)

Preference: Private option

Position: Love and support either way

Process: Loved one to decide

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The Family

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Philosophy

• Mind + body = 1, not 2• Not just biochemistry• Trauma: a huge factor

• Interdependence• Open dialogue• Inclusive. Collaborative.

• Psych Rehab

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Preferred Approaches• Recovery model (EBP)

• Recovery = “finding new meaning”• Person-centered, self-defined & directed• Holistic. Based in hope.• Full supports, community-integration• Non-linear, time-unlimited• LT continuum of care

• Psychology• Reflective listening, CBT, motivational interviewing, etc.• Listen, Empathize, Accept, Partner (Amador)

• Medications• Judicious, minimalist

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History

• 2003• Difficulties at Rutgers; withdrawals• DWI in two towns• Drug use in Worchester• Difficulties at Dynamy; withdraws

• 2005• Difficulties at Pratt; withdraws

• 2006• Community college for credits• Re-enters Rutgers; lives at home

• 2007• Difficulties at Rutgers; withdraws• 3/30/07: First psychotic episode• Carrier, Princeton House outpatient• Princeton House inpatient, outpatient

• 2008• Self confesses addictions to

amphetamines, marijuana• Second Nature Entrada• Difficulties at WestBridge; terminated• Princeton House inpatient• Pasadena Villa: admission refused

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History, 2

• 2009, 2010• Walmart jobs, etc• D&D • ER visits• Lost while driving

• 2011• DWI• Princeton House detox• Difficulties at New Hope Foundation;

withdraws• Discharged to own apartment• Continuing visits to Dr. Steubben

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More recently…• 9/17/11: Arrest after episode at Princeton University

• Inebriation Trespass Outburst at Muslim Students dinner• Arrested, charged with four crimes, including Class 4 bias felony• ALCOHOL

• 9/20/11: Call to county crisis center fails• 72 hour evaluation thwarted by Haldol, lack of HIPAA releases• Fuld releases to the street

• No referral, no discharge plan, no change in medications

• ALCOHOL

• 10/1/11: Involuntary commitment to Hampton House• ALCOHOL

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…, 2• 10/18/11: Involuntary commitment overruled

• Judge orders release.

• 10/20/11: Botched discharge from Hampton House• Released to Mercer County PACT Team…• …without PACT’s knowledge.• 11 days without services

• 11/1/11: Admitted to Princeton House Outpatient• Dr. Stanley in charge• False start; leaves when hearing voices• Starts again; deemed “inappropriate for outpatient”

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…, 3• 11/7/11: Enter Princeton House Inpatient (Voluntary)

• Doctors want faster meds change; resists proposed meds changes• Dr. Kazi’s compromise accepted: injectable for more time voluntary

• 11/11/11: Committed to Princeton House STCF (Involuntary) • Dr. Pahl in charge. Time limited.• Within 48 hours…

• Stripped off Zoloft; blasted with Thorazine, Invega, Lithium

• No family meeting; rushed decision before Thanksgiving• Dx on discharge: Schizoaffective; GAF = 20.

• 11/23/11: Transfer to TPH• Dr. Ghazili in charge (Drake Unit)• Dx upon admission: Bipolar I, GAF: 35

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…, 4• 12/7/11: Leave TPH; Enter Princeton House Outpatient

• Dr. Stanley in charge• Lives with parents to support recovery, overcome institutional trauma

• January, 2012: ICMS engaged• Patty Crater

• 1/26/12: Court appearance: PTI approved.• 40 hours community service; completion of treatment plan

• February: Beck Institute engagement begins• 1x per week

• March: Step-down to Princeton House IOP

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…, 5• April

• Leaves Princeton House• Engages APN Peter Njili at Greater Trenton• Begins weekly at Beck Institute (Dr. Cotterell in charge)

• May: Relapses (2 small episodes)• ALCOHOL

• 5/24/12: First family participation in Multi-Family Group

• 6/10/12: Enter Princeton Hospital ER• Voluntarily.• “Bored”• ALCOHOL

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…, 6

• 6/12/12: Failed AAMH admission• “Can’t handle groups”

• 6/13/12: Enter Princeton Hospital ER (3 pm)• Massive relapse; 420 ml in 30 minutes; BAC: .38 (Lethal dose: 40)• $: CDs pilfered from home• Botched discharge

• Refused for Princeton House inpatient, released at 4 am. BAC ~ .20?

• ALCOHOL

• 6/17/12: Mother and sister to Singapore for a month.

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…, 7 • 6/30/12: Enter Princeton Hospital ER

• 150 ml in one hour• $: cash pilfered from father’s wallet• ALCOHOL

• 7/1/12: Enter Princeton House Inpatient

• 7/17/12: Mother and sister to return from Singapore

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What’s happening?

• Voices• Constant, loud, denigrating

• Depression• Desperate to avoid

• Discomfort with groups• Can’t discuss voices (AA)• Can’t discuss deeply

personal issues

• Anxiety about school

• Anxiety about self• Identity• Appearance

• Anxiety about life• No cash, no car• Uneasy with ADLs• Highly dependent on others

• “Bored”• Understimulated• Underappreciated• Uncertain

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The recent crucible…

• Police• Arrest; overcharging• Inappropriate release• 5 encounters since September

• 72 hr. “crisis” watch (Fuld)• Sedated with Haldol• Released with no plan

• Hampton House• Involuntary• 3 unit changes in 18 days• Uncoordinated judicial ruling• Rushed, botched discharge

• PACT• Dropped handoff• 11 days without services

• Princeton House • OutPx: “Inappropriate for PHP”• InPx: Voluntary Involuntary• Major meds changes• But only 2 weeks…

• TPH• Different diagnosis• Overcrowding, fighting• Psychiatrist assaulted

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…, 2

• Princeton House• “Why TPH only 2 weeks?”• PHP, IOP

• Greater Trenton• Depressing experience• No psychiatrist contact• Problems in adjusting meds

• Beck Institute• Long trips• Inconclusive results?

• Legal case• Stressful preparation• Court appearance• Community service• Reporting

• Job search• No support• No responses, except…• CVS’s response

• 3 ER visits in 2 weeks

• Family stress

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In the last 10 months…

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Police encounters 5Arrests 1Calls to Crisis Center 3Hospitalizations 10Outpatient programs 3Court appearances 1Prescribing psychiatrists/APNs 14Diagnoses 3Meds changes over 10Outside Therapists 2Group sessions InnumerableInstitutional case managers 12Ambulance rides 6

Result?...

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VoicesFears of depressionAnxiety, DoubtUncertaintyUnresolved issuesNo controlSide effects

Police encountersLegal recordBotched transitionsChanging treatmentsHarsh medicatingLack of care continuumOscillating moodsNo available jobStigma

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Trauma Pain Despair?

Recently expressed desires• A simple job• Good health and body• Music• Become a Mason• One on one counseling• Live at home• Esoterica

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What these need…• Diligence• Consistency• Skills• Achievement

• Sobriety• Symptom control

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How to get these?...• Reduce the voices…

• Medications carefully applied• Therapy mindfully engaged

• Arrest the drinking…• Supports firmly established• Temptations avoided (i.e., “Boredom”)

• Go at the right pace.

• Enhance skills, increase experience

• Grow more confidence

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Best approach?...• Holistic approach (not just meds)• Full family and team support• Patience, consistency, steadiness, calm• Good resources and methods

• Time

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A future vision

• In 5 years…• Five years sober• Fewer voices• Finishing school with B.A.• Working PT in music store• Member of Masonic lodge• Living in supported housing• Friendship group membership• Wellness training• Sharing with parents

• In 10 years…• 10 years sober• No voices• Assistant manager• FT job• Financially more secure• Working to exit SSI/SSD• Significant other• Wellness living• Helping parents

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Optimal Tx Plan

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Intensity Level 5 Hospital Setting (Highly Staffed)

Level 4 Professional Care Setting (Moderately Staffed)

Level 3 Residential (Treatment) Setting

Level 2 Partial Hospitalization (Day Program)

Level 1 Community (Outpatient)

Very High

High

Moderate

Low

1.Hospital

Need(IDDT)

2.TreatmentResidential

3.SupportedResidential

4. IOP

4.IndependentResidential

SuppEmp/Ed

The Gap

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Very High

High

Moderate

Low

Hospital


Gap(Integrated Dual

Disorder Treatment)

Public System Services

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Very High

High

Moderate

Low

Hospital

Gap(IDDT)

PACTLocalPHP

Local IOP

State Hospital

Local Supported Housing

Hospital

AA/NA

4. IOP


Private Sector Possibilities

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Very High

High

Moderate

Low

Hospital

Need(IDDT)

Farm/Work Residential

Clinical Residential

HospitalHospital

4. IOP


GroupResidential

Apartment-based

Community

What Private Sector approaches?• Long term residential clinics

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http://www.menningerclinic.com/

http://www.silverhillhospital.org/

… 2• Private long-term residential therapeutic communities

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“Public Option”

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Very High

High

Moderate

Low

Hospital

Gap(IDDT)

PACTPHBHPHP

PHBH IOP

TPH SERVSupported Housing

PrincetonHouse

4. IOP


Note: Staying at 50 Balsam Lane not possible

“Private Option” (12-18 months?)

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Very High

High

Moderate

Low

Hospital

Gap(IDDT)

PACTPHBHPHP

PHBH IOP

SERVSupported Housing

PrincetonHouse

4. IOP


Need(IDDT)

CooperRiis, Spring Lake Ranch,

Hundred Acre Homestead, etc.(6-12 months)

Menninger(8 weeks) Austin Riggs(6-8 months)

Private Option requirements• 30 days of sobriety• No benzodiazepines• Interviews• Consultations• Documentation• Sizeable prepayments• Travel arrangements

• Research and clarification of options• Personal motivation

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Future ways ahead• Private Option

• PH Therapeutic Clinic Therapeutic Community Transition Residential Local SuppHous and SuppEmp, etc. Independent Living

• At 50 Balsam Lane, if desirable

• Public Option

• PH PHP IOP Local SuppHous and SuppEmp, etc. Independent Living

• At Griggs Farm or elsewhere

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Next Steps…• Think and talk about this… Take time to decide…• Timing: assure enough to bridge smoothly

• “Private option” is time-unlimited• But, likely only available once• What will be its “value”?

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To do• ICMS

• Mobilize for public option• Supported housing, supported employment

resources, day programs

• Mobilize psychiatrist• Help integrate private and public options• Facilitate court reporting

• Princeton House• Provide bridging to transition• Accommodate preparation requirements of

private option• Assist loved one with one-to-one

counseling in the decision making• Facilitate loved one’s access to Family

Therapist and ICMS worker

• Family Therapist• Be available to loved one• Assist in consideration of options• Consult with PH and ICMS • Advise individuals and whole family

• Attorney• Facilitate PTI accommodation• Guard client against undue legal actions

• Family• Mobilize for private option• Support its loved one• Assist all possible ways

• Loved one• Be open minded; talk to others; state preferences• Choose

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Documents

DISCUSSION As of 7/6/12 1. Outline Background What’s happening now The treatment landscape Options Next steps Proposal: Two options (private and public)