

The Epidemic of Family Trauma

On The Front Lines of a Global Emotional Battlefront

Dr. Stephen Seager MD and M. Altman MSW

Copyright © 2015

#  Preface

Is our world in Crisis?

How many epidemics have we endured?

What is the epidemic of untreated mental illness?

Is your family at risk for being shattered by an untreated mental illness?

What we need to know is in these pages......

Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship.

\----------Buddha

#  A Description of the Book

This work is a compilation of informative articles that are dedicated to understanding the complex issues facing families of our untreated mentally ill citizens and the mentally ill individuals themselves. Families are the heart and soul of society and the backbone of our culture. In this book we hear the voices of families who suffer with stigma, lack of mental health resources and have lived experiences that have not been brought to light until now.

This is a work that has involved many courageous people who need to express feelings, thoughts and who also are engaged in advocacy. Families are rescuing their loved ones from a broken mental health system and our society cannot afford to ignore them. As the numbers of mentally ill citizens increases and as jails and our streets overflow we are in an epidemic that will not be cured until we reform the mental health system and this work is dedicated to that effort.

#  Table of Contents

Preface

A Description of the Book

Table of Contents

Introduction

The Purpose of this Work

Part 1

Introduction

Forward by Dr. Stephen Seager M.D.

Redefining terms in the new DSM 5

 Info Graphic: The Patient at the Center of the Mental Health Crisis

 Chapter 1 - How We Can Mend Our Shattered Mental Health System

Chapter 2 - The Truth about Trauma

 Chapter 3 - Don't Blame the Family for Mental Illness

 Chapter 4 - Watching mental illness take a loved one

Chapter 5 - Shattered Families

 Chapter 6 - Outside the mind of the mass killer

Chapter 7 - Shattered Youngsters

 Chapter 8 - Medical Model? Recovery Model? No Problem

 Chapter 9 – Kim, An Asian Family Shattered and Isolated

Chapter 10 - No Place like Home

Chapter 11 - Suffer little children

 Chapter 12 - Voices From Inside The Lived Experience with Mental Illness

 Chapter 13 - Brain Talk; More Treatment=Less Stigma

Chapter 14 - A Cure For Mental Illness

Conclusion

Part 2

Introduction

 Chapter 1 - An Epidemic of Complex Family Trauma

Chapter 2 - Resilience

 Chapter 4 - Focus upon Depression; Context and Conflict of Values

 Chapter 5 - Youngsters with Mental Illness and Medication in a Broken Mental Health System

 Chapter 6 - Why Some Communities Avoid Treatment for Mental Illness

Chapter 7 - The Missing

Conclusion

About the Authors

#  Introduction

A Book in 2 Parts

Part 1

Part 1 is collection of informative articles that focus upon the lived experiences of families with untreated mentally ill loved ones. Through the narrative voice, true stories, case examples and the passionate words of family members the reader is engaged on the front lines with families in crisis.

This work personalizes the critical situation for families today. This could be your family.

Part 2

In part 2 the focus is narrowed to an exploration of Complex Family Trauma as a unique condition that poses a powerful threat to the strength of every society. The Family is the backbone, the heart and soul of society and when it is shattered, the strength and resilience of the social structure is in danger.

#  The Purpose of this Work

The Traumatized, Shattered Family

The landscape of American history is one of growth and constant metamorphosis. Much like the human brain, society and its institutions are networked in complex interaction and react to internal as well as external pressures. Our social structure is only as strong as it's component parts and retains its integrity through time and crisis when those parts are resilient and hold value and meaning for all of us. The backbone of society is the family where the heart, soul, body and mind of the individual develop and where meaning and value are taught and learned. Families have traditions and

responsibilities and though these differ cross-culturally and over time these duties are integral to the culture and, when they are compromised or they become disabled then the consequences are a critical escalation of ill health, poverty, alienation and acute unrest.

The emotional and physical well being of citizens is dependent to a large degree upon the health of the family and the reverse is also true. The family is powerfully impacted when a mentally ill loved one is a family member. When the mentally ill family member is untreated, is blocked from obtaining treatment due to a broken mental system or due to the nature of the illness itself then as we demonstrate here, the family undergoes traumatic experiences that derive from inside and outside of its protective, loving walls.

Mental well being, the valuable and underappreciated gift that empowers us to live a meaningful life to care for ourselves and each other is the heart and soul of our collective well being. The family is the first line of support and protection of our mental well being.

In the early decades of this country as our social, political and economic institutions were establishing their foundational roots and values the issue of mental health and mental illness were on the far horizons of our collective consciousness. The asylum and brutal treatment methods of those years has been well documented and the evolution of our understanding and treatment methods continues to expand and be refocused. The devastating issue of trauma, for example, is bringing attention to brain changes and environmental situations that invoke lasting, debilitating fears to children and adults.

This purpose of this work is to bring awareness to for the need to ensure that the backbone of our society and our value system-THE FAMILY-is protected and supported

Our goal is to enhance awareness of the reality of Family Trauma due to untreated mental illness.

Through the voices, case histories, narratives of family members we will focus on the challenges that families face when living with and caring for an individual with mental illness. More specifically we listen to family members who cry out for help in seeking treatment within a broken mental health system.

It is our belief that understanding and emphasizing with a mother's pain a father's frustration, a sibling's terror and a child's distress will help us to appreciate and advocate for reform.

  * Families are subjected to incredible and traumatizing abuse at the hands of a mental health system that is ineffective, and harmful.

  * Families are blamed for the mental illness of loved ones

  * Families are excluded from the process of treatment

  * Families are struggling to meet overwhelming challenges and still provide love and care for all members.

Let us not forget the youngest and most vulnerable family members; the children who witness the family pain and who are often left feeling helpless, frightened and alone.

A note to readers. In this work there are reform programs noted that remain subjects of passionate debate in our communities and legislatures. The authors respectfully hope that readers consider all options for reform and make educated decisions based upon their own research and experiences.

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#  Part 1

#  Introduction

Voice of a mother; "Raising a child with mental illness is a roller-coaster ride through hell. If we're asleep and he does something, you know, that's just one of my fears. I've never had that fear as bad as I have it now because he's getting older, bigger, and stronger."

These small, quiet tragedies don't usually make headlines. The 75 million American families touched by mental illness, largely deal with it in private every day. It frays bonds, breaks up marriages. It steals hope.

The Family is the heart and soul, the very backbone of American society. Although the nature and composition of the family has evolved over the decades, the caretaking, educating, comforting and protecting functions of this nuclear group has remained the standard tradition in our and other cultures.

We enter the world as a dependent, fragile and unique human beings and our survival depends upon a circle of caring others whether they are one person, or an extended community as in Eastern cultures. The tasks of this "family" provide the foundation for learning, socialization, a self-identity, resilience and health. This is an enormous responsibility and it is taken to heart by most people even when threatened by such crisis situations as war and dislocation, death, poverty, and mental illness. There are circumstances that test and can ultimately shatter a family's capacity to provide safety, compassionate care and an environment of hopefulness. A serious mental illness in a family member and a lack of resources to help that person will shake the family's foundation to its core and will direct energy and attention to the person in crisis. This desperate internal shift will create an imbalance that threatens the very vulnerable family members during their peak developmental years; the young children and adults who are aging or in poor health.

In the following articles we focus a great deal upon the young members of these at-risk families because they tend to be lost in the perpetual crises of mental illness as they witness trauma and pain and are helpless to protect themselves. These children are terrified on lookers when their loved ones become self-destructive, agitated, paranoid, aggressive and when police and emergency agencies enter the home. What they see, hear and feel is beyond written description. Caretakers no matter how vigilant they are and how diligently they strive to protect their children are often blindsided by the crises, unable to predict the course of untreated mental illness and desperate to keep the family intact while seeking help for their loved one.

Here are the cries of a child witnessing an aggressive incident

  * Don't kill her! My step-dad is trying to kill my mommy," a small voice replies.

  * "Does he have any weapons?" "Yes, he has a knife," the boy says and then shouts away from the receiver, "PLEASE! Don't kill her!"

Every year, millions of American children witness episodes of violence that can haunt them for the rest of their lives. In 2011, one in 12 children witnessed a family assault, and one in three reported witnessing one in their lifetime.

Voice of a mother whose mentally ill spouse becomes delusional and self-destructive: "You just don't see the kids in the middle of it. I mean, the violence was happening and the kids continued to play and it never entered my head to actually ask them how they were feeling... the kids are pushed into the background and it took me until 2 years ago to realize, hang on, Deirdre, what the fuck are you doing... I never once thought of my children. You just don't think, you are listening to so many things, when you are focusing on barring orders and protection orders, and you are trying to get to doctors or whatever. You never stop to think of the children... it's tough, like it's tough, and I think kids can't express how they feel. They're angry, they're hurt, and they don't know what the emotions are."

Drawn by a child witness

The stress upon the American family has intensified with pressures that derive from economic, ideological and socio-political sources. Parents or caretakers are struggling to maintain a balance between the quality of their own adult relationships, the emotional and educational requirements of children and the material needs of all family members. When a family encounters challenges from without or within its boundaries, the system is tested for resilience and when these challenges are formidable and rooted in a culture of stigma, inequality and lack of understanding, the family unit may experience a battering that shatters its integrity.

Such is the problem of untreated mental illness within the family system where the very nature of the illness combined with the lack of a functional mental health system creates a storm of massive proportions. From the very youngest and most vulnerable child family members to the elderly grandparents, the siblings and friends who act in a family capacity, all are traumatized by a broken mental health system. A great deal of the focus is upon the mentally ill individual but through a wider lens we view the youngsters, the teens, the adults whose suffering tends to be minimized even though

it is extreme and disabling. There is no blame involved in focusing upon the pain of the mentally ill family member because untreated mental illness demands attention by its very nature.

There is no conscious neglect of the other youngsters in the family or the elders. There is no deliberate avoidance of the traditional family tasks of education, socialization and support for all. In truth, trying to obtain help for the mentally ill person, dealing with the chaotic and inefficient mental health and simply existing day to day takes all of the energy that a family has.

Voice of a father of a 12 year old mentally ill son: "I have been walking around this week, doing all the things one must do, work, eat, dishes, interact with people. But if I stop for a minute, and just sit and be quiet, this terrible ache inside becomes apparent. It hurts, it hurts a lot. I can't put my finger on it, where is it coming from."

Voice of the son: "Please, please, please help me," he whimpers. Imaginary voices bark at him. "Go away," he tells them. "Go away! Go away!"

The fact that the mental health system is broken, few can deny. In terms of timely access to care, available crisis centers, hospital beds, outpatient programs and treatment facilities the absence of resources is glaringly clear. The jails are overflowing with the mentally ill who languish longer than other inmates and are abused, no street is without its homeless mentally ill individual, emergency rooms have mentally ill "boarders" due to lack of beds.....And the families? Without access to information, without programs and resources the families are in emotional pain as they watch, as they wait, as they witness the deterioration of a loved one.

This is a series of articles dedicated to informing readers about this dire situation and encouraging engagement in the process of reform. On an optimistic level, what has proven to work is comprehensive treatment using therapy and medication if needed, outpatient monitoring and interventions with provisions to ensure compliance with treatment, a trained police force, professionals and lay persons who are trained specifically in helping the seriously mentally ill, and a range of placements including recovery homes, independent living arrangements and crisis centers.

A father speaks: "Other things may change us, but we begin and end as a family."

#  Forward by Dr. Stephen Seager M.D.

My name is Stephen Seager MD. I have been a psychiatrist for twenty-five years and have worked extensively with the seriously mentally ill (SMI). Recently, I wrote a book, "Behind the Gates of Gomorrah, a Year with the Criminally Insane," and while doing publicity for this book, I came in contact with many families of persons with SMI. Listening to them and recalling my own experience, it quickly became apparent that whatever national mental health system once existed has now totally collapsed. Where once we offered treatment, patients with SMI now suffer unspeakable degradation as their families endure intolerable pain and indignity trying and failing to get needed medical care for their disastrously sick children.

Seeking treatment, families and patient's face federal and state laws that actively deny sick people care. They face a system that supports homelessness and encourages treatment refusal. Today, 1,300,000 persons with SMI languish in prison - often in solitary confinement. Often in prisons run by companies whose profits depend on incarcerating more and more mentally ill persons. 350,000 persons with SMI rot on our urban streets. Many are shot by police. Most die 20 years sooner than expected. And their families must stand by helplessly and watch this happen.

This must change. We can build a system that provides medical treatment, housing, compassion and care. We can stop the suffering and indignity. We can stop the shootings. The pointless and degrading mass incarcerations. The disease and death.

Shattered Families will also propose solutions for our national nightmare. For solutions do exist. Solutions of which we can all be a part.

That's where you come in. Nothing changes minds, educates and motivates like a movie. And "Shattered Families" will be a movie like no other. It will be a movie to which families can turn and say, "Watch this. This is what I've been talking about. This is what I've been trying to tell you."

This is where your contributions will go. To produce a movie that will change minds and hearts and \- we fully believe - lead to a change in our mental health laws, and a fundamental change in how we care for persons in our country with SMI. We are asking for 20,000 dollars but we could use more.

The money will be spent for first-class, post-production editing and then national publicity and film festival entires. This is where eyeballs will meet the screen.

Making a first rate movie is expensive. National publicity for a first-rate movie is expensive. Changing minds and laws is expensive. But we start here. Many people complain about America's mental health system. Here is something concrete that everyone who has a mentally ill relative, friend, or who cares about this subject, can do. Something you can get behind and become a part of.

This will be your movie. Your concern. Your action. Please take that action. Please contribute. "Shattered Families" will happen. We are entering the Sundance Film Festival as well as many others. We will show the film around the country or the world if we can raise the needed funds.

"Shattered Families" will matter. Let's make it matter a lot. Send something. Big or small. Make a difference. It's the least we owe those persons who suffer with SMI and their families.

We are a better people. A better country. We can do the right thing. Please help make things different. Share this message with your friends and family. Use IndieGoGo Share tools. Tell everyone you know. Make some noise. If we do nothing, nothing will change. And nothing makes noise like a movie. Please visit our fund-raising campaign at Indiegogo.com. Any contribution - large or small - is greatly appreciated. For a contribution larger than $100, we will send you an autographed picture of our cast and crew. For any contribution, your name, or the name of a loved one, will be mentioned in the closing credits...Thank you

A note to our readers

Becoming involved in an action to support reform will go far in encouraging the kind of advocacy that leads to the awareness of increasing numbers of mentally ill individuals within our families...our communities...our societies. In this way we can prevent such accounts as the one below in December of 2015 in which the untreated, delusional mentally ill son of a family took their lives in an act that appeared to be sudden and unpredictable. But was that the case here?

"In a brief statement, their first in the wake of the slayings, they said that the deaths of David Wilson and Chapin "leave behind a massive hole in both their family and their community."

Chapin and David Wilson "struggled for years to help their son, Nathan, with his mental health issues," the family members said. "The family asks that focus is brought to mental health awareness."

Wilson experienced delusions, anger and displayed other possible signs of mental illness through the years, friends of the family have said."

#  Redefining terms in the new DSM 5

Schizophrenia is characterized by delusions, hallucinations, disorganized speech and behavior, and

other symptoms that cause social or occupational dysfunction. For a diagnosis, symptoms must have

been present for six months and include at least one month of active symptoms.

Major Depressive Disorder (MDD) is a medical illness that affects how you feel, think and behave causing persistent feelings of sadness and loss of interest in previously enjoyed activities. Depression can lead to a variety of emotional and physical problems. It is a chronic illness that usually requires long-term treatment.

People with ASD tend to have communication deficits, such as responding inappropriately in conversations, misreading nonverbal interactions, or having difficulty building friendships appropriate to their age. In addition, people with ASD may be overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items. Again, the symptoms of people with ASD will fall on a continuum, with some individuals showing mild symptoms and others having much more severe symptoms. This spectrum will allow clinicians to account for the variations in symptoms and behaviors from person to person.

Under the DSM-5 criteria, individuals with ASD must show symptoms from early childhood, even if those symptoms are not recognized until later. This criteria change encourages earlier diagnosis of ASD but also allows people whose symptoms may not be fully recognized until social demands exceed their capacity to receive the diagnosis.

PTSD is triggered by exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:

  * directly experiences the traumatic event;

  * witnesses the traumatic event in person;

  * learns that the traumatic event occurred to a close family member or close friend (with the actual or

  * threatened death being either violent or accidental); or

  * experiences first-hand repeated or extreme exposure to aversive details of the traumatic event

This new disorder is called Disruptive Mood Dysregulation Disorder (DMDD), and its symptoms DMDD is characterized by severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation. These occur, on average, three or more times each week for one year or more.

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out daily tasks. Symptoms of bipolar disorder can be severe. They are different from the normal ups and downs that everyone goes through from time to time.

#  Info Graphic: The Patient at the Center of the Mental Health Crisis

Multiple Systems in the Mental Health Domain

Figure 1 These Percentages are higher in the untreated category in 2015

#  Chapter 1 - How We Can Mend Our Shattered Mental Health System

By Dr Stephen Seager MD and M. Altman MSW

Our country, right now, is in an emotionally shattered state. We are experiencing and expressing our collective emotional pain and we are united in our feelings of; anger, grief fear and confusion are the feelings being expressed over the mass shootings. We share in these universal feelings and we witness

a frantic, disorganized search for the underlying cause; is it the prevalence of guns? Is it the person's untreated or inconsistently treated mental illness? Is it our fractured society or the population of alienated people who are in states of vengeful rage?

It is in the context of mass atrocities, that mental illness comes into sharp focus because we cannot understand the motives, emotions and thoughts of the perpetrator. Some propose links between mental illnesses such as Schizophrenia and violence and others assert an actual causal relationship between the two but there has been no such causal formula found in science or psychology. The fact is that only a small percentage of mentally ill commit violent crimes.

Violence is also an issue that surges to the forefront after a mass tragedy and becomes linked with guns as well as with mental illness. Violent behaviors are rampant in our society and the behavior involves all strata of our population and takes many forms. Violent acts range from self-inflicted harm, to domestic violence, murder-suicide, terrorism, and mass murder. Violence is perpetrated by individuals with diverse characteristics; sociopaths, depressed individuals, delusional individuals, alcohol and drug addicted people etc.

As a country that is the "richest" in the world we see on-going problems that deconstruct our economic and cultural wealth and make us poor in spirit and sick at heart. At the very core of our weakness are the families that should be the backbone of our society, the heart and soul of our enduring strength. One of the most powerful negative influences upon our families is our broken mental health system the thousands of untreated, jailed and homeless mentally ill and the families who are powerless to help them.

A strong and intact family is a protective factor against all forms of illness and aberrant behavior.

A family may not be able, on its own to "cure" a person who is depressed, delusional, antisocial or drug addicted but the support, the education, the guidance and love that family offers is a vital part of sustaining an individual's self-esteem, motivation, social relatedness and empathy.

The forces that shatter a family are the sources of our pain as a society. The most insidious of these forces are poverty, discrimination, untreated mental illness, drug and alcohol addictions. These problems are often co-occurring and to take action against one is to begin to address the others.

When we look at our broken mental health system and listen to the voices of families in pain we can begin to become informed and to empathize about what they endure and why their suffering affects

all of us. A mother cries for her son because the laws prevent her from obtaining information on his care;

From a mother of a mentally ill person: "I can't go on this way. Nothing I do is right. It's nothing but fight, fight, fight and I am getting weary of it." This grieving mother speaks about the police arresting her son who has been in and out of hospitals and jails and who is directly impacted by cutting of hospital beds, lack of crisis centers and her inability to be directly involved in his treatment even though she is his primary caretaker."

A brother speaks: "I emailed her doctor many times, a well-known psychiatrist and professor at a world-class university. Usually there was no response at all. When there was, it was just a brief statement: "he has yet to give me permission to speak with anyone."

A Grandmother speaks: "As I lay, M hit me again and again in the head, continuing to speak in his strange language. I remember that I raised my hands to shield myself but M continued undeterred: he beat me until my fingers broke and the white bed, the white walls, the white vaulted ceiling were splattered with blood."

Mental illness goes untreated for many reasons among which are; lack of access to the systems of care, inability to obtain insurance coverage, cutting of hospital beds, changes in government insurance funding, lack of professionally trained staff, stigma, co-occurring drug addiction, the incapacitating problems of the illness itself. Other strong barriers to care are; the failure to give families the information that they need due to civil rights objections and the lack of support for the family in need and an out-patient system that monitors and can intervene when a crisis occurs. In the face of these destructive obstacles the police are called in, the mentally ill person may go to jail and be abused for months; the individual is left to survive in the streets or has a short and ineffective hospital stay.

Currently and unfortunately all of these barriers are still in place. There is, however, movement in the form of Assisted Outpatient Treatment in 45 states that addresses the urgent need for consistent, comprehensive treatment with monitoring and compliance provisions. These programs are being challenged constitutionally (NY has won its challenge) and each program differs in its provisions.

There is still a great deal of reform work to be done.

Part of this reform work is to increase awareness about the dangers involve with the shattering of the family structure as the family is nucleus for recovery, prevention and for comfort. It is good to read about the challenges that the family faces but many of us need to see and hear and feel the pain in order to grasp the intensity and urgency of their needs.

The film, Shattered Families, will accomplish this goal and drive compassion and motivation for change. The film is a compendium of voices and information, compiled by Dr. Stephen Seager, Psychiatrist, author and passionate advocate who is on the staff of Napa State Hospital.

Dr. Seager's vision for reform cuts across and utilizes all effective strategies and it is in place in a Napa State Hospital where challenges to treatment are extremely strong and only effective treatment survives and changes lives.

You can add your voice to this conversation. Visit Dr. Seager on Facebook

#  Chapter 2 - The Truth about Trauma

By M. Altman MSW

The Latest Data on Trauma; expanded definition, developmental windows of Vulnerability, Transgenerational Factors

What is trauma? The definition has undergone an expansion and now, realistically, encompasses more experiences. Currently, the description of traumatic events is; direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.

The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior. Every person's experience is unique what events are traumatic for one person may not qualify for another and studies have demonstrated that some individuals are more biologically or psychologically more vulnerable and sensitive to fear-inducing situations.

As you can see, trauma is usually defined on an individual basis and Family Trauma in the form of unexpected events that impact the entire system has not yet been scientifically explored. The current terrorist, migrant, financial and Ebola crises point to an urgent need to look at Family Trauma through a wide lends and cross culturally because it is qualitatively and quantitatively different from other traumatic situations Family Trauma also needs to be considered from a time perspective due to the changing nature and structure of this traditionally 2 parent system and the stress that alternative patterns may change the nature of the stressors that are now being placed upon families.

Two key points to be made here is that in many other traumatic events; war, domestic violence, kidnapping etc. the attacks is goal-oriented and that goal is to assert power and compliance over the victim. In the case of family trauma due to untreated mental illness there is no goal involved and this randomness exacerbates the emotional damage of the trauma. The next critical point is that the mentally ill individual is a loved family member, a person with whom there are strong attachments, for whom there is a strong sense of responsibility and a bond of trust that has developed over time. These factors stand out in stark comparison with other traumatic situations and need to be recognized.

The new science of Epigenetics adds to the cause for hope and for concern in this domain. Science has demonstrated that traumatic experiences literally change the brain and therefore change the life course for many individuals. These changes are transgenerational and therefore can be passed down to children and grandchildren. On the other side, the brain has a degree of plasticity that brings in the possibility that changes in a positive sense can be integrated into the systems of the brain.

The fact that Trauma is cumulative and additive in that once sensitized a person is likely to be vulnerable to more traumatizing events makes the new data from science more critical. Experience "gets under the skin" early in life, and does so in ways that affect the course of human development. Heart disease, diabetes, obesity, depression, substance abuse, school success, premature mortality, disability at retirement, and accelerated aging and memory loss all have determinants in early life (in particular, childhood psychosocial adversity affects multiple outcomes, including smoking, suicide, depression, obesity, illicit drug use, alcoholism, teen pregnancy, sexual risk behaviors and sexually transmitted diseases ). Although physical and emotional abuse and other dramatic traumatic childhood events have health and developmental consequences it is often the less memorable yet prevalent, co-occurring, day-to-day misfortunes of early childhood (e.g., disruptive parent-child interactions) that have a lasting influence on the subsequent life course.

Trauma doesn't just terrify or horrify us—it also forces us to make profound biological adaptations in how our brain operates. Basically, the brain is a control system that keeps our body functioning properly. The brain regulates how our body functions to keep us alive, and when our body is safe and working well, the brain extends its efforts to the "higher" functions that enable us to not only survive but also to become a conscious individual—a self or an identity that makes each of us and our lives unique and not only pleasurable (or tolerably painful) but meaningful.

When the brain detects serious threats to our bodily survival, traumatic stressors such as severe accidents, disasters, violence, abuse, or betrayals, the alarm system in the brain is activated and literally hijacks the rest of the brain's operations in order to put all systems in emergency mode until the threat is escaped or overcome.

Often the brain's alarm system doesn't automatically or rapidly re-set itself. When the brain's alarm continues to signal danger even though safety has been restored it creates a constant, ever-present state of anxiety and hyper vigilance as the individual is always on the alert and perpetually ready for danger. All other behavior becomes secondary to safety and the actions reflect this fearful, irritable emotional state. The behavior effects the social systems that the individual interfaces with and in families this may become an overwhelming and traumatizing situation when the behavior is expressed in abusive ways.

In the course of human development, people are more vulnerable to trauma at certain stages and these occur during brain development and re-organization. Primarily during infancy, early childhood and then in early adolescence people are acutely sensitive to traumatic assaults neglect. Exposure to peer emotional abuse at age 14 was the most important predictor in females of symptoms of depression In contrast, non-verbal emotional abuse/traumatization at age 14 was the most important predictor in males of developing Major Depressive Disorder. Non-verbal emotional abuse is characterized by a parent or other important parental figure: (1) being very difficult to please; (2) not having the time or interest to talk to you; 3) withholding important secrets; and 4) causing you to prematurely shoulder adult responsibilities. The non verbal abuse is a form of parental rejection and the present findings suggest that being rejected at about 14 years of age may be a crucial, traumatic, underlying risk factor for the emergence of depression in both males and females.

The trauma cycle is self-perpetuating when treatment is not available or is insufficient to meet the challenges. The destructive cycle shatters everyone involved and is passed down through the generations to compromise the very foundations of human life; emotional and physical health, resilience and the belief that there is positive meaning for one's existence.

A Briefing on Part 2 of this book

In Part 2 of this book we narrow the lens to consider the components and consequences of Complex Trauma. Complex Trauma is an intensely powerful combination of threatening forces that converge to produce immense barriers to treatment. Families of our untreated mentally ill loved ones suffer from Complex Trauma and their experiences are voiced in Part 2 so that we may learn about the reform work that needs to be done and the strengths that families find to endure the storms. Below is a preview of the factors involved in Complex Trauma:

  * This form of trauma involves a loved family member with a prior history of strong loving attachments within the family, with a bond of trust and empathy with parents, siblings, children and grandparents, with an expected future of successes and satisfaction.

  * This form of trauma is not goal-oriented as in war, domestic violence, kidnapping. There is no known cause or reason for the paranoia, the attacks, the self harm, the absence of joy, the inability to connect and communicate.

  * This form of trauma is repetitive and occurs intermittently over extended periods of time. Complex trauma is unlike a battle, a virus, an animal attack or robbery. It is an explosive and unpredictable situation that has no end and continues to re-traumatize and further weaken the victim.

  * This form of trauma presents no effective safety mechanism except for complete isolation or joining in the attack. Hiding is almost impossible as the attacks carry no exemptions'; schools, hospitals and other "safe" havens are as likely targets as any other.

  * This form of trauma has few, if any, recovery pathway because of the repetitive and enduring nature of the experiences. Recovery from trauma almost always is based upon an end point to the traumatizing experience so that the emotions can be processed within an atmosphere of trust and safety.

  * This form of trauma comprises attacks and threats from inside and outside of the victim system. On a macro scale many countries across the globe are internally weakened and socially fragile are now threatened with austerity programs and divided by an influx of migrants, a rising poverty level, racism and discrimination. Terrorist threats and attacks bombard them from outside and the situation becomes doubly disastrous. On a micro scale families have untreated mentally ill loved ones with unpredictable, often aggressive and harmful behaviors within their system and are also threatened with multiple external threats. These threats include the terrorist situation and pervasive atmosphere of fear and depression and, more importantly, threats deriving from the broken mental health systems and closed doors to treatment, stigma with its threats of social isolation and dehumanization.

A mother describes complex trauma: "It's like being terrorized all the time," she said.

#  Chapter 3 - Don't Blame the Family for Mental Illness

The decade of the brain has led to a surge of genetic and biological research in order to explore what has been called the "last frontier". The goal of these studies and the millions of dollars that funds them is to find a "cause" for the serious mental conditions that create pain and suffering for thousands of people and their families. As scientists reach into the genetic code, the immune system and the intricate network of brain systems and synapses other researchers in the fields of psychology, sociology, behavioral science are finding correlations (not causes) between poverty, marginalization, poor diet, trauma and mental illnesses.

The investigations are on-going but as yet no irrefutable causes for the disorders of Major

Depression, Bipolar Disorder, ADHD, the Autism Spectrum and other conditions has been found. A causal relationship is very difficult to determine and blaming any one or two factors is simply not demonstrated in any of the investigations; the evidence is not in as yet. The end result, as many people point out will be multiple causal factors that underlie and exacerbate mental illnesses with probably no one direct and foundational cause for all illnesses or even one of the disorders.

Families of mentally ill individuals suffer tremendously from the lack of knowledge, from our broken mental health system that fails to involve and inform them, lack of resources for the seriously mentally ill and the pervasive stigma. In some cases they are blamed for causing the mental illness and this adds to the burden that they carry. Numerous studies have demonstrated that children are born with unique and different arousal systems. Genetically some youngsters are more sensitive and easily triggered by stimuli from outside or inside their bodies. During the critical developmental periods many situations can arise that arouse an anxious state in a young sensitive child and these situations are common and inevitable along the pathway to maturation.

No one family member or a family system can cause a major mental illness to develop. Families as well as the loved one with the mental illness suffer from the lack of understanding, the inadequate resources, the stigma that serious mental illness imposes. Families struggle to protect, to care for and to find treatment for the loved one who is emotionally and physically battered by depression, hallucinations, paranoia, confusion and unregulated moods.

Blaming the family or the brain or any single factor simply takes attention away from what actually can be done at this stage to provide help and treatment for those with mental illness and their families. We all would rejoice if a cause were found tomorrow-especially the families who are crying out for help.

Unfortunately even famous psychologists tend to blame parents for the child's mental illness and their voices are loud and damaging. An example is below.

Voice of a mother: "In one video clip I did see, my mom friend laughed nervously at her son's explosive behavior. Dr. Phil chastised her, telling her that her cavalier attitude was contributing to her child's problems. Newsflash, Dr. Phil: we laugh when our children lash out because we're trying not to cry. And our children's mental illness is not "our fault," any more than a child's cancer is the parents' fault."

Families of mentally ill individuals suffer tremendously from the lack of knowledge, from our broken mental health system that fails to involve and inform them, lack of resources for the seriously mentally ill and the pervasive stigma. In some cases they are blamed for causing the mental illness and this adds to the burden that they bare.

#  Chapter 4 - Watching mental illness take a loved one

By M. Altman MSW

In the history of mental health there has been a lack of attention paid to the emotional and physical process that a family endures as they observe and try to help a mentally ill loved one. This process is a traumatic one that shatters the vital core of the family and leaves devastation in its wake. Each family member and the cohesive framework of the family system are impacted by the deterioration of their loved one and by the mental health system that fails as a treatment opportunity, as a safety net and as a social/psychological resource. The family's on-going traumatic experiences affect parents, grand-parents, siblings, cousins and children who are not yet mature enough to understand what has blown the family apart and created chaos and ruin in its path.

The field of Epigenesis informs us that stress and trauma affects the genetic core of our being and that gene changes are passed down through the generations. This scientific fact awakens us to the lasting impact that living with stress, and emotional pain will have upon future generations. Trauma, as we now know, doesn't just terrify or horrify us—it also forces us to make profound biological adaptations in how our brain operates and this affects thinking, decision making and planning. When the brain detects serious threats to our bodily survival, traumatic stressors such as severe accidents, disasters, violence, abuse, or betrayals, the alarm system in the brain is activated and literally hijacks the rest of the brain's operations in order to put all systems in emergency mode until the threat is escaped or overcome. Family trauma has long lasting emotional, physical and social implications and it has become a problem that our society can no longer ignore.

Mental health reform in the domains of; access to care, identifying people who need but cannot accept help, bringing families into the treatment team and applying all treatment methods that are effective is the key to relieving the suffering of a multitude of people.

This article delineates the 3 primary stages of Family Trauma (Seeing, Searching, Securing) with input from family members who have written about their lived experiences. Their voices and expressions will be available in a film "Shattered Families" produced by Dr. Stephen Seager.

1. Seeing the deterioration

"No one understands like other parents. No one"

Watching a loved one spiral into confusion, isolation, harmful behaviors and paranoia is an emotionally traumatic experience for a family member. Many of the serious mental illnesses such as

Schizophrenia, Bipolar Disorder and Major Depression are characterized by behaviors that may begin in childhood but are not diagnosed until adolescence and early adulthood although the current trend is for earlier diagnosis. The expression of symptoms; hallucinations, delusions, paranoia, unpredictable behavior may be taken as adolescent acting-out at first or as drug/alcohol related

behaviors and families often are in hyper aware observation mode as the problem begins to escalate.

Many parents attempt, at first, to mitigate the situation themselves by pampering the individual or simply leaving them alone. They watch and wait and some deny the critical nature of the deterioration for awhile. This is a stressful time for the family as they hope that things will go back to "normal".

Soon it becomes clear that the situation has become dire. There are angry arguments between parents, siblings are ignored, young children are in shut down mode or act out, and the family begins to break apart as family members are in opposition about what is going on. The cohesive framework of the family is weakened as each member struggles to make sense of the behavior that they witness and they are unsure of what to do. As they stand by in a helpless position other people may intrude with comments and suggestions. There is shame and embarrassment along with fear and anger.

A mother speaks: "There is a sense of helplessness, alarm and fear when the person does not respond to your outreach and your efforts are responded to with anger and suspicion. You know something is terribly wrong and at this stage, without information, all you can do is try to make contact and watch the frightening process unfold."

A Father speaks "He was no longer the boy he knew – the happy-go-lucky child with the black mop of hair who preferred to play with the family's pots and pans than his own toys. He was someone else."

The "Seeing" phase often culminates with a crisis that propels the family into frantic activity.

From a 76 year old grandmother: "On this particular morning, M didn't smile back. His face was flat and his eyes were stony and he began speaking in a deep voice in a bizarre language that confused me. M then stepped toward my bed, brandished one of my metal walking canes, and struck me in the head with it. I cried out and tried to stand up but my legs failed and I toppled to the floor. As I lay, M hit me again and again in the head, continuing to speak in his strange language. I remember that I raised my hands to shield myself but M continued undeterred: he beat me until my fingers broke and the white bed, the white walls, the white vaulted ceiling were splattered with blood."

2. Searching for Help

This is a very disruptive phase for families who have had reality hit them hard and they know that their loved ones need urgent care. The family system often remains in turmoil; divided on the existence of a critical problem and/or what to do about it. As we will see in the narratives below, some members continue to deny the seriousness of even the existence of a problem due to the stigma attached to mental illness and their belief that love will conquer all problems. Others begin a frustrating course of contacting doctors, agencies, tip lines, other relatives and come face to face with impenetrable barriers. The barriers to obtaining help are massive. They begin with the individual who does not believe that he or she needs assistance and the professionals who may have met with the person and cannot give information due to legal constraints. And then the walls continue to grow and family members become desperate, angry and very depressed. The abuse is cumulative and stress usually results in sleeplessness, fatigue and other physical symptoms that are lasting. We read the descriptions from parents, siblings and others who are in a cycle of pain and who experience the broken the mental health system; inability to obtain vital information, the lack of hospital beds and the laws that make involuntary commitment difficult , the terribly short stays in hospital and lack of treatment programs to monitor out patient care.

Throughout this tragic process the mentally ill loved one continues to deteriorate, in front of the families eyes, in a home where chaos reigns and parents have completely lost control.

A brother speaks: "I emailed her doctor many times, a well-known psychiatrist and professor at a world-class university. Usually there was no response at all. When there was, it was just a brief statement: "he has yet to give me permission to speak with anyone."

A young sibling speaks: "A 911 call on the night of June 13, 1997 captured the horror of 11-year-old

Kenny Meehan as he witnessed his father Joseph, 43, nearly dismember his younger brother Michael, 8, in their Toronto home. Suffering what psychiatrists called either bipolar disorder or a form of schizophrenia, Joseph Meehan fell under the delusion that his son was the devil. "My dad's killing my brother," Kenny told the 911 operator. "He's got blood all over him ... I'm gonna die. He looks so sick.

He was strangling him. Oh, my God ... I think he's not alive."

A mother speaks: "She became increasingly delusional and paranoid. I emailed her doctor many times, a well-known psychiatrist and professor at a world-class university. Usually there was no response at all. Pretty much this regulation tells loved ones that, 'I'm sorry, but your son must die or your brother must die, or your sister must die, or your mother must die, or your grandparents must die, before we can get your family member the treatment that they need,' " she said. "I mean, does that make sense?"

Calls to the crisis team are useless. On more than 20 other occasions, by a mother's count, the family were told by crisis intervention staff that either it wasn't worth pushing for a commitment or that her son didn't meet the criteria.

From a sister: "She suddenly exploded at me after hours of nursing a perceived slight. Her brain tells her things that aren't true, so she doesn't always act right. She can't help it, and she loves us. "She has yet to give me permission to speak with anyone."

The family exists in a state of fear. Living in fear; He said that they didn't understand what was going on and that if they stood in his way he would "blow their heads off."

A mother is shaking in terror: "I cried in the waiting area. The accumulation of a year's worth of anguish and stress was now compounded by a new realization for her: I no longer felt safe living with her own son."

The mentally ill person speaks: "... please send the police out to shoot me."

A father explains that short stays in hospital are not effective: "Under Pennsylvania's involuntary commitment law, a hospital must release a person when they are no longer considered a danger to themselves or others and medical staff judge that person can be placed in the "the least restrictive" setting to achieve treatment. Pretty much this regulation tells loved ones that, 'I'm sorry, but your husband must die or your brother must die, or your sister must die, or your mother must die, or your grandparents must die, before we can get your family member the treatment that they need,' "she said. "I mean, does that make sense?"

The behavior of the mentally ill person crosses the line into criminal behavior as the family seeks treatment. One day, after hearing a song play on a local radio station, Michael interpreted it as a message from God to head to town and find her. The woman soon filed a restraining order against him and Michael was fired from the Kutztown Tavern.

There is Jail and Prison as the person devolves into paranoia and delusions. An estimated

56 percent of state prisoners, 45 percent of federal prisoners, and 64 percent of jail inmates have a mental health problem.

From a mother: "My son was handcuffed, clad in a white jumpsuit, my son was shown being led by a police officer into the Berks County Courthouse in Reading. As he walked, his head lolled from side-to-side and his eyes were listless – as if he were in a trance. Barely looking at the camera, he raised his middle finger in its direction. Due to a lack of free beds in Wernersville State Hospital, he waited a month longer in Berks County Prison before he could be transferred."

When attempts to get help fail and the loved one faces life in the streets or a cycle of jail, hospitals and death, the family will take the person back into the home. There are many programs for those with drug and alcohol problems but few for the seriously mentally ill. The Government Agency, SAMSHA has prioritized funding for high functioning and drug and alcohol programs and limited funding for the mentally ill programs.

Parents and grand-parents will come to the rescue, often risking their health, their lives and their relationships. The family shifts into a protective mode attempting to keep people away, to reduce interference, to create a calm and loving atmosphere. But they live in states of constant fear and hopelessness.

3. Securing and Protecting the Loved One

In the process of trying to maintain a safe place for the mentally ill family member, many have decided that calling the police is dangerous. For parents of children with mental illnesses, this scenario is the stuff of nightmares. Many of these parents—often still caretakers for their adult children—are reluctant to call 911 in fear that a poorly trained officer will escalate a mental-health emergency into a crime. But faced with violent or self-harming children and a lack of support services, they often find they have no other options.

For parents of children with mental illness, calling the police for help when a kid becomes violent or agitated can devolve into a nightmare.

A narrative from parents description: On Nov. 12 of last year, 37-year-old T left the home she shared with her mother and teenage daughter in nothing but a nightgown for the second time that night. Knowing that A—diagnosed with bipolar disorder and schizophrenia—was barefoot and out in near-freezing temperatures, her family called the police for help bringing her back.

Within an hour of their call, A would be dead, as a result of being physically restrained by officers with the Cleveland police. Though A was neither armed, violent, intoxicated, nor suspected of criminal activity, according to the wrongful-death lawsuit filed by her family against the city of Cleveland, she was slammed onto the sidewalk, and her face pushed into the pavement, before she was handcuffed and left unconscious and half-naked on the street.

For parents of children with mental illnesses, this scenario is the stuff of nightmares. Many of these parents—often still caretakers for their adult children—are reluctant to call 911 in fear that a poorly trained officer will escalate a mental-health emergency into a crime. But faced with violent or self-harming children and a lack of support services, they often find they have no other options.

From a mother Her schizophrenic son was said to have "charged at police" after she called 911. "It was rapid fire – boom, boom, boom, boom. I didn't hear no warning," she reports.

"What's wrong with you guys?" her son said after he was shot – which, according to witnesses, were her son's last dying words.

As the family tries to secure and protect their loved one they, in turn, become more isolated and fearful. Some families accumulate guns and others remain behind locked doors rarely venturing outside. The children are confused and socially isolated, often performing poorly in school. They have learned not to speak about the situation at home and rarely come to the teachers attention because

they remain in a shut-down state.

Like a pebble thrown into a pond the ripples of trauma spread outwards as the stone sinks into the mire. As you read this article do you recognize any of the families that are speaking out? Perhaps your family is experiencing these traumatic events, or your neighbor? It is never so far away that we can, if we are caring and responsible people, let it remain hidden and allow the pain to go on unabated.

#  Chapter 5 - Shattered Families

By M. Altman MSW

Family Trauma: The Trans generational impact of untreated mental illness

Behind bars: The shattered lives of a grandmother, a teen and a mentally ill man

This article is part of a series Family Trauma; The Trans generational impact of untreated mental illness. This is a true story from the Los Angeles County Jail. Many individuals who are seriously mentally ill remain untreated by either medication or a combination of treatment modalities that address the complex nature of their serious emotional disorders. Whether they refuse treatment or cannot access resources, the devastating cycle of their illness has a traumatic effect upon all members of their family. The family unit (parents, grandparents, children, siblings) is the physically battered and emotionally shattered victim of lack of treatment and the effects of the emotional and physical trauma are inherited by future generations. Science informs us that trauma changes the brain and is enduring in the genetic profile. Traumatized family members who have seen, heard and felt the behaviors resulting from paranoia, delusions, confusion may pass these changes on as an unwelcome inheritance. In addition, the trauma experienced by family members leads to depression, anxiety and physical illness.

When we speak of families we must not forget the youngest and the oldest casualties of untreated mental illness. Young children in the family, when traumatized, are confused and angry.

They are terribly afraid and ashamed. Their needs are ignored as the family frantically searches for help. The youngsters cannot share their pain, instead they act out or shut down and are, therefore, at high risk for failure in all aspects of their lives. The elderly family members who are often in close contact with the mentally ill person, face illness and a rapid decline in emotional and physical health due to their age. Society suffers when families are shattered the very fabric of our culture is weakened and great divides open up that separate and isolate us. Although we may appear to be standing, as a society we are falling into factious, opposing groups that defeat many plans for moving forward.

The following article is a true story of a grandmother and young sister who would be invisible and forgotten casualties if their story was not told.

It was on a hot Monday morning when I sat at my desk in Tower 1 the new billion dollar Los Angeles jail building that housed the "mentally ill" inmates as well as those who were drug addicted and the LGBT inmates. The message light on my phone was blinking and a pile of "kites" (messages sent by inmates asking for help) was competing for attention. The office was glass walled as are all of the dormitories and wired for sound. From this fish tank I could see deputies in full gear striding past the office, inmate workers in yellow garb scrubbing the floor and I could hear the shouted orders over the PA system. I was part of a new 2 man team (the Jail Mental Evaluation Team) that had been set up after a Justice Department investigation and million dollar law suit regarding a psychotic inmate who had no psychiatric treatment in jail and attempted suicide after release and had his legs amputated by a train as he lay on the tracks. Our mission was to find the "mentally ill" inmates throughout the jail system and bring them into Tower 1 for psychiatric evaluation and treatment. The task was overwhelming with hundreds of mentally ill inmates dispersed among thousands of others and in 4 separate jails. The task was urgent since many of them were being abused and were in very deteriorated states. The task was not welcomed by the deputies who considered us "inmate lovers" and called the mentally ill inmates "dings".

The first phone message was from what sounded like an elderly person with a quavering, soft voice.

"Please help me find my grandson, Marlon. I think he is in jail and he is sick. He has schizophrenia problems and he been missin' for 3 weeks. He is only 20 and he been in jail and the county hospital before. He won't eat nothin'' in jail and I am worried sick. I am his guardian. Please call me, my name is Ruby Smith. The number is......."

I called and spoke to Ruby for more than 30 minutes. She told me that she had taken Marlon and his baby sister from his drug addicted, depressed mother when he was 5 and that he had been neglected and abused from infancy. Marlon had severe developmental, emotional and cognitive problems and was diagnosed with Paranoid Schizophrenia by age 7. At the age of 13 he was put on medication and his behaviors as she described them included; refusal to eat, or take medication, hiding under his bed or in closets, talking to himself, taking things that didn't belong to him and being terrified by anyone in a uniform to the point where he would strike out and spit if he couldn't run and hide. Because he stood out as an African American male who wandered the neighborhood picking things up from people's homes and because was an exceptionally skinny boy with hair that stood up on his head and added to his 6 foot 5 inch height, the police were frequently called. They took him to the county ER or directly to jail and then he was released to the streets and he found his way home. This time he didn't.

I was very concerned about the 2 weeks with no food and the condition that he might be in. Ruby also informed me that his younger sister was "out of control" with worry about her brother and was avoiding school and cutting herself "again". Ruby herself had diabetes and a "heart problem" and she was feeling "poorly".

After the conversation I called my partner deputy to meet me at the Men's Central Jail; the old dilapidated facility where they housed inmates of every description. Many mentally ill inmates slipped through the screening process and wound up with hardened criminals as cell mates at CJ. The jail data base only showed that Marlon had been booked in almost 2 weeks earlier and was awaiting a court hearing. His location was noted as CJ.

My deputy partner and I walked the "cat walks" of the old jail scanning each 12 man cell for signs of Marlon. The cells were crowded, black flies swarmed over uneaten food and the men paced or cursed or slept amidst the chaos. In the last cell, where an elderly man lay on the floor in his own urine, an inmate called me closer to the bars. He whispered; "Hey psych, there a boy under that bunk and he not come out. He loco or somethin' "

It took 3 deputies to pull an emaciated young man out from under the bunk. The stench was awful and roaches had invaded his hair and body, making it look as if his clothing was moving in waves. He couldn't stand unsupported and he fought feebly so that one deputy jerked his arm behind his back. I knew this had to be Marlon although he couldn't speak due to the fact that his lips were sealed with dried sputum. We finally got him through the tunnel that linked CJ with Tower 1 and into the small medical clinic where the nurses put on gloves, masks and protective clothing. Aside from insect bites,

Marlon was covered with sores and bruises that looked infected and painful but he was too weak even

to moan in distress.

I went back to the office and called Ruby to tell her that we had found Marlon and that he was in poor shape. She began to cry and I could hear her granddaughter yelling "What's the matter? You gotta tell me! Is he dead?" Ruby did not ask for details and wanted me to know that Marlon was a "sweet" boy when he was feeling OK and had been on his medication "for a minute" He would bring her tea when she was in pain and cover her feet when she was cold. She loved him unconditionally and would pray for him constantly. Even when Marlon was agitated and once had picked up a table knife in the kitchen she had never called the police. She explained. "There's nothing the police can do," she said.

"And a lot of times I'm in my safe zone upstairs and I can't get down to open the front door for them, and then what? They'll bust the door down, Marlon will come at them, and there's no good way for that to end." She had been unable to get Marion to the local mental health clinic because he refused to go and when she went by herself they told her "Ma'am there is nothing we can do if he doesn't come in. You just have to call the police like everyone else does."

Marlon was transferred to the jail hospital at the same time that Ruby was hospitalized overnight for what she called "a heart problem". We met one week later in the jail hospital where Marlon was in a medically induced coma. His prognosis was guarded and Ruby was beyond overwhelmed with fear and grief. She was a tiny lady with an expression of profound sadness on her face and her granddaughter appeared to be angry at the world. The youngster blamed her grandmother and "the system" and she became so loud and furious that she was told to leave the ICU.

When Ruby finally left she put her frail arms around me and thanked me. I knew at that point that I was seeing the breakdown of a family, the decline of 3 people who were shattered by their traumatic experiences and were invisible in the massive systems that should have protected, treated and cared for them.

The end of Marion's story is not uplifting; he survived with such profound emotional, cognitive and physical deficits that he will probably spend the rest of his life in a State Hospital with tube feeding and complete care. Ruby and her granddaughter have agreed to counseling and one can only hope that there is a slow repair of some of the traumatic damage done. There are flickers of light at the end of the mental health tunnel. Some advocates for reform propose a complete overhaul of the system with a total emphasis upon non medical treatment. This is one end of the spectrum and at the other end point we have a complete medical model with very limited use of psychotherapy and other alternative strategies. Somewhere at mid-point and more pragmatic is a comprehensive plan that deploys evidence-based and effective techniques on an individual basis to address the complex problems of those with SMI. Part of this plan involves the AOT programs (Assisted Out Patient

Programs) now legislated in 45 states. These programs are fairly new and thus long-term evidence is barely coming in but the news is positive. A description of AOT in brief is; AOT provides courtordered treatment in the community to people with serious mental illness and a history of treatment non-adherence and commits service providers to delivering appropriate care to the most high-risk, high-need individuals. The federal agency added outpatient commitment to NREPP after an independent assessment concluded the program met its requirements for demonstrating positive outcomes in multiple, rigorous peer-reviewed studies. In conjunction with AOT there is an urgent need for easier access to care for those who accept that they need treatment, training of police officers and better screening for mental illness in the correctional system. Some of these problems are beginning to be addressed.

Currently, the best news is that the mental health system has come into the conversation and that a dialogue has begun. But we still need to focus upon the family, lest they become lost in the reform efforts and their faces, voices and feelings need to be seen, heard and to influence decision making.

Families continue to cry out for help and they need a better platform than this written article in order to bring their plight into the forefront with an impact that stimulates the needed changes. These faces depict only part of the story. The upcoming film "Shattered Families" will give voice to the families and others who are struggling to be heard.

#  Chapter 6 - Outside the mind of the mass killer

By M. Altman MSW

News Bulletin: October 4 2015 Today 4 teens arrested for Planning a miss killing at a California high school; Summerville Union High School District Superintendent Robert Griffith said. "Their parents were called." Tuolumne County Sheriff Jim Mele also revealed that the students confessed. According to Mele, they said "that they were going to come on campus and shoot and kill as many people as possible.

The Devil we know rather than the reform that we need.

Our country is in a state of collective mourning due to the recent mass murder. We are united in expressing feelings of grief, anger, fear and in searching for the "causes" of this terrible tragedy. As human beings, this search is a natural, survival task that we hope will prevent future occurrences, protect us and our families. This is the overarching goal; to prevent future mass murders. The ultimate solution as we will see is early identification, early intervention and treatment. This could be accomplished If we were searching in the right place, this might lead to a fruitful outcome However our efforts to deconstruct the inner mind of the mass murderer is, currently and with our knowledge base an impossible task. When we try to interpret the individual's feelings, we are using a very narrow lens and will come up with divergent opinions regarding the personality and character traits of that particular person and each individual is unique in regard to how their emotions and cognitions are displayed in behavior. In addition, many of these individuals have not shared their emotions and thoughts and so we end up with our own subjective "diagnosis". We then can ask; Was he suicidal?

Depressed? Paranoid Schizophrenic, a Psychopath and the search goes on.

We need a wider perspective and we need to search within a data base that we can see, hear and feel in order to achieve the goal of identification of problems, early intervention, treatment and ultimately protection from other situations. We will probably not find any glaring red flags with a wide lens but there are warning signs, cues and significant evidence of trouble brewing. As a country we have an important decision.

The wide lens immediately picks up a dominant marker; many of these individuals were barely known to their communities. They were strangely apart, and the usual comments of neighbors are "he was quiet, a nice guy always said hello and that's all. I can't believe......" There are more markers below.

What we see through the wide lens

The Home situation: Hiding in plain sight is a trademark of a person who is often alienated from society, perhaps having been rejected socially or mistrustful of others. It places the person in a position where their own feelings and thoughts do not undergo reality checks and therefore misjudgments flourish. There will be no parties at this person's home, no banners welcoming guests, no persons coming in and out and little noise. This is a strangely quiet house on the block, it stands out because of the lack of social traffic and neighbors find it easy to ignore their observations concerning the home where they know nothing about the occupants until after the fact.

The Workplace: If the individual works, it is often clear that he or she does not fit in with the group and has issues with the boss or authority. Grievances are common as well as complaints and often absences. The Individual may file complaints, move from job to job, and are viewed as be "odd" "eccentric" or "angry". They are often fired and leave in a very overtly hostile fashion that is observed in the workplace. When they exit they are quickly forgotten until the explosion takes place and then they remember the worker who was angry, threatening and didn't participate in the team efforts.

Social situations: When this individual must be in a social situation their anxiety will be notable in body movements and distancing from others. There will be no sharing of experiences or feelings and the situation itself may well take on a tense tone until they leave.

Family: If this person has a family the members are often very aware that trouble is brewing but become protective and frightened. They will be under great stress and may be giving clues that there is a problem within the home. We tend to disregard any statements that they make as "personal" but they are important. Children will demonstrate to their teachers that they are under stress in their drawings, their high anxiety, inattentiveness. Families are also aware of alcohol, drug abuse and escalating isolation and may provoke aggressive behavior when they attempt to modify the situation.

These disturbances may be infrequent but are signs of significant problems within the home. After the fact, families are shattered and in shock. They may deny knowledge of the individual's behavior but this is primarily due to their protective attitude and the guilt that they feel.

School Situation: When the individual is in school there are signs of pending disaster in their erratic school performance, their being targeted for being bullied, school absences, lack of friends, marked depression and often their lack of participation in team experiences. These should be red flags for teachers, counselors, peers and anyone who is observing the behavior of the students.

Police: Some of these individuals have been violent in the past. Adam Lanza threw coffee at people on the street. Police may actually have a record of other violent crimes and a cumulative record should be a clue for them.

The Doctors Office: There are instances when the anger and fear that these individuals experience lead to somatic complaints such as headaches, stomach aches that have no medical basis. Doctors could ask the critical questions about emotional issues and see these pains as markers of severe emotional problems.

The Counselor's Office: More than one of the prior mass murders saw a therapist and was on medication for anxiety and depression for a short time. Therapists are in a unique position here to build a trusting relationship and intervene early in the process. Any verbalizations about wanting to get revenge or harm others should be taken seriously and the individual should be questioned about their access to guns.

Social Media: Almost every mass murderer has used social media and has communicated their anger, their feelings of rejection, and thoughts about violent retaliation and plans for revenge. Some of this data is read by others and is an important marker that is reported after the fact.

Individuals who commit mass murder rarely seek therapy or openly talking about their problems but they do leave clues and make threats. Threats should always be taken seriously although many of us tend to minimize their importance.

Points of contact

The key to identifying problems and initiating treatment is to intervene early and before the behavior is entrenched and the person is completely isolated. Young individuals who are starting on the dangerous road to destructive behavior may be more amenable to the helping process and studies show clearly that early intervention and treatment is often successful.

When there are observable signs and red flags are apparent there are ways to bring these concerns to the attention of others. People who are in key positions and who become aware of potential problems and can take action to intervene are; teachers, family members who are in a position to talk with the person, supervisors at work when they first become aware that difficulties are emerging, the police with reports on hand, counselors who can ask the right questions, observe behavior and begin to form the important emotional relationship that is lacking in the person's life.

What is urgently needed

There are several critical things that need to be put into place and that have become political and economic issues. They are barriers to early intervention and to treatment and present challenges for those who are ready to act upon signs and red flags.

There is a need for agencies and crisis lines for people to talk about what they observe and their concerns. Many people are hesitant to call the police or a mobile crisis team made up of police and mental health representative unless they have "proof" that a situation is about to occur. An intermediate contact person or agency would fill that critical gap.

There is a need for reform in Mental Health; Our system of mental health presents formidable barriers for families who need to be involved. Confidentiality laws and civil rights groups are on opposite sides in terms of giving families and caretakers the information they need to help the individual stay on track with treatment, to access treatment and to be informed about what interventions work or are ineffective. Stigma is a pervasive problem for individuals who are experiencing emotional problems and this part of our social consciousness needs to change. Accessible treatment and resources need to be in place; non-hospital crisis centers, therapists, hospital beds when they are needed, case managers to provide information on resources and community mental centers that are adequately staffed. There is a need for integration among the agencies and people providing the care and communication so that crises can be avoided in the earliest stages. Schools need to be funded for more counselors who can identify youngsters who are being victimized, who are depressed and isolated. Police should be trained in interacting with individuals who are angry, fearful and who lack trust. Some departments are instituting police crisis teams and they are extremely effective as this mother reports;

"The LAPD Mental Crisis Team helped our son when he was 51/50'd on Venus Beach. At least they took him to a hospital, and not jail. Unlike the Seattle PD who took him to jail instead of a hospital.

Thanks guys"

We, as a society, need to identify and treat people who are walking the path of destruction. Several important solutions have been proposed and some have been implemented that contain provisions for

Assisted Outpatient treatment, training for police and resumption of Medicaid insurance for psychiatric inpatients on a limited basis. It is important to note that since school counselors have been de-funded in many states and hospital beds have declined, the number of mass shootings has increased.

Please note; many people are divided on the merits of reform programs and some states have not adopted all reforms. The programs above require consideration and great thought as they will impact many people but they can be modified and made more effective. They have a degree of plasticity as does the brain. And therefore we put this here for thoughtful debate and readers, families and individuals as well as state legislators will decide upon the outcome.

There are films in production, including "Shattered Families" that will inform people about the development of the Mental Health System and the ways in which it has failed to meet the needs of individuals and their families. This film stands out from the crowd in that its creation is the work of a psychiatrist, Dr. Stephen Seager, who is on the front lines of treatment at Napa State Hospital and brings a wealth of experience to the production. Through this film we connect emotionally with the families and caretakers who struggle to access treatment and who are the committed backbone of the mentally ill individuals in this country.

The process of picking up the signs, intervention and treatment does work and we hear and read that from families and the mentally ill persons themselves. In a statement about a well known performer we have an expression of hope and encouragement; " He also takes medication," Melinda said. "And he has a huge support system at home. That's important to anybody with mental illness. A lot of times, being left to their own devices only causes more misery. I tell anybody that's really interested in conquering mental illness, they need the right doctor, the right medication and the right support. It's not just one, it's all three."

#  Chapter 7 - Shattered Youngsters

By M. Altman MSW

Around one in six parents with a dependent child have a mental health problem or mental illness.

Depression, anxiety and stress are the most common. Many children will grow up with a parent who,

at some point, will have some degree of mental illness. Most of these parents will have mild or short-lived illnesses, and will usually be treated by their general practitioner.

The following article is dedicated to uncovering the pain that the youngest individuals experience in the course of living with untreated adult mental illness. The children, siblings and other youngsters who are involved with adults who remain untreated for depression, bipolar disorder schizophrenia are our most vulnerable population group. Yet, they are often forgotten, their confusion and sadness is over ridden in the frantic search for help for the adults around them. They may be ashamed, afraid and too confused about the situation to talk about it. We must be their voice and the source of their comfort and begin to repair the trauma that they endure. The following true narrative is composed of 3 voices; a 9 year old child, her mother who struggles with bipolar disorder, and the school counselor. The purpose of this work is not to point fingers of blame, but to highlight the problems of children who are caught up in the cycle of mental illness. Everyone suffers in this paradigm but for now we focus our attention on the youngest.

Early on a Tuesday morning 9 year old Stella is awake and still in the grips of a nightmare in which she was sinking into mud and unable to move or call for help. It's a recurring dream and she's glad its over but anxious about the day ahead. She goes quietly into her mother's room and bends over the bed, a strand of dark hair off of her mother's face so that she can hear her breathing. This is her usual pattern, and she checks the pill bottle on the nightstand, but there seems to be a mix of different capsules and she can't be sure anymore if Mom is on pills or not. She remembers her mother yelling something about pills and money late one night and her aunt asking about medicine but all that is beyond her understanding. All that Stella knows is that the kids at school say she's a head case. For just a moment Stella loses track of what she is doing and then realizes that she has the pills cupped in her hand and 15 minutes has slipped by without a remembered thought or feeling.

As she dressed for school her mind starts racing ahead, anticipating the walk among kids who snicker as she passes by, the disappointed looks of the teacher because she didn't finish her homework, the remarks because she is wearing yesterday's clothing. She feels her stomach clench and her head starts to ache as she enters the school and goes to homeroom. Under her chair there is a folded up note and it is a crude picture of a woman with a rope around her neck. Stella crumples it up pretending not to care. The day progresses and Stella sits in her classes, preoccupied with worries about what her mother is doing at home and what she will find when she returns home in the afternoon. She wishes that she had stayed home to look after her mother who might be groggy from the medication and stumbling around or crying in her bed or even worse, taking all her pills. It's happened before several times and when she called her aunt, her aunt called the police and the rest was a disaster. Her mother was carried from the house to an ambulance, admitted into the hospital and before Aunt Tracy could get there and make arrangements Stella was remanded to a foster group home where she stayed for a week. Stella missed her mother terribly, her soft hands, her smell, her hugs and even her tears. She thinks that she could do more to help her Mom and the guilt that she feels is suffocating. She believes that something is torturing her mother and that it is not her Mom's fault. She feels anger and helplessness inside because her Mom says awful things to her and doesn't remember what she said. These are times when the neighbors call the police because of the noise.

In art class Stella draws several pictures without really concentrating on what she is depicting. In math class she is told to report to the counselor's office.

Mrs. Poll the school counselor is studying the drawing that the art teacher brought in and wondering about the child that the teacher described as; thin, tired-looking, unwashed, and unhappy looking. The picture is of 2 people; one adult one smaller person lying flat on a bed. The whole scene is in black marker, the faces of the people are blank except for dashes representing their eyes. It is a morbid piece of art and Mrs. Poll shakes her head thinking about what she might have to do if the child expresses any thoughts that might be considered severely depressed or even suicidal. That would mean a mountain of paperwork, phone calls to the district office for a psychological

evaluation, waiting for the appointment or even having to call in the psychiatric evaluation team for a 72 hour psychiatric hold application. "There goes the rest of the day!" she mumbles to herself.

At home, Stella's mother, Claire, is trying to get her thoughts together. She feels exhausted and so drained of energy that she considers dumping her medication into the toilet. Anyway her government insurance is going to change and probably her meds will be cut again. She stumbles to the kitchen looking for coffee, forgetting that in her budget there is no place for coffee at this point. Somewhere in the distance the sound of sirens are coming closer and for a moment she believes that they are coming for her because she ranted to her sister on the phone about how depressed she was about money, about being alone, about being a terrible mother. Her sister reminded her that she was doing better than before when she was on drugs and in and out of jail and Stella was in and out of foster care until she was 4 years old. Since then Claire has been hospitalized 4 times and her aunt has taken her for 2 of those brief admissions. Her sister, trying to be helpful always reminds her to take the pills because she is permanently disabled and her brain doesn't work right. Claire knows that she tries but sometimes she runs out or the insurance changes or she is just too tired to remember to take them.

On the refrigerator a picture drawn by Stella captures her attention and the tears begin to flow. She is overwhelmed by guilt about neglecting Stella and by anger about her illness and fear that she will lose her daughter once again. If she talks about this to anyone they may call child protective services and so she is trapped in a never ending cycle of pain.

In Kansas a young woman in the throes of a psychotic depression with paranoia and thinking that her child had been raped, took her to the hospital. As a consequence she has waited 4 years to get her child back due to delays in the systems of care, lack of family support and lack of funds for a private attorney. In N, 200 parental terminations per year due to parent's "mental illness" and it's impossible to know how many parents lose children unnecessarily because of the stigma of mental illness, it's clear that the process for deciding such cases is deeply flawed. Children pay a price when courts overstep. Research shows that forcing children in and out of different homes can leave lasting emotional scars.

Stella walks home through a neighborhood of gangs, graffiti covered buildings and abandoned stores. She had a brief session with the counselor during which she was careful to deny any problems, and her heart pounded in her chest with anxiety. She is relieved to see Mom awake but sad that the woman has reddened eyes and is sitting slumped over at the kitchen table. She wraps her arms around her Mom and together they will endure a night of uncertainty and stifled feelings, Stella will keep a close eye on her mother trying to please her, attempting to raise her spirits and to protect her. They are hiding, hoping to be invisible to a world that has not been safe or consistently helpful. For Stella, this hiding and the covering up of her depression and anxiety may work for a short while but the consequences of repeated trauma will surface.

Multiple studies have demonstrated that the increased psychiatric risk for children of mentally ill parents is due partly to genetic influences and partly to an impairment of the parent-child interaction because of the parent's illness. Furthermore, adverse factors are more frequent in these families, as well as a higher risk for child abuse. Genetic and psychosocial factors interact with one another. For example, genetic factors moderate environmental effects; that is, the effect of adverse environmental factors depends on the genetic profile.

This does not take into account the impact of untreated or inconsistent treatment which escalates the trauma to the next level. There has been a great deal of research upon the attachment process between mother and child and its vital importance in emotion regulation, cognitive development and the general health of the child. In the cases of intermittent interruption of attachment, when the parent is taken to the hospital or has emotional crises the youngster suffers from emotional upheavals that result in difficulties managing feelings, problems with memory, attention and decision-making. The parent as a role-model becomes fraught with negative and positive attributes leaving the child with a self-image that is incoherent and usually negative.

There are cases where the child takes on the role of protective adult and the experience of childhood is overshadowed by responsibility and worry. Children wind up lonely and frightened in foster care or act out and are placed in the juvenile justice system.

Still, some youngsters show remarkable resilience and maintain a love and devotion to the parent that withstands most of the trauma. One young man, known to this author, was able to care for his mother who has bipolar disorder and go through school achieving a B.A. and finding employment. Throughout multiple hospitalizations his mother maintained her consistent affectionate and supportive role by virtue of her own strengths and values. Nothing weakened the bond between mother and son.

Below is a list of resilience-building factors that have been proven to be effective.

  * A sense of being loved by their parent

  * Positive self-esteem

  * Good coping skills

  * Positive peer relationships

  * Interest in and success at school

  * Healthy engagement with adults outside the home

  * An ability to articulate their feelings

  * Parents who are functioning well at home, at work, and in their social relationships

  * Parental employment

  * A parent's warm and supportive relationship with his or her children

  * Help and support from immediate and extended family members

#  Chapter 8 - Medical Model? Recovery Model? No Problem

By Dr. Seager

Regarding the treatment of serious mental Illness (SMI), there is currently a fundamental rift between two camps, one known as the "Medical Model," basically scientific psychiatry, and the "Recovery

Model," based of personal experience, learning and support. Bad feelings, misspent public funds, and bad medical outcomes have resulted from this apparent dichotomy.

This is all completely unnecessary. In well-run programs for the people with SMI, these issues never arise. Both approaches are melded into a seamless fabric of excellent care. At Napa State Hospital, where I work, we use a combination of the Medical Model and the Recovery Model. Used together, they work wonders. It's one of the reasons we have such a high recovery rate. Comprehensive Treatment works for individuals who are hospitalized, or at home. This is confirmed by one famous spokesperson.

Brian Wilson regained his life because of his family, his mental healthcare providers, and his own desire to seek recovery. As he told Ability Magazine in a 2014 interview, "Yes, I've been seeing a psychiatrist once a week for 12 years now, and he's become a really close friend of mine. We talk and he helps me out." He also takes medication to manage his condition.

But here's the key. Everyone, and I mean everyone, is clear about what we are dealing with and how we do it. We function on the medical model first and foremost. Proper medication management is the bedrock treatment for SMI. Period. Of this, no one at Napa has any question. After active symptoms are under control, however, then the WRAP plans, groups, and peer support—a complete array of

Recovery Model therapy approaches—are applied to deal with the cognitive and behavioral issues that will be so necessary for a person suffering with SMI to function in the community.

Voice of a parent: "The only reason n my son is better is because he is getting this type of treatment, it's the only treatment that works!"

The problems arise when you put the cart before the horse. When you try and do therapy or peer support and anything else in the Recovery arsenal while people are still actively sick. The Recovery Model works for people who have been made well by their medications. Psychotic people can't do therapy. Everyone knows that. First we get them well. Then they can use the vast array of effective therapy tools effectively. And if there is relapse of symptoms, it means a readjustment of medications.

This combined model is used by the most successful outpatient treatment program for SMI—the California statewide Conditional Outpatient Release Program (CONREP). CONREP handles the supervised care for most SMI patients released from California state hospitals. Medication adherence and group attendance is mandatory. And if a person fails on either count, they go back into the hospital. This is the only truly functional model for treatment of SMI. It may ruffle some feathers, it may be expensive, but it's the best by far.

#  Chapter 9 – Kim, An Asian Family Shattered and Isolated

By M. Altman MSW

I first met Kim when he was carried into the Emergency Room by 3 Police Officers who had handcuffed him and placed a spitting mask over his head. He was agitated and bucking, yelling unintelligible words and we could all smell the odor of sweat and fear in the room. One of the police officers gave us a quick report; Kim is 17 years old, known to the police force from numerous arrests for trespassing, disturbing the peace and known to other Emergency Rooms as neighbors called 911 when sounds of fighting emanated from his home.

"He's a 5150" the police officer said, as a doctor got a shot of "the cocktail" ready in case the youngster was not able to calm down and communicate a few words. The injection was given and the mask was removed as we heard the report; "Neighbor called this in because he saw this kid fighting with his father on the front lawn. The Dad begged us not to take him to jail; he gets beaten up there so we brought him to you guys. His Dad is in the waiting room when you need him he says the boy is off his pills."

Kim became less agitated from the medication, still mumbling and unable to tell us what was going on. I met with his father who was a very thin, worried looking Korean gentleman who bowed his head respectfully when he spoke with me and was wringing his hands in despair. He told me that Kim's mother had recently developed diabetes and heart problems and could not be present. Kim's father shared the history of his son in a soft voice and asked me to "forgive" him for causing this "disturbance" He was clearly ashamed and I was aware that in the Asian culture a child must show respect for his elders and that Kim's behavior had mortified the family. His father had brought Kim, his younger brother and wife from Korea when Kim was 12 years old. The youngster had never adjusted well; he was bullied in school, he had difficulty with the language, he fell behind in his studies and had no friends. By the age of 14 Kim's pain was evident in his isolation from the family, the remarks that he made about his brother spying on him, his inability to sleep and his compulsive rituals. He began to argue with his parents, to leave the house and wander the neighborhood and to disrespect his parents. Kim's parents were alarmed and too ortified to seek help. Finally, the school counselor and principal called them in after suspending the boy for threatening another child and he demanded that the parents obtain a psychiatric evaluation.

Kim was diagnosed with Paranoid Schizophrenia, a term his parents had never heard of, and was given medication. The parent's shame and confusion about the diagnosis and medication as well as Kim's anger and paranoia were strong barriers to compliance with treatment. Kim refused the pills and threatened harm to his family when they tried to encourage him to take the medication. His parents did not disclose the problem to the family in Korea for fear of being criticized and marginalized. The family became socially isolated from the Korean community around them and went into hiding in their home. Both parents suffered emotionally and physically and the younger son who had been doing well began to stay home in order to "protect" his parents from possible assaults. Kim did push his parents and threatened to harm them with a knife but they never called the police. Theyendured the pain that was creating physical harm as well as emotional trauma. Their home, once a place of comfort where the family could continue their spiritual and cultural traditions and remain connected to their community became a prison.

"I love my son" Kim's father told me repeatedly. "I think that he has angered one of our ancestors and that is why he is tormented. Please don't let him go to the jail. They beat him with their fists until he cannot walk. The judge is very angry with him and will send him to the big prison for 30 years. That is what he told me last time."

On the in-patient ward, with medication in his system, Kim was sleeping a great deal, eating and less aggressive. He refused to talk to me or to the doctor and barely spoke to his parents when they visited except to demand to be taken home. After 10 days during which he took his anti-psychotic medication only when told that compliance would allow him to be discharged, Kim was taken home by his father. When the treatment team had tried to find residential programs for the youngster they were informed that his history of jail, non-compliance and aggression would not make him a suitable fit for a residential program. He was referred to out-patient mental health and it depended upon the family to get him into that clinic setting.

As Kim and his father walked out of the locked in-patient unit the father stopped for a moment, bowed his head and said; "We thank you for all that you have tried to do. We are sorry for the inconvenience and hope that you will remember that we are doing all that we can for Kim. I will think about what you said about not being ashamed and that Kim's pain and his actions are not our fault."

Kim was brought back into the Emergency Room 2 months later by police officers who did not know him and he had been roughly treated and tased. He was in very bad shape and was in ICU for a week while his wounds were tended to. This is not the end of Kim and his families journey through our shattered system of care that puts unimaginable burdens upon family and patient and thereby weakens the fabric of our society.

#  Chapter 10 - No Place like Home

By M. Altman MSW

Can you see me? Can you hear me crying? Do you know where I am hiding? Don't look for me....I am invisible even to myself. I may be closer than you think, your next door neighbor? Your friend's child?...Your child?

Chris walked home from school, past the group of older boys hanging out in front of the corner market, through the alley where the homeless man's stash of bottles lay wrapped in a garbage bag and up the stairs avoiding the puddles and wads of paper. He put his book on the kitchen table and jumped when he heard a crash from the bedroom. The noise was followed by screaming; "I'm not a fat sleeze! BIH!" he heard as his step-sister texted someone. He knew she was being teased and was texting the other girl to burn in hell.

Since it would be hours before his father got back, the 12 year old retrieved his stash from the hall closet and pulled out the stool he had stored there. He sat down to smoke and drown out the noises in his head that seemed to get louder when he was at home. In time the waves of sound crystallized into 2 of the usual voices that ran a familiar dialogue in his mind; "You can get rid of them today if you got the guts to do it" and "I don't wanna go to prison" He knew that somehow they were talking about him and would probably begin to call him names if he didn't zone out with the drugs. By the time Dad stumbled in he would be loose and hungry, not worried about anything except for the food situation. since there was often nothing in the fridge. He was, however, grateful that he was not in foster care the judge had given part custody to his Dad and his grandparents since his step mother) was trying to get off drugs and his older brother was in a jail-diversion program. He was really messed up himself, and they called him a Schizo behind his back. He was pretty violent at times and Chris had been slapped around and punched ever since he was a little kid. He was scared of his big brother and the attacks he seemed to have so often. But he has learned how to hide and when to hold his breath so that the big guy couldn't always get to him. Everything bad began to fade away except for the knot of pain that lived in his stomach ever since Mom died. He dreaded weekends when he was dragged over to his grand-parents home where he couldn't smoke and dull most of the pain.

According to current analysis, today 15% of children are living with two parents who are in a remarriage. It is difficult to accurately identify step-children in the ACS data, so we don't know for sure if these kids are from another union, or were born within the remarriage. However, data from another Census source — the 2013 Current Population Survey (CPS) — indicates that 6% of all children are living with a step-parent. The remaining 5% of children are not living with either parent. In most of these cases, they are living with a grandparent—a phenomenon that has become much more prevalent since the recent economic recession.

The nature of "family" has been transformed over the last decade but the human need to attach to a caretaking person, to be protected and to be loved will never fade. Although the "actors" in the evolving family system are changing when there is affection, loving receptivity, and an atmosphere of safety within the family then the work of the family can be done. The family is tasked with encouraging empathy, teaching values, imparting a strong self-esteem and resilience in its members and these tasks require soil in order to flourish. The fertile foundation that supports these tasks is trust.

In our society the financial, health and management burdens are heavy but the heaviest of all is the emotional and physical weight that untreated mental illness places upon family members. It causes emotional upheaval, fears and sadness and anger to erupt in homes where an individual who has untreated mental illness resides. There is no sense of safety for children or adults when there are unpredictable outbursts and the often sudden and traumatizing intervention of police and child welfare workers. The present and the future seem to be bleak and dark when the cycle of illness endures day after day. These families remain in traumatizing situations and their quality of life declines with every day's beginning and every day's end. Small children are forgotten, siblings ignored, parents are battered. Even with unconditional love the family is shattered and broken.

The collapse of our mental health system has had dire consequences for the families who number in the tens of thousands and whose cries have fallen upon deaf ears for the most part. Let us not forget the most vulnerable of people and cultures; the young children, the Eastern cultures that are too ashamed to even whisper for help, the elderly who are targets for abuse. And the parents, stepparents, guardians and other relatives who have the courage to continue to embrace the mentally ill individual and to hope that their pain will somehow, at some time be relieved.

This is the time to fight for a balanced system of comprehensive treatment and for systems that are integrated, that look at each individual as unique in their life experiences, that engage the person in consistent care and that use all available treatment resources with flexibility and compassion.

#  Chapter 11 - Suffer little children

By M. Altman MSW

"What's done to the children is done to society."- Buddha

Police Officer Smith: "I'm at the home now, neighbor called in a 5150; a mental lady who is yelling and may be running around with a knife. She's done this before, we had to call in back up and get her into the Psych ER at Madison Hospital. Neighbor says there's a little girl in this house so send social services with the back up. OK I'm going to access the residence, I can hear yelling..."

Two hours later

Social Services Worker: " I am coming in with a 5 year old girl. Found her hiding under the bed.

Her mother had a kitchen knife and had cut herself so the police are taking her to the ER. We have to find out if there are other family members to take this child when I get in. The girl is really scared and shaken up and she needs family around her. Looks like she hasn't been fed or washed in awhile."

One in six parents with a dependent child has a mental health problem or mental illness.

Depression, Bi Polar disorder, PTSD, severe anxiety are the most common. Many children will grow up with a parent who, at some point, will have some degree of mental illness. Most of these parents will have mild or short-lived illnesses, and will usually be treated by their general practitioner. On the other side of the curve are the parents and adult caretakers of children who have serious and persistent mental illnesses. These are the children that we rarely hear about; the voiceless, traumatized, isolated and frightened kids who end up in foster care, with relatives and later on in jail, detox centers and quite possibly in psychiatric hospitals.

Can you hear them crying?

Can you find them hiding under their beds?

Can you understand how they feel?

The following article is dedicated to uncovering the pain that the youngest individuals experience in the course of living with a family member with a family member with untreated adult mental illness. The children, siblings and other youngsters who are involved with adults who remain untreated for depression, bipolar disorder schizophrenia are our most vulnerable population group. Yet, they are often forgotten, their confusion and sadness is over ridden in the frantic search for help for the adults around them. They may be ashamed, afraid and too confused about the situation to talk about it.

We must be their voice and the source of their comfort and begin to repair the trauma that they endure.

Adults with mental illness that has been present and untreated for any reason for a length of time often wind up in hospitals, emergency rooms and in jail. The disruption in their lives is traumatic and the interruption and devastation in their youngster's lives is also traumatic. The jail has become this country's largest mental health holding area and will become more so since funds are being cut for hospital beds and alternative treatments are rare in many rural and poor areas.

One in 14 children has at least one parent behind bars and children in these situations suffer from low self esteem, poor mental and physical health, and other problems, a national research organization says. that when it comes to black children, the number who have had an incarcerated parent rises to one in nine, and poor children are three times more likely to have had an incarcerated parent than children from higher income households. Rural children are more likely than urban children to have had an incarcerated parent, the report says. In the 6-to-11 age group, children who have had parents behind bars have problems in school, and the likelihood of such problems increases among older children.

Parental incarceration doesn't happen in isolation. Often, children who have had a parent behind bars also have experienced other childhood traumas, such as divorce or living with a parent with a substance abuse problem. More than half have experienced divorce, compared to one in six of other children, and more than a third experienced domestic violence, compared with one in 20 of other children.

A Unique Traumatic Experience

"This is for the kids who know that the worst kind of fear isn't the thing that makes you scream, but the one that steals your voice and keeps you silent." -Abby Norman

There may be many kinds of traumatic experiences in a child's life; having a mentally ill parent/sibling/caretaker has a quality that may be unique. In situations where the adult is abusive due to alcohol or drug abuse, for example, a child may find a pattern in the behavior that alerts them and enables them to prevent some of the harm. The child may predict that Dad gets intoxicated on the weekend and the child may be able to be with others or even to find a hiding place. The adult may predictable single out a target for abuse and this may deflect some of the trauma although witnessed abuse is traumatizing in it is own right. With untreated mental illness there is no cause that can be explained to the child and stigma keeps the situation under cover. There is usually no predictable course of events and so the explosions may be very different, at unexpected times. There no place to hide.

Deep Emotional Wounds

On an emotional level the feelings of guilt and shame are the most damaging feelings that a youngster can be burdened with. When parents have problems, children feel responsible and guilty When the problem is mental illness the issue of stigma pervades the situation and shame is likely to cast a dark shadow over the child's developing self-esteem and the ability to communicate his or her own feelings.

Absolute Isolation

One of the most unfortunate aspects of having a mentally ill parent is that the ill parent often receives all the attention and resources, while the children involved are left to fend for themselves. Further, managing a parent's mental illness can be extremely isolating. Children do not appropriately develop healthy peer relationships with friends, engage in personal interests or hobbies, or even know how to talk to others about what they are going through. Reaching out for help and breaking the silence is often the first step in breaking the isolation.

The Shattered Family

As I lay, M hit me again and again in the head, continuing to speak in his strange language. I remember that I raised my hands to shield myself but M continued undeterred: he beat me until my fingers broke and the white bed, the white walls, the white vaulted ceiling were splattered with blood.

An adult family member is out of control. Although the causes of his or her mental illness are still unclear, the family knows that the behavior is not truly intended to harm them, they are terrified yet they have love and empathy, they need help but are afraid that if they call the police a violent conflict will emerge. The family is under extreme pressure from inside and from outside. Resources are drained, sleep, rest and pleasurable activities are cancelled and life is one crisis after another.

This is a shattered family and the tasks that a family traditionally has responsibility for; educating, socializing, protecting the youngest members, demonstrating ideals, are not a priority. In fact, priorities shift with the daily crisis and primarily concern coping with the mentally ill family member.

The song below illustrates the plight of the youngster who is lost in the rubble of the broken family system. We need to hear the voices of these children and make them a significant part of mental health reform whatever shape that takes.

What About Me

Helen Bristow and Catherine Howard

Chorus

I will remember you will you remember me

My face was one of many too many for you

I scream "What about me?" - help me see this through

See Mum experienced mental illness - none of it her fault.

Dad had no insight even though he was adult

So often it was me a small and frightened child

Who took the roll of parent even though it drove me wild.

I'm so afraid of darkness because I just can't see

What's waiting 'round that corner robed in secrecy

Is it Mum in a psychosis or Dad not able to see

And how will they react this time when they see me?

Chorus

As part of her illness we had workers everywhere

But they didn't do a lot - sometimes didn't even care

"What about me?" I said, the child in all of this

Who kept us all together, I can't keep this up forever?

#  Chapter 12 - Voices From Inside The Lived Experience with Mental Illness

By M. Altman MSW

"Who am I?" I might be a family member; your spouse, your child or your parents. I could be a neighbor or co-worker or a friend. If you look down the street you may see me lingering on the curb looking lost, unkempt and confused. If you distance yourself from me it would be because you are afraid or ashamed to be near someone who is different and just doesn't fit in. I could even be you if you have experienced a serious mental illness and if you have then you are aware of how it felt to you but everyone is unique and the people who comment below may have had a different cycle of pain.

Serious mental illness is very difficult to emphasize with in terms of putting yourself in the shoes of the mentally ill person. The cause of the various disorders has not been discovered, the symptoms vary from person to person, and the symptoms fly in the face of our Western ideals and beliefs about a person's worth and value. In our society where independence, hard work, being competitive, achieving capital gain and having resilience are highly valued characteristics, the mentally ill individual becomes marginalized. He or she does not come up to standards and expectations and since we do not yet understand what creates the illness the person becomes a stranger in their own home, to their families and to society.

In mental illness at the height of a crisis there is usually an inability to clearly express feelings and thoughts although the person is as intelligent as anyone else. They are misinterpreted, judged and dealt with often roughly by those who are not family, friends or compassionate caregivers.

Yet they need to have a voice, even though it may be after the crisis has somewhat abated. We need to hear, see and feel the lived experience of seriously mentally ill individuals.

Although some individuals report that their delusions, hallucinations are within a range that they can cope with them and even interpret their meaning, most critically ill individuals describe how they felt, what they heard and envisioned in extremely negative terms. When they are verbalizing they may report that the voices they hear are saying bad things about them, or commanding them to do things. Their visual hallucinations span a wide range from animals to monsters and family or friends. Unfortunately their behavior may look aggressive when what they are actually feeling is intense fear. The emotional component of their psychosis is often misinterpreted and thus they are treated as if they are threatening instead of threatened and paranoid.

Below we read statements that describe the lived experience of psychosis and a psychiatrist describes how brutal the images, voices and delusions can be;

Statement From a psychiatrist, "E, you'd be better off with cancer, because cancer is easier to cure than schizophrenia."

From his patient; "I was by now so tormented by the voices that I attempted to drill a hole in my head in order to get them out."

From Others

  * The voice of my mental illness two years later, and the deterioration was dramatic. By now, I had the whole frenzied repertoire: terrifying voices, grotesque visions, bizarre, intractable delusions. My mental health status had been a catalyst for discrimination, verbal abuse, and physical and sexual assault

  * Describing his own voices, an American matter-of-factly explained, "Usually it's like torturing people to take their eyes out with a fork, or cut off someone's head and drink the blood, that kind of stuff." Other Americans spoke of "war," as in, "They want to take me to war with them," or their "suicide voice" asking, "Why don't you end your life?

  * I first started experiencing my symptoms when I was 19. It started with olfactory hallucinations, I would smell excrement mainly but also things as strange as wet dog type of smell. I can't really pinpoint the exact moment my auditory hallucinations began, but I remember it started with screaming. I would hear a male voice scream while I was trying to sleep; it would sound like he was in some sort of pain and agony. I was extremely disturbed for a long time and couldn't tell anyone.

  * Eventually a male voice began talking to me. Not all the time, before I started taking meds it would happen maybe a few times a week. He says all sorts of strange and bizarre things. His name is Jack and he claims to be my unborn twin brother. He critiques things that have happened throughout the day like choices I've made and my behavior during social events. He makes me feel terrible, ashamed and I want to just hide away from everyone. The worst one was when I heard a girl screaming for help in my closet and I went looking for her but the voice was coming from my sock drawer. Then the voice started skipping like a broken record and then it just stopped. I've had a couple more like that but I've always equated it to bipolar disorder. Are you on any meds?

  * I felt as if I disappeared into a dark world (e.g. with evil all around) - like being sucked into a vortex; I kept trying to make sense of strange things that were happening such as television presenters talking to me, voices coming from phones or electronic devices. At the same time I stopped caring for myself properly, didn't wash or brush my teeth, and couldn't work.

  * Soon, my parents began to notice I was acting strange. They told me I wasn't making a lot of sense and that I was talking to myself. They told me I had some sort of illness called Psychosis. Angry, I didn't believe them, and ignored them. Later though, I began to get so angry, and act so strange, that they rushed me to the emergency room. HE was there. And I could hear him talking to me the entire time. A nurse came and talked to me, and tried to tell me that I had Psychosis, but I could hardly hear her over him yelling that she didn't know hat she was talking about, that she was lying. Later my parents told me they thought it was a good idea to live in the hospital for a while, so they could monitor me on this new medication I was given.

  * As they said their goodbyes, leaving me in the hospital room, I felt angry and betrayed. How could my own parents leave me in some loony bin? I wasn't insane, I was perfectly normal.

  * I am convinced that I can fly and believe me, I try. Night after night I don't sleep. I start to seethings that other's don't and I begin to shake and stutter. My communication becomes more and more obtuse until my mother finds me one snowy day walking barefoot around in circles muttering to myself. I don't know I am here but I do know that I'm supposed to be. My mother is afraid and doesn't know whether to be mad or ignore me but finally reacts and does the inconceivable. She calls a psychiatrist who tells her that I am not safe, and the next thing I know I am being dropped off at the local psychiatric hospital. My mother drives away, worried that maybe she's been seen here with her child. No one in our family has ever even seen a psychiatrist. People should learn to pull themselves up by their bootstraps and get on with their lives.

In the course of sinking into psychosis family bonds may weakened as communication fails to explain what is going on. Trust between family members and the mentally ill person is betrayed as the actions of the ill person do not fit with expectations, promises or norms of society. The ill individual experiences increased stress as the family struggles to understand, to cope, to find help. Conflicts flare and the family system becomes traumatized, learning the mentally ill member without a safe place, without a stable environment to hold on to.

#  Chapter 13 - Brain Talk; More Treatment=Less Stigma

By Dr. Stephen Seager

We hear a great deal about the "stigma" associated with serious mental illness. We read that it's a bad thing, something to combat. The stigma of serious mental illness leads to shame, economic disadvantage, bias in employment, housing and other necessary areas of life. The issue of stigma is so serious that the federal government funds a cadre of Disability Rights Attorneys to search out, litigate and change laws wherever they find stigma against those with serious mental illness. This is certainly a good and laudable goal. But it doesn't seem to be working. And the reason is clear. We've got the whole concept of stigma backwards. We're doing things all wrong.

First a definition: What exactly is "stigma?" Stigma is a Greek word which means a "dot, puncture, brand or mark." A more general meaning would be "a sign." Stigma then is a physical mark (the Greek verb is "to puncture") that sets a person apart. In ancient Greece the stigma was a mark or tattoo burned or cut into the skin of criminals, slaves or traitors in order to physically identify them.

Modern research has identified three categories of persons who bear stigma. 1) Persons with physical deformities 2) Poor personal traits and 3) Tribal or group status. It's easy to think of examples for all three groups. But this misses the point.

The larger point is this: Stigma is a mark. Something physical. Something that sets a person - or group - apart from the rest. It is NOT the reaction of others to that mark. Society's often bad reaction to those with serious mental illness is simply the symptom of the problem, not the problem. The root of the problem is the mark, the stigma.

Then what is the true stigma of serious mental illness? The mark? It's the often bizarre, psychotic, violent behavior of those so afflicted. This is what marks the serious mentally ill. This is what causes the public aversion. This is what we should be spending money to correct. People will never tolerate bizarre, violent, psychotic behavior. Never have. Never will. To think otherwise is tragically naive.

Treating the effects of stigma is the classic mistake of treating the symptoms of a problem and not the root cause. It's the psychotic, dangerous behavior that needs to be addressed. That's the stigma. That's the mark. And removing the mark will go a long way towards removing all the unfortunate consequences that follow from it .

If you want better conditions for persons with severe mental illness. If you want social and economic barriers to fall. Then you need less violent, dangerous, psychotic behavior. And if you want that, you need more treatment, voluntary or otherwise.

If the federally funded Disability Attorneys, mental health advocates, patients, friends and families of those afflicted, truly want less stigma, they must advocate, litigate and fund programs to eradicate the true problem: untreated mental illness. Remove the mark. More Treatment = Less Stigma.

#  Chapter 14 - A Cure For Mental Illness

By Dr. Stephen Seager

Imagine we had a cure for mental illness. Today. Right Now. Imagine we had a pill, a "magic bullet," that, if taken on a daily basis, would eliminate the voices, delusions and cognitive difficulties of schizophrenia, the mood swings and psychosis of bipolar disorder and the grinding depths of depression. What would that world look like? How would things change? Would it be the ultimate day, so longed and hoped for? The end of millennia of suffering? Maybe. Maybe not.

In the July 11, 2014 issue of Psychiatric Times, Dr. Thomas R Insel MD, Director of the National

Institute of Mental Health (NIMH,) address this hypothetical issue and draws some salient, if disturbing conclusions. Insel compares the situation of a potential cure for mental illness to that of the current situation with HIV/AIDS treatment. Recent advances, primarily in Antiretroviral Therapy

(ART), have changed AIDS from a certain death sentence to a treatable chronic illness with a near normal life expectancy. Despite this, however, fully 75% of persons infected with the HIV virus do not have complete access to treatment. They either do not participate in care, get partially treated or drop

out of treatment for various reasons: side effects, cost, they don't feel "sick" anymore.

I began training as an internist and discovered that this 75% phenomenon is not limited to HIV. It's the same for high blood pressure medications, antibiotics and pretty much any treatment for any chronic illness. Insel believes, and I do as well, that a "cure" for mental illness will face this same 75% barrier.

The same persons who don't think they are mentally ill to begin with, still won't think they are mentally ill. We have good treatments now, and many patients don't want it. I don't believe a "magic bullet" would change this. A good proportion of people would complain of side effects. The new drug – guaranteed – would be very expensive. And once a mentally ill person feels well, they will do what many people do: stop taking their medications.

What does this mean? I think it means that regardless of any scientific breakthroughs looming on the horizon, the treatment for mental illness tomorrow will look pretty much like it does today. Mentally ill persons will still need a coordinated team of professionals to deliver adequate care. We will still need psychiatrists, psychologists, social workers, financial assistance programs, outreach teams and crisis intervention. There will still be sticky court cases regarding "forced" treatment. Psychiatric hospitals, outpatient offices and emergency rooms will still be there.

Whether this is good news or bad depends upon your perspective. But I think it allows the scientific inquiry into mental illness to proceed full speed without a diminution in the role for the other members of a patient's treatment team. It appears that as long as human beings with a chronic illness continue to act like human beings, we will see things in the mental health field continue pretty much as they are.

Unless, of course, a vaccine is developed that prevents mental illness entirely. But that's a topic for another day.

#  Conclusion

The authors have a great respect for the many families who have been strong, compassionate and persistent in attempting to access treatment for their loved ones. Parents, siblings, grand-parents and other care-givers have shouldered heavy and painful burdens imposed by society, the mental health system, and mental illness itself. The family's backbone is constantly battered by the realities of our broken mental health system; lack of hospital beds, privacy laws that exclude the family from getting information, scarcity of emergency clinics, untrained police officers and laws that easily criminalize the behavior of mentally ill individuals such as trespassing.

As one tired and frustrated father put it; "Parents aren't doctors but are expected to do the job's of social worker and psychology etc. While trying to work and maintain some kind of normalcy! Some of us are old and dying ! We neglect our own health to advocate for our adult sick children."

The desperate stories that families have courageously shared are emerging from the shadows where they have been hidden for decades due to a lack of understanding and empathy for what they endure.

Their voices need to be heard and become part of our moral consciousness. A mother tells the tragic story of her family here:

For years, M felt powerless as she watched her son disintegrate into the distorted reality of schizophrenia. Over the years, when her son became incapacitated, she called 911, as so many family members do. She learned of the major difference in emergency response, behavioral policies and health care delivery for those with "mental illness."

She was shocked "mental illness" was carved out of the medical system and managed by a separate health care delivery system called "behavioral health," that relied on law enforcement, not paramedics, as first responders for emergencies and crisis intervention.

M noted a vast difference in the interpretation of mental health law between responding agencies, depending on whether they were medical treatment teams, "behavioral health" teams or law enforcement.

The local "behavioral health" crisis team used her son's "behaviors" and "civil liberties" to base its decisions, not physical and biological symptoms or mental capacity. She realized she had a hit-or-miss chance of getting her son treatment if she involved law enforcement, which had as a top priority the community's safety. When her son turned 18, trying to escape bullying from peers, he refused treatment, sending the family spinning for years in the revolving door of hospitals, jails and crisis.

"Our hands are tied to help him gain treatment before tragedy," M noted.

Our nation has traded hospitals for jail cells; we have traded compassionate care for the cold, harsh elements of the streets; we have tied the hands of parents and caregivers.

We have to frame mental illness as a physical illness so families don't have to play a game of Russian Roulette trying to get loved ones treatment before tragedy.

When the ultimate tragedy occurs and violent death is the outcome our awareness is elevated

The sad reality is that families have lived with personal tragedies of lost loved ones for decades without anyone taking notice. Only when our sick kids explode in the community do people share an opinion.

And yet our society tends to resist the changes that are needed. When tragedy shatters one's own family then the brutal reality of a failed mental health system hits home. A prominent government figure, a father of a mentally ill son describes his loss and his new insight.

"In every sense of the word, my son was my hero," A Virginia state Senator said at a National Press Club address in Washington, D.C., in the spring of 2014. His son, G, played the harmonica, piano, guitar, banjo, fiddle and mandolin. "He was handsome and witty. He had it all going for him." When Gus had a relapse in his bipolar disorder, emergency room staff at a local hospital said they couldn't get an open bed in a psychiatric hospital. His father had to return home with Gus with nowhere else to go.

The next morning, Gus attacked his father with a knife and then killed himself. "Gus was a great kid, he was a perfect son. It's clear the system failed. It's clear that it failed Gus. It killed Gus."

It has been said that there is no loss greater than losing a child. Not only the parents suffer and grieve, the entire family is terribly impacted and those who go on to become advocates for change are the most courageous of all.

What do we need to do so that more families don't go through the devastation of watching a loved on spiral into psychosis, searching for help, waiting for the cycles of deterioration, hospitalization, incarceration and the never ending efforts to protect the loved one?

1. Provide comprehensive treatment that has demonstrated effectiveness and is based upon individual needs. Treatment must be long-term and sustainable with a focus upon preventing relapse and integrating the individual back into family and society whenever possible.

2. Develop better early intervention models for families, teachers, doctors and therapists to use and educate the public about early intervention.

3. Evaluate the individual with emphasis upon listening to their needs and painful symptoms.

4. Involve family and support their efforts and goals for their loved one and the family as a whole. A family focus is needed for prevention and resilience in the face of inevitable challenges.

5. Provide training for police and emergency workers so that they can respond to individuals in crisis states with minimal or no force.

6. Develop the infrastructure for monitoring individuals and encouraging them to participate in their treatment regimen.

7. Integrate systems of care and sharing of vital information to prevent people from becoming "lost" in the systems.

8. Fund beds in hospitals and staff them with trained professional and support staff.

9. Continue to do the research that will lead to finding the causes of mental illness.

10. Work towards making reform a priority in the realm of moral social consciousness and not a

political or economic issues.

11. Explore alternative models of care that are becoming effective in other countries; respites, peer-led centers, etc.

"Without change there is no innovation, creativity, or incentive for improvement. Those who initiate

change will have a better opportunity to manage the change that is inevitable." -By William Pollard

Epilogue

"The Missing Link"

Maria and John are sitting at the tiny kitchen table while Maria's 14 year old daughter occupies herself in the tiny alcove that she calls her room. There is the usual tension and in the air that makes conversation and even breathing an effort. Someone is missing from this scene and his absence creates a black hole that is constantly on the horizon of his mother,s vision.

At the young age of 34 Maria has endured a great deal of pain in her life as a young mother, wife of an abusive alcoholic, mother of a mentally ill son and a daughter who is struggling with adolescence in

the midst of a continuous cycle of family crises.

When John speaks, Maria's heart sinks and a feeling of dread sweeps over her.

"You might have to let Ethan go" he says "this is killing you...killing us and I can't stand to see you suffer anymore. This can't go on and on with him being arrested or in the hospital for 3 days and then out in the streets with you and I in a panic trying to find him"

Maria knows what is coming next and her stomach clenches in pain because John has been with her, her most supportive loved one for 3 years during which her son's Schizophrenia/Bipolar disorder has become the center of her attention. She has been unable to have him treated for any length of time, she has been unable to find long-term therapy that is covered by insurance and she has been blocked from getting information about his medication and whatever brief treatment he has received. Even the programs that she has called refuse to take him because he becomes agitated and paranoid without medication. And he stops his medication because it "controls" his mind as he puts it.

From the age of 7, Ethan has had terrible problems with his moods, his thoughts and his behavior.

He was diagnosed with Schizophrenia at age 8 and Maria has been his advocate as well as his loving mother, encountering obstacles and barriers to treatment and always moving forward. John has made

a big difference in her life and he genuinely cares for Ethan. But now, with Ethan missing again and

Maria in the throes of acute panic it seems like he's reached his limit.

There is nothing that compares with knowing that your sick child is missing. The feelings that are overwhelming Maria and hundreds of mothers and fathers just like her are powerfully frightening.

There are visions of your child being abused in the streets, hungry and cold, hearing voices that tell him to do awful things to himself and with no one to comfort him or give him a safe place to rest.

There are feelings of guilt; maybe something could have been done? Some step that was missed?

There is the black, helpless shroud of depression and the anxiety level is so heightened that there are physical symptoms.

Maria is very frightened and her emotions are at war with each other; she is afraid that her family is crumbling around her, she is in love with John and she loves her children equally, she is in pain physically and emotionally. She sits silently, unable to express herself as John stares down at the table.

Then he says something remarkable; "You know, honey, I miss Ethan right now. He's a good kid and he has made me feel pretty welcome here. Even though he's sick I believe that he wants to have his family around him and we always find him when he goes missing. If he didn't want to be found and to come home he would find a way to get lost permanently."

With a big sigh, John reaches across the table and takes Maria's hand. Her daughter has been standing in the doorway and smiles. When the phone rings John jumps up to answer. "Hello. Yes this is Ethan Forbes family. You've found him? Ok we're on our way!" The call was from a shelter where Ethan had gone after his release from the hospital. He had asked the supervisor to call his family. Thankfully she did and Ethan was picked up that evening.

The film "Shattered Families" may be the most important film that families and advocates for the seriously mentally ill individuals view.

Please contribute. "Shattered Families" will happen. We are entering the Sundance Film Festival as well as many others. We will show the film around the country or the world if we can raise the needed funds. "Shattered Families" will matter. Let's make it matter a lot. Send something. Big or small. Make a difference. It's the least we owe those persons who suffer with SMI and their families.

We are a better people. A better country. We can do the right thing. Please help make things different. Share this message with your friends and family. Use IndieGoGo Share tools. Tell everyone you know. Make some noise. If we do nothing, nothing will change.

For a contribution larger than $100, we will send you an autographed picture of our cast and crew.

For any contribution, your name, or the name of a loved one, will be mentioned in the closing credits...Thank you.

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#  Part 2

#  Introduction

This section of articles and information is more specifically within the realm of complex family trauma. In these pages we present important and relevant new highlights on post partum depression and its powerful influence upon family members, on treatment that involves medicating children, on minority groups and the double stigma that they encounter in their search for treatment and then on cultural practices diverse from Western culture that inform us about resilience and withstanding emotional stress. Mental disorders can, as we will see be treated in ways other than traditional strategies and be effective when the culture has a different basic value system. Cross cultural research also informs us about ways to stay healthier in times of extreme stress.

Although complex trauma has been explored in other publications it has primarily been within the context of individual symptoms and treatment. The family system is a dynamic, interconnected, mutually dependent, active and reactive system that must be appreciated on a different level. This system changes over time and is integrated with the community, the society and now with the global environment. When the family encounters extreme stress from within and outside, the consequences are highly significant on all levels as well as the individual level.

Critical family events are under reported unless they reach epic proportions such as mass murder. There are events in the lives of families with untreated mental illnesses that are not unique but that take on an emotional quality for the family that has not been recognized because of several factors including the families need to protect their loved one and fears of involving authorities who may become involved in physical altercations or even remove young children from the home. Other causes of not reporting are the stigma associated with mental illness and the tendency to blame either the family or the mentally ill loved one for the "disturbance". One of these events which families encounter is when a vulnerable member goes missing and the family is prevented from obtaining information due to privacy laws. For teens and angry individuals to leave home is not uncommon but in these circumstances that possibility of death for the vulnerable loved one becomes a real possibility and the suffering is momentous and the search never ends. The chapter on missing contains narratives from several dramatic and painful cases including post-partum depression which is difficult in most circumstances and can be a major crisis when the mother requires support from within and outside of the family. Post partum depression has only recently been acknowledged; it had been considered "normal" for new mothers to be depressed, tired and irritable for decades.

This is vital information for all of us and through their experiences and through the voices of family and the mentally ill themselves we now have a window of opportunity for learning.

We live in an era of traumatizing events and there seems to be no quick fix or end in sight. Therefore the issue of complex trauma in its broadest sense should be understood by parents, teachers, caregivers, youngsters and our seniors. Threats of harmful events are emanating from all domains - financial, political, military, environmental, and ideological. If we are to thrive and not merely survive we need to know how to stay strong and not be overwhelmed with anxiety, depression and anger.

#  Chapter 1 \- An Epidemic of Complex Family Trauma

This chapter is presented during a time of global unrest and crisis. Across the world the threat level indexes are elevated to their highest point and in most societies people are in states of persistent and exhausting anxiety, terror and depression. Due to threats of unpredictable, brutal attacks, families reduce social contacts, shelter in place and look outside of their own traditional protective walls for comfort and for military security. This is the culture of Complex Trauma and it will endure and continue to damage and dominate our emotional, physical, social and political lives.

Complex traumatic experiences, witnessed or dramatically portrayed in the media are now commonplace and trauma has reached epidemic proportions. The impact of complex trauma upon the family system is of particular concern as we will explain below. Complex trauma; what if consists of, how it is experienced, what makes it unique within the trauma spectrum, it's consequences over time and how we may mitigate its formidable impact is the broad subject of this work. The urgent reality is that complex trauma is distinct on many levels, it has reached epidemic proportions and this very dangerous form of trauma will continue to plague our world for generations to come. These facts demonstrate a need for exploration of this critical issue now.

The author have taken a ground breaking critical look at the impact of complex trauma upon the most vulnerable and growing sector of the population; families of the untreated or poorly treated mentally ill. These families have, in fact, experienced complex trauma for decades, they know what it is and how it feels and the challenges that it presents in terms of predicting and recovering from its powerful impact. Their needs have been mostly neglected as we have focused our attention upon individual cases of trauma (PTSD, domestic violence, child abuse) Now the broader population is facing this powerful form of complex trauma and there is a life or death urgency to paying attention.

The focus upon complex family trauma critically important for several reasons. The family is the backbone and the core of every society. When large numbers of families are failing in their vital functions due to threats and mental disorders and when they shatter, then cultures are weakened and lose their value, their resilience, their meaning. This is an epidemic that involves all of us. As the numbers of severely depressed, anxious individuals increases more and more families are impacted. Thus we need to examine and understand the unique factors in complex trauma more completely in order to effectively assist the increasing numbers of people and

their families with strategies for prevention, treatment and recovery. We also find that through their lifelong experiences with severe mental disorders, the families of mentally ill individuals have knowledge of the progression of mental illness; the initial signs, the observed changes in behavior and thinking that are usually neglected by professionals. They can inform us and provide a pathway for early intervention.

What is complex trauma and complex family trauma? Complex trauma has unique factors that we will enumerate here:

  * This form of trauma involves a beloved family member who has had, prior to the onset of illness, a strong attachment to family members with feelings of empathy, a foundation of trust and an expectation of future successes in life. Therefore this is qualitatively different from stranger violence, natural disasters, war and other traumatic events.

  * This form of trauma is not goal oriented, there is no plan, no rational reason for the illnessdriven behavior. In other forms of traumatic events the goal is to exert power over the victim and gain complete compliance.

  * This form of trauma is repetitive and occurs intermittently over extended periods of time. Complex trauma is unlike a battle, a virus, an animal attack or robbery. It is an explosive and unpredictable situation that has no end and continues to re-traumatize and further weaken the victim and family members

  * This form of trauma presents no effective safety mechanism except for complete isolation or joining in the attack. Hiding is almost impossible as the attacks carry no exemptions'; schools, hospitals and other "safe" havens are as likely targets as any other.

  * This form of trauma has few, if any, recovery pathway because of the repetitive and enduring nature of the experiences. Recovery from trauma almost always is based upon an end point to the traumatizing experience so that the emotions can be processed within an atmosphere of trust and safety

  * This form of trauma comprises attacks and threats from inside and outside of the family system. Many countries are economically unstable and in social unrest due to the migrant situation, rise in debts, poverty levels and rising costs for health care. Countries are bombarded with terrorist threats from outside and inside and the prospect of prosperity is not positive. From outside comes the constant terrorist threat that creates heightened anxiety and lack of trust in the countries protective abilities. Families feel the impact of these extreme stressors as do the mentally ill themselves. This compounds and amplifies the traumatic experiences and the cumulative effect is on-going.

  * This form of trauma involves systems of care that do not provide the level of care in terms of quantity of resources or quality of services that are needed for the families and their mentally ill loved ones.

A mother describes complex trauma; "It's like being terrorized all the time," she said.

Looking at other less visible but equally influential forces that act compounding forces for the family and loved one we can identify a set of beliefs within may Western cultures that that is entrenched within our social systems and that holds us to expectations and standards of behavior. To be outside of this set of beliefs leads to feelings of unworthiness, shame, blaming and to depression. These beliefs generally underlie the stigma attached to mental illness as the individual cannot live up to these expectations. The belief system therefore assumes the following:

  * That the cause of emotional distress is located within the person and not the social context. If you are anxious or depressed the reasons are to be found in your inability to cope with life stress. It is your fault, your weakness and you can pull yourself out of it- if you try hard.

  * That because mental illness is a weakness and a personal defect others must step in to manage and control the situation.

  * That great progress has been made in understanding and treating emotional distress (via genetic research, MRI studies, and new drugs). and that mental illness is unrelated to the broad issues of abuse, trauma, stigma, inequality, discrimination and poverty.

  * That only violent and unstable people have mental health problems. That mental illness causes violence and psychiatric diagnosis can predict gun violence before it occurs.

  * That mental illness it is chronic but there are "treatments" that provide effective, long term solutions for adults and for children.

  * That there is a standard definition of "normal" and that you should live according to these standards.

  * That your freedoms are unlimited even though you must compromise many of these freedoms on the job, in your relationships and in your plans for the future.

  * That important facts and statistics are conveyed by media, political representatives, your doctors, and that they have evidence that proves what they say

  * That "mental disorders" exist in the same way that diseases like tuberculosis and cancer exist. Therefore they can be treated and cured with medication.

Voices of parents being blamed for son's mental illness: "We were alone then. We were accused of filling him with poisonous medication because we didn't feel like creating structure or enforcing rules. Strangers cursed us when he had a meltdown in public. Acquaintances felt justified in beating their breasts and declaring they would never send their children away. More children in this country die by suicide than cancer, diabetes, and every birth defect combined, but somehow, trying to keep our son alive was considered "bad parenting."

It is fair to say that in most countries the mental health systems are far below the bar in terms of meeting the needs of families and individuals. The reasons for this comprise a long list of issues; funding, stigma, political agendas and other factors that are the subject of other articles in this work.

For our families the pathway to treatment is a frustrating and demeaning journey that often leads to failure or inadequate management and support for the family. This external barrier creates misery for the mentally ill family member and crises erupt constantly and de-stabilize whatever functional structure has been assembled. These crises lead to jail sentences, homelessness, loss of income for the family, and feelings of hopelessness, anger and guilt.

From a mother of a mentally ill person: "I can't go on this way. Nothing I do is right. It's

nothing but fight, fight, fight and I am getting weary of it." This grieving mother speaks about

the police arresting her son who has been in and out of hospitals and jails and who is directly

impacted by cutting of hospital beds, lack of crisis centers and her inability to be directly

involved in his treatment even though she is his primary caretaker."

The nature of the mental illness itself adds to the complexity of the situation for family and loved one

Mental illness takes many forms and symptoms differ from individual to individual. The commonalities across domains of diagnoses include; paranoia, strong and powerful emotions (depression, anger, fear) that may appear suddenly and then provoke unexpected outbursts, unstable sleep patterns, uncharacteristic behavior (shop lifting, trespassing, leaving home, threatening or harming others, self-harm, etc) Some of these behaviors then lead to jail and criminalization, and confusion. The very nature of the mental illness is traumatizing to all in the family as the individual's thoughts, feelings and behaviors become unpredictable and worse over time.

When one system fails, another may take over and be completely inadequate and harmful to the person. For families of the untreated mentally ill the reality of criminalization instead of treatment becomes an all too frequent reality for individuals who cannot access the broken mental health system. Spending months in jail serves to re-traumatize the mentally ill person and the family for decades after the event since the individual carries this on his or her record. Mentally ill persons spend more time in jail due to delays in finding public defenders, and the reality that they are considered less important than other inmates. Without strong advocates their periods of incarceration lead to physical abuse by other inmates and increasing pain for the family. The correctional system has become the largest psychiatric institution in many countries and negotiating the justice system is a frustrating and dehumanizing process for many families. It is yet another source of trauma.

Let us not forget that inside of a family system that is encountering multiple threatening forces there are young and old members with widely different needs , strengths, weaknesses and goals. Young children are undergoing developmental stages all of which are vitally important; attachment, exploration, separation, individuation and this progresses through adolescence and young adulthood.

The crisis-prone atmosphere and focus upon the mentally ill member may result in the unintentional

consequences of neglect and denial of problems with other family members. Young children may suffer the consequences of a fear-based environment and become depressed, anxious and prone to acting out or self harm. Care givers also suffer depression, anxiety and burn-out from lack of self-care.

When the person is hospitalized, on the streets or in jail the youngsters become terrified and feel abandoned. There is often no explanation that they, when they are very young, can understand and they blame themselves. With little external support and stigma the feelings are usually hidden and the situation may escalate and produce more than one family member in crisis. The internal system combustion is not a rare occurrence but is rarely noted by systems of care. These families are truly shattered and, for generations to come they cannot fulfill their traditional functions in society.

In many cases of trauma the victim looks for ways to recover and as we have mentioned this presents yet another frustrating and anxiety-provoking obstacle for families and their loved ones. Trauma recovery strategies have been employed for individuals with some marked successes. They involve steps that emphasize finding a safe place, avoiding more trauma-inducing events, re-connecting with others, open dialogue and mourning the losses. For families of mentally ill individuals these vital steps are almost impossible to achieve due to the constant crises, the on-going threats and disturbing behaviors, the atmosphere of fear, anxiety and depression that pervades the family home. Without recovery, in the absence of a significant time period of calm and predictable routines the family system remains in an unbalanced and unhealthy state in spite of courageous efforts to restore a semblance of structure and comfort to all family members.

When one looks back at the overwhelming features that combine, overlap, accumulate and intensify each other to produce situations that are minefields of traumatic explosions the critical nature of the situation becomes clear. And the numbers of mentally ill individuals and families rises day by day.

From entrenched value systems that demean disabled persons, to terrorist threats and funding that does not approach needed amounts to provide services to the nature of mental illness itself the path of families towards their goals is like Sisyphus pushing a house sized rock up a hill.

Although the pathway is long and very difficult it serves to give us a valuable learning experience along the way. Families have eyes and ears and they identify early signs of an episode before it happens. These signs and symptoms can be as small as a gesture, or as loud is screaming. They may in the case of young children be normal variables of growth but it is useful to know what these families see and be attuned to the behavior of a child. This information enables early intervention and possible prevention of highly explosive episodes. The developmental course of human growth and milestones are not identical for all individuals but a child who, for example, does not socialize or a teen who isolates, becomes suspicious, gets unreasonably aggressive is a signal to pay closer attention.

Here are the families' voices from their experiences over a lifetime of experiences. The key words are: paranoia (with persecutory delusions) shame, anger, depression, anosognosia.

From a mother: "I have a 30-year old daughter who has been sick since high school. When her

problems first started, we took her to psychologist who diagnosed her with "normal teenage

defiance." For ten years, no one knew what was going on in her beautiful sick brain. They call it

"presenting well." In secret, she sees aliens, a FBI informant, the Messiah, and I can go on and on.

Finally, after ten years, her illness got so bad that other signs related to schizophrenia became

apparent."

From the mother of a daughter with bipolar disorder who described the major predictors of an oncoming episode as worsening depression and dissociation symptoms: "She was convinced that buildings moved (shifted shape) at night. She was going out all hours of the night and taking photos of various light effects and the buildings. She heard other voices for awhile when she spoke on the phone and, as she was miles away (in actual distance) it

was hard to find away to communicate. She is still is convinced that in the past she experienced

some unusual things in the "multiverse." At that time she was convinced she had more than one mother: She says that her major issue is depression and ADD"

From a mother who observes the same behavior when an episode is coming on: "He shakes and hits his knees over and over. Then, he stands and paces. He swats the air. His head darts back and forth, as if trying to shake the demons he sees and hears. This doesn't happen all the time," she says. "It happens when he has something really stressful going on at school or he has a cycle. Sometimes, the cycle comes every two months; sometimes they're more frequent. I'm happy when they're gone for five months, but that hasn't happened for a while."

From parents who were unable to access treatment prior to a self-destructive episode: "But for the last 2 weeks, he's mostly stayed in his room. He lives in fear every day because his "spirits" constantly threaten his life. I can't leave him alone at times, because his fear of being killed is so great. I worry that these spirits will cause him to act out and hurt himself or someone else. I know that my loved one could experience what your son's illness did to him. I'm fortunate because he lives with me. I can keep an eye on him and am aware of changes that could be red flags. You weren't in the same town, let alone the same state as James."

From a mother: "The disease never went away. L knew a breakdown was coming; just not when.

Twice a year right in front of me he disappears into psychosis...Then the medicine resurrects him for

a few months...then he dies again."

An article "Results of Family survey-onset of Schizophrenia" recently reported that one of the core symptoms of Schizophrenia that emerges before language is the inability to interpret contextual information. This involves the capacity to examine an object and to determine its function even when the object is displaced (a toy car upside down). Parents of children have observed the difficulty that some youngsters have with this ability which is also used in social relationship contexts. The results of the absence of this ability often leads to social isolation, anxiety and to depression and then may evolve along with other factors into schizophrenia. Below we highlight the key words with an explanation.

  * Paranoia; families have observed that their loved ones usually begin a cycle with expressed fears that they are being watched, targeted, talked about in negative ways. This may begin in a mild form; as in believing that others are "gossiping" and then intensifies and generalizes to many people and situations. At mid point in the cycle the individual begins to isolate from others and intervention becomes more difficult.

  * Shame; the emotion of shame is a powerful feeling that leads to the belief that one is bad and will be rejected by others. It leads to a lack of empathy for others as they are thought to be the rejecting parties and it escalates into overt blaming of family , friends and complete strangers for condemning and harming the person. Shame-based emotions may be verbalized and often the person will write about the rejection in on-line manifestos, journals etc.

  * Anger; feeling anger and expressing anger is often the outcome of having a painful mental illness. These feelings are often directed at close family members and may be unprovoked but are clearly recognizable. When anger is expressed often and leads to breakdown in communication it complicates a families ability to reach out to the individual and re-establish the bond of trust that is important in trying to get help.

  * Anosognosia: this is the lack of insight that is common in people with mental illness and it is often verbalized when the individual is questioned about what is going on with them. The typical answer will be "I'm fine, nothing is wrong, you're the one who has the problem" Lack of insight is difficult to deal with and confrontation or any debate about the issue is often rejected. This is an important sign for families to note and not one that they can effectively change. However, it points to the urgent need to keep the trust bond alive and strong, to seek help and to provide a great deal of positive reinforcement for the behaviors that are positive and healthy. In addition, research points to the fact that this condition may lead to more aggressive behavior and thus it is a signal for families to be more aware of this possibility and seek help.

Families see the early and often silent symptoms of serious mental illness long before professionals can diagnose and treat them. Their observations are more precise and informative than most of the clinical inventories used in practice today and we must not ignore their voices. A family should be part of any treatment process and work within an integrated, comprehensive system of care.

#  Chapter 2 \- Resilience

If there ever was a need for resilience, for the ability to stand strong, stay involved, remain hopeful then persevering through the heartache of mental illness presents that need. Being with a mentally ill loved one in day to day, minute by minute contact is one of the most stressful situations that can be imagined. The mothers, fathers, siblings, children close friends and others are witness to the kinds of suffering and behavior that strikes fear, anger and disgust in many people and when asked how they do this many of them simply say "He's my child, my partner, my heart and soul and I love him"

There have been studies done on the issue of resilience in the face of trauma in order to select those characteristics that resilient people have. One such study examined the survivors of the WW2 concentration camps and found that people who stayed emotionally healthy had certain things in common:

  * They remained positive and hopeful about the future throughout the ordeal.

  * They were spiritually oriented.

  * They did not engage in self-blame.

  * They were loved by someone.

  * They had had successes in the past due to their own efforts and perseverance.

These vital factors come up in a discussion with family members who have managed to cope with death, crises and complete disruption of their lives due to untreated mental illness and the challenges that exist in getting help and in staying involved in the family system. We will present 2 examples of parents who exemplify these characteristics and are now advocates for mental health reform.

Now we include cross cultural research on resilience in order to broaden the view on what creates and maintains emotional health under stress.

"One touch of nature makes the whole world kin" - Shakespeare

In the year 1880 on a remote and untouched island in the Andaman Sea a British ship captured 2 elderly people from the Sentinelese tribe and brought them back to England. They died of disease shortly thereafter being separated from their extended family, living among strangers who neglected and disparaged their culture and shamed them. They were truly traumatized in multiple ways. And further British expeditions to that rugged and beautiful place were met with javelin wielding men and dense jungle. We know little about this tribe other than they live in peace and harmony with their environment, and openly show their positive emotions. They are protected, they are resilient and they are satisfied with life.

When detailed cross cultural studies have been done, they give us vital info on how other cultures cope with the mundane and with the cataclysmic events in life. These lessons help us to move out of our cultural box and to observe and practice diverse ways of experiencing life, relationships and the environment. Cross cultural research opens our minds to how other cultures manage and explain their feelings of well being and sadness and the often amazing ways that they have developed in unison with family and community to heal and to thrive in good and in stressful situations.

This article is about the theory of Salutogenesis, a cross cultural theory dedicated to finding the underlying and universal characteristics of people who have proven to be resilient in the face of stress, who feel competent and have found meaning and coherence in their lives. These are individuals who experience feelings of well being and satisfaction. The theory is based upon research with survivors of abuse and trauma.

The fundamental premise of the above theory is that when one has a pervasive, enduring feeling of confidence that (a) the stimuli from one's internal and external environments in the course of living are comprehensible (eg structured, predictable, and explicable (b) the resources are available to one to meet the demands posed by these stimuli and (c) these demands are manageable challenges, worthy of investment and engagement, then people can weather even the most stressful situations.

This article in which the core principles of Salutogenesis are synthesized, will be particularly useful to people who are on a search for relief from anxiety, depression, compulsive behaviors and for parents who wish to fortify their children with emotional and cognitive strengths.

"Men's natures are alike...it is their habits that carry them far apart" - Confucius

Western culture has a distinctive paradigm that is often described by other cultures as isolative, driven by self-interest, superficial and uninvolved with the natural and spiritual world. Some of this is very true and the social mores that drive Western individuals from early childhood and that they are told to conform to are evidence of this. In this article we deal primarily with the topic of mental health and the cultural mores that persist and may be barriers to the pursuit of well-being. This is relevant since the numbers of individuals who suffer emotional distress is rising, many of our treatments are barely effective and our cultural mores may be at odds with the pursuit of emotional well-being.

In the domain of mental health the more popular mores that have evolved are founded upon

Western cultures individualistic precepts and the focus upon an illness-based model of scientific research; the search for cures from the perspective of pathological symptoms and diagnoses. We have detailed the assumptions and beliefs that have come to define us and guide our paths in Western culture; we are responsible for our own health and healing, mental illness is brain-based and chronic, we must be independent, competitive, successful and "normal". In addition we are expected to conform, respect authority and power and avoid dependence.

Other cultures have very different beliefs that are congruent with their collective-oriented, holistic and traditional world views. Eastern cultures seek help through family, friends, community, spiritual and ancestral sources and perceive the mind, body and environment as a dynamic and collective whole. In many groups, the future is not considered to be a fearful place, for it is where and when you will meet your ancestors and be born again or do the required repair work for your earthly mistakes.

The Salutrophic Method as presented here is a synthesis of several health-oriented, cross cultural concepts (including Salutogenesis) that can be practiced in order to bring about the strengths of resilience, and effectiveness, the feelings of well being and satisfaction and the sense of meaningfulness and purpose in one's life. Three of these concepts are of primary importance and have been well researched in the psychological and psychiatric cross cultural literature.

Into the Future

The Chinese culture is rich in traditions that perpetuate the connection with family and ancestors and with beliefs that comfort and give meaning to life, illness, health and death. Historically, they do not look to the future with fear or think about it in negative ways. There are ceremonies and rituals that bind them together and bring coherence and meaning into their lives. After death, they believe the soul that never dies but goes somewhere and they have lavish funerals with gifts for the departed to bring into the next world. This culture comes together in times of trouble such as famine or war. The family is a solid source of support and they teach children that they will be the caretakers when parents are aged. Therefore the future is a more secure place where people will find respect and have their needs fulfilled.

Research on Western cultures has demonstrated that there is a great deal of fear about the future and that people who predict a negative future are prone to chronic and severe depression and anxiety. One

British study (Depression and prospection) from the British Psychological Society) concludes that living with a bleak view of the future actually can cause depression and therefore a change in perspective and thinking is important. In order to move forward in this regard the strategies would be to maintain a focus upon the present through mindfulness and to begin cognitive re-training exercises. In addition, reading the words of such philosophers as Confucius may help with the shift in perspective and provide a pathway to well being and reduced anxiety.

Episodic Memory and story-telling narratives In many other cultures the tradition of sharing experiences with children and others has a primary place in daily activities. A great deal of bonding and the passing down of cultural information is passed down through generations and this is fundamental in creating a coherent, meaningful context for group members. Storytelling for the Cherokee Indians was a daily occurrence to educate children as to their roles in the community. In The Dance of the Blue Blanket for example little girls are taught by grandmothers that native dance is a way of practicing adult female roles in the family. The story is gentle and descriptive so that children will recall the intricacies through the images, the words and the dance steps.

Narratives provide another ingredient that builds resilience. In children as young as 2 years, storytelling builds episodic memory. This is the part of the memory system that enables humans to connect experiences together in meaningful ways, to form relationships between events and to see themselves in as part of the group experience. Episodic memory has now been demonstrated to be a source of resilience in the processing of thoughts and it is weakened in such illnesses as Schizophrenia. Scientists are working on exercises (including narratives) to strengthen episodic memory functions in people with Schizophrenia. When a parent includes storytelling that involves the child in a past, pleasant narrative it reinforces the bond with others and makes memory more effective. With a strong memory individuals usually experience feelings of competence and have the mental resources that enable them to persist in times of stress.

One practical form of storytelling is journaling and this is known to be a wonderful resource for teens and adults in terms of expressing thoughts and feelings, creating new strategies for coping and revisiting confusing situations to obtain a sense of coherence. Parents can include storytelling time with their children and families may share narratives around the dinner table.

As we know, humans are social beings and relationships of every kind bring meaning, strength and comfort with them. In order to withstand stress, illness and the multiple changes in life people need to be connected and supported emotionally, physically and often spiritually. From birth onwards, social contacts build the brain and with the degree of plasticity that our brains demonstrate we know that there is no end point to the constructive gains that relationships bring. Social isolation is used, as we know, as a form of abuse and punishment and may lead to severe disability when it occurs in early life. Along with resilience and satisfaction, relationships add to the physical health of the individual and bring the possibility of additional resources to protect against unwanted shifts in fortune.

Connectedness with family extends into the next domain for many non-Western cultures and they have traditions and ceremonies that provide food and other necessities to honor the deceased. These traditions maintain the theme of constancy and coherence in the life-cycle; the spirit of the person is still with them in a tangible fashion.

The Navajo people have a culture that is rich in its relationship with nature. They have lived in harmony with plants, animals and the seasons and have many ceremonies and taboos that guide them in maintaining their connection with their natural environment. They express their love and respect for nature in their sand painting art, their dances and their folklore all of which create the feelings of satisfaction, coherence and well-being that have sustained them through the decades. Having a relationship with the natural world stimulates the creative mind and this is a great source of strength and emotional gratification. The taboos that they believe in keep them safe and secure within their world and demonstrate that they have a wide perspective of life and their place in the universe. This culture that honors the rain, paints the powerful coyote, considers the owl a friend and wears the

Eagle feather as a symbol of strength is a model of the valuable contribution that nature can make in human lives In order to promote this practice a walk in the park and paying attention to the flora and fauna would be a good place to start.

Establishing or re-establishing relationships with family and friends may sometimes seem like a formidable task for those of us who have little time and energy. Confucius would tell us to move forward one step at a time and to take the Golden Path or Middle Way. He would caution against extreme measures and taking his advice an individual might begin by making a phone call or writing that letter that has been on the back burner.

"It doesn't matter how slowly you go as long as you do not stop" - Confucius

As you consider what has been written, hopefully you will digest these ingredients and they will help you move into a more meaningful, satisfying and a healthier tomorrow.

Here are 2 examples of resilience. In the first narrative it is clear that a loving family, gratitude for what one still has and the ability to stay involved and work towards a future play vital roles in this mother's ability to stay strong.

Example 1

I miss my normal. I grew up having huge Thanksgiving celebrations. My dad was the baby of seven and Thanksgiving was a very special family time in the Clarke family. When I was young, I remember driving to Chico, Red Bluff or Sacramento to see Aunts, Uncles and cousins. I had so many cousins that I could never remember all of their names. My cousin (more like my sister), Linda, was the one to remind me who was who. She died suddenly of a brain aneurism about 11 years ago and it was never the same on Thanksgiving. I miss her and everyone we have lost since. I miss normal.

I remember that it was always the very best day with food, family and sometimes fights. Fighting was common in our family. But, we had deep love for each other.

We stopped having our traditional big family Thanksgivings several years ago because they just got too big. Now, I cook every year for our little family, which I love. Except one person is always missing, our Danny.

Danny LOVED Clarke Family Thanksgivings. He still asks about my cousins and his cousins every year. But, Danny hasn't been home for Thanksgiving for over 6 years. He was due to come home for his first Thanksgiving in 2011 when a double medical emergency hit our family. Both my mother in law and Danny were hospitalized on Thanksgiving eve in 2011. My mother in law ended up in the ICU on a ventilator. Danny ended up on an inpatient psychiatric unit of our county hospital.

On Thanksgiving Eve 2011, Danny began having serious anxiety or panic attacks and called us constantly from his CRISIS residential home. I knew how excited he was to come home and be with family the next day but he was not doing well. He was also due to begin his first community placement the following week. He had been transitioning out of locked facilities and was ready to move forward.

Except that day he was struggling.

I was due to host a dinner for about 30 people so I was in full-blown cooking/cleaning mode. But, I stopped and made all of the calls to the county staff to alert them that Danny needed to be monitored closely to prevent a full blown crisis. They promised me he would be put on a one on one and "shadowed." Too bad that they didn't offer emergency meds but his was not a medical facility. A little Ativan may have prevented years of being locked up at a cost of hundreds of thousands of dollars to our county and state. Not to mention the human costs.

I remember how excited I was that day because I knew my son was coming home and that our family would be whole again. The first blip in the day was a call from my husband that he was taking his mom to the ER because she was not doing well. Next thing I knew, she was in the ICU.

At the same time, Danny was calling and begging to come home. We couldn't go get him because we were with my mother in law. Then, he called and said that he WANTED TO GO TO THE HOSPITAL.

He knew that he was in trouble. He was begging for help. The facility did not respond appropriately to this medical emergency UNTIL after Danny had a complete melt down and ended up in a fight with one of the residents. Danny ended up behind a locked hospital door that night instead of coming home. He hasn't been home since.

Danny spent Thanksgiving 2011 on the locked psychiatric inpatient unit 4c of Contra Costa Regional Medical Center. I never dreamed that when I advocated for the patients of that unit to be served a family style meal that year that my son would be there to eat it, too. I was grateful for the staff of our hospital that had partnered with the patients and families to make this happen. It is the little things that can help us find normal.

Our Thanksgiving dinner went forward that year. We were all in shock and wanted to be together. The next several days were a spiraling of events between my mother in law's condition and Danny's psychiatric emergency. My mother in law died on December 11th. Danny never got to kiss his Nonie good bye. His anger turned inward and outward and that is how he ended up going to Napa State Hospital in January of 2012.

"Today I am thankful that Danny is doing well. It took 4 years of forced treatment to get him stable.

He will likely be returning to the Napa County jail in the coming weeks to have his competency to stand trial determined for charges that occurred while a PATIENT at Napa State Hospital in 2012.

It costs over $200,000 a year for California state hospital bed. It would have only cost about

$40,000 a year to provide the medically necessary assisted outpatient community treatment he needed in 2011. Thankfully, that community treatment is available now in Contra Costa County for patients like Danny. Laura's Law is due to be implemented in my home county any day now and will save lives and possibly our souls.

I am thankful that today I am again in cooking and cleaning mode and that I get to go pick up our beautiful daughter, Laura, this afternoon. She and I will spend the evening chopping and chatting in preparation for tomorrow's meal. I love, love, love my family and friends and I am so thankful for all that I have been given in this life. But, I miss my son and I miss my normal.

I am thankful for those at Atascadero State Hospital who are caring for my Danny. As we move

through our day tomorrow I hope we all will keep a special place in our hearts for those who are

without family and friends"

Example 2

It was my son who did this.

Sometimes, often really, things break - irreparably. And it takes your breath away ... straight away.

It took my breath away when my son stormed into the bathroom, frustrated, angry, fed-up for his very own, very significant to him, reasons. And when he chose to SLAM the bathroom door, causing the heavy mirror mounted to the front to slip out of the hardware holding it in place and crash onto the floor - a million, BROKEN pieces were left reflecting the afternoon light.

I was quiet. I surveyed the damage and took a deep breath. Put the dog outside so he wouldn't cut his feet, put the cat in the basement for the same reason.

I walked into the backyard and felt the hot tears streaming down my face. It's amazing how alone you can feel as a single parent in moments like these. I realized how scared and disappointed I felt. Did this really just happen? Yes. This was real.

And as I stood and considered whether or not this was an indication of his developing character, I heard his tears through the window above me, coming from inside the bathroom.

His soul hurt. This was not what he expected either. Hello, Anger - I don't remember inviting you into my house.

Scary.

Terrified.

Ashamed.

Worried.

Scared.

Deep breath, #MamaWarrior. Deep breath. That small, fragile soul needs you right now. He needs your very best. Your biggest compassion. Your most gentle and firm mama love and reassurance.

More deep breaths. Go Mama.

Go. Go now. Go open the front door, tiptoe through the broken glass, hear him hearing you coming, watch the bathroom door crack open, see the face you love most in the world red with worry and wet with tears, his voice is suddenly so small: "Mama, I'll never do it again, I am SO sorry." More tears.

More weeping. Such uncertainty on his sweet face.

Go Mama. Get him. Go now. Scoop him into your lap. Yup, you're crying too. Damn this was big.

Hold him tight. Watch how he curls into a ball in your arms so quickly. See how eager he is to be loved by you. To be reassured by you. See how small he still is. See how fragile that spirit is.

I love you.

You are safe.

I am right here.

The worst part is over now.

I've got you.

I'm here.

I love you.

Go Mama. Tell him about Anger. Tell him now. Anger is a really powerful feeling. You have a right to your Anger. Anger burns hot. It can purify. It can also destroy. He nods. He feels it. He's met Anger now.

There's a better way to show your big feelings.

We'll work on it together....tomorrow.

I'm here to help you.

You are safe.

You are never alone in your anger.

You are never alone in your fears.

I'm here. We're here together.

Now we will clean together.

And we cleaned up the broken pieces. We swept and we vacuumed. It was quiet work. It was careful work. It was thoughtful work.

Sometimes things break. Sometimes we break them. It's not the breaking that matters, the how or why. What matters is how we choose to respond to the broken-ness. Does it kill us? Does it throw us into a downward spiral of blame and punishment?

OR

Does it help us remember how to love deepest? Does it push us towards compassion

and over the hurdle of "rightness" and "wrongness" into LOVENESS?

Yes. LOVENESS.

Go Mama. Go now. Get that baby of yours. Teach that. Show that. Live that. It's called LOVENESS.

Go. Now.

This beautiful narrative expresses the family bond that breathes trust and love. This is the heart of resilience, it is the word "loveness" that we all must remember when stress from outside and inside threatens to break us apart.

Chapter 3 - Post Partum Depression; the Complex Trauma That Spreads Through the Generations

In the domain of complex family trauma post partum depression holds a place of its own in terms of effecting multiple people, interfering with developmental processes, confronting barriers to medical and psychiatric treatment and holding a family hostage to watching a terrible illness infect the innocent and the vulnerable.

The voice of a new mother: "I'm tired of trying, sick of crying, I know I've been smiling, but inside I'm dying.

Would you like to know how I feel?

Have you ever had a nightmare in which you're so scared that you try and scream so loud for someone to save you, but not a sound comes out of your lips?

That's how I feel every day, all day."

For many decades maternal mental illness was unrealized or hidden, which of course made it difficult

to study, and to treat. But by increasing awareness, new research is helping to remove the stigma of maternal depression while also increasing the likelihood that a woman may first recognize her own symptoms and then get the help she needs.

Recent studies have revealed that at least one in eight--and as many as one in five--mothers develop symptoms of mental disorder in the year after giving birth. This can mean the sort of postpartum depression we tend to think about when we think about disordered moms, but it can also mean other things: anxiety, bipolar disorder, obsessive-compulsive disorder or any combination of disorders.

Such illness is also not necessarily confined to the postpartum period: In one 2013 study of 10,000 postpartum women, researchers found that 14 percent had depression four to six weeks after birth.

For a third of them, however, the depression actually started during pregnancy.

Here is a narrative that describes the complex trauma.

Amy is my pretty 19 year old sister and the mother of my 4 year old niece Sara and she lives with her boyfriend who is unemployed and can be abusive when he drinks. Rick, who is not the father of the little girl complains often about Amy because of her "spells" that make her tired, irritable and so sad that she stays in bed. She gets welfare for herself and her daughter and government health insurance but she rarely goes to the doctor. While we were growing up our family was plagued with poverty and the drug abuse of both of our parents. We were on our own and I knew that Amy had times when she wanted to be alone, she was tearful and sometimes would make marks on her arms and thighs. No one knew about this or about her use of diet pills to pull herself out of her "bad moods". She left home at 16 to live with a man and then she and Rick got together and she rarely had contact with me. I worried about her constantly until she appeared on my doorstep late one night with Sara and said that

Rick had been violent with her. My fiancé and I took her in not knowing that she was pregnant, unaware that her "moods" had become terribly powerful and that she heard critical, condemning voices that made her feel suicidal.

Amy had learned how to hide her feelings and we both had done that in order to avoid the thrashing by our parents when they couldn't get their street drugs. When Amy was 7 months pregnant and her condition was obvious she refused to see a doctor until I told her that she would not be able to keep her baby in the county hospital without some prenatal care because the case managers would say she was not capable of caring for the infant. I told the doctor that she was depressed but he said that that was "normal" given her situation and Amy refused counseling.

The delivery was hard and Amy seemed to be unenthusiastic about her baby boy. I saw that she held him loosely, seemed distracted and let him cry for long periods. Again she refused to see a doctor even though there were many times when she didn't feed or change her baby (I took over) and she cried or slept most of the day. When I observed her talking to herself and punching her stomach I insisted that we make a counseling appointment but it was 5 months away due to long wait lists at the post-natal clinic. By the time we went in she was very thin and exhausted looking but the doctor did not think that her condition warranted medication and he referred her to group therapy which she refused to attend.

One evening Amy went missing. She had been ranting and raving all day and had covered all the windows with sheets so that the government agencies who were spying on her couldn't see in. I was completely frantic; my heart rate went up, I had panic attacks, couldn't sleep or eat and had to wait for the police to start a search. One week later they found Amy on the road, wandering and confused. Her baby and her daughter had suffered enormously; my niece had eaten little, cried all night and the baby looked sad and pale.

We were all physically sick and emotionally drained when they had her admitted to an ER and then had to wait 4 days for a psychiatric bed to open up. In the hospital I couldn't get any information and when she was discharged after 3 days I found out about it from another patient who got my number and called me to pick Amy up. She appeared angry in the car, accused me of trying to harm her and even tried to open the door. At home she ran up to her room and immediately got into bed, refusing to talk to me or her daughter or even hold her baby. This continued for a week as I called clinics for help and was told that if she wasn't trying to kill herself or harm others there was nothing that I could do.

We all suffered enormously until, very late one night, Amy made a large gash in her arm that wouldn't

stop bleeding. The police came with a mental health crisis team and they involuntarily admitted her back into the psychiatric unit. This was just the beginning of many months of hospitalizations, early discharges, long waits for appointments and grief for everyone. There was no help available, walls were up in every direction that I tried to pursue. My fiancé left our relationship in frustration and despair. I was alone and desperately afraid and anxious.

Amy ran away again after 6 months of terrible turmoil and is still out there. She is terribly depressed, confused and listening to voices that tell her awful things about herself and others. I know that someone is probably abusing her. I will never stop looking for her because I love her and she needs someone to at least try and get help for her. Whatever I did....it simply wasn't enough and the help was not there when we needed it.

When a mother is severely depressed the entire family system struggles with her illness and the impact that it has upon all family members. Feelings of helplessness and guilt over not being able to "solve" the problem makes life a struggle. Not finding help can create the kind of anxiety that pervades the household and changes the dynamics in the families functions of providing a safe haven, educating children, stimulating exploration and growth.

When we discuss depression in women we must not overlook the impact of depression upon her children. Youngsters are resilient and many women have depressed episodes that do not have a major effect upon their kids; life is full of situations that create periods of sadness and this is normal and expected. In the case of severe and lasting depression the impact may be quite powerful. Infants as we know require nurturing and stimulation for their brains to grow. Mothers who have eye to eye, mind to mind attachments to their babies and touch and talk to them are giving the infant an optimal environment for brain development. As the child matures, the stages of separation, individuation and the regulation of emotions can be effected by lack of maternal emotional input. There are situations when another caretaker can certainly provide this stimulation and indeed grandparents, foster parents and care takers can step in with good results.

Mothers who experience depression and other forms of mental illness can't help what's happening to them, and surely they're suffering. The mentally ill often aren't capable of seeing the impact of their illness on others, so all-consuming it often is.

Conclusion. As this article points out, families with mentally ill loved ones suffer with complex trauma due to the multiple traumatic forces that converge upon them. These powerful forces from inside of the family system and compounded by the failure of external systems of care, stigma and political agendas are often overwhelming.

#  Chapter 4 - Focus upon Depression; Context and Conflict of Values

By M. Altman MSW

There is an "epidemic" of mental illness across this country and people (including young children) are being diagnosed with depression, bipolar disorders, anxiety disorders and ADHD by the thousands.

Individuals are rushing to find remedies; from doctors, gurus, and from diet programs, exercise routines and over the counter pills and tonics. When you stand in line at the checkout counter with that vial of energy supplement grasped in your hand think about the fact that people in other cultures cope with depression, anxiety and mood swings in very different ways. We can learn from their traditions and their strategies.

The field of cultural anthropology was my focus for many years and I learned that the lived experiences and traditions of other cultures can provide insights and wider perspectives for professionals and lay persons. We, the majority, view mental health issues through the narrow lens of our own cultural traditions, and we have adopted the assumptions that our Western society advocates. The assumptions about mental health are as follows:

There is a category called "normal" and that it can be described and defined in emotional and behavioral terms.

Emotional distress "mental illness" is primarily a biologically and brain- based set of illnesses and that diagnostic categories and algorithms lead to effective medications that have been scientifically proven to treat these diseases.

Mental illnesses exist as chronic diseases and should be treated as internal disorder and the context (environment and lived experiences) are of secondary importance.

Those who are diagnosed with a "mental illness" are not strong or functional individuals who can solve their own problems and cope with stress or understand their own disorders. They require a doctor's help to recommend treatment.

It is important that step outside the boundaries of our own historical assumptions and view mental health through a wide lens. The assumptions mentioned above can be oppressive and dictatorial and lead us to consider ourselves "abnormal" if we have feelings and thoughts that do not fit into a "normal" template that has no real definition. We need to be able to expand our views, to capture our lived experiences in positive terms and take back our freedom of expression.

Within our society there are minority populations that have not and do not buy into these and other assumptions about mental health. This article speaks about the African American community specifically because of the author's own experience base with this community and the reality that their voices should be heard in relation to mental health issues. Other cultures (Asian/American for example) also have their own perspectives on mental health but have unique qualitative aspects and should be considered separately.

Depression, its "causes" and treatments is a subject of constant debate and Depression is, because of its prevalence and the multitude of forms that it takes, a key target for drug companies and their research department. Recently. a new drug advertised as an "add on" for Depression has been developed by Otsuka Pharmaceuticals ( a Japanese company) and the drug is Rexulti, as reported by U S News July 13, is FDA approved after 2 six weeks trials with 1300 people.

There are a substantial number of individuals who, although they suffer from depression, will not be influenced by the craftsmanship of the advertising for this drug nor will they seek medication at all.

Many individuals in the African American community and especially Black women, who tend to be the spokespersons in this community, view the biologically-based model of mental illness and the medication-based approach as oppressive and abusive. The issue of Depression within the Black community in general has been examined due to concerns about the low participation rate in the mental health system of this population.

Depression is very common within the Black community and according to numbers from various sources there are 7.5 million African Americans with Depression as a "diagnosed mental illness". Up to the same amount are affected but undiagnosed and women represent more than twice the number of males with depression.

The questions that we need answers to for our own education are; why don't they reach out for help within the mental health system? What do they see as dysfunctional and damaging within this system? How do they perceive and cope with their own emotional distress?

The voices and views of Black women have rarely been taken into account and they have been an invisible population within the mental health system.

From an African American advocate: "To me, it seems perfectly adaptive and pragmatic for many of us to refuse yet another label and its associated prejudices and preconceptions. And, it is highly disturbing that we would be pathologised for, essentially, resisting further oppression.

Putting a medical label onto an experience does not make the experience any more or less real or painful. Nor does it validate it; all it does is just this: it gives it a medical label. The imprisonment of

Black women's experiences within a medical discourse needs to be questioned. Indeed, it does not speak to all of us. Personally, it was only during the course of my psychology studies that I realized that this recurring feeling of imminent passing out had a medical term: 'anxiety' or 'panic attacks'.

Calling this 'anxiety' did not provide comfort or reassurance. I did not think: 'great, now I know what's wrong with me'. I felt angry. Angry and invisible. Angry and re-traumatized"

There are several areas to be looked at here that tell us why African Americans will not partake of the medical model or ask for an invitation to the drug company's medication orgy.

First and foremost is the discrimination barrier. One must take a chronological view of the African

American experience in this country with our history of slavery, racism and dehumanizing of this population. This long and devastating oppression is the foundation for mistrust, for underlying expectations that the system in general is not going to meet the needs of Black Americans. We are aware that racism still exists, that the degrading experiences of the older generations are transferred to the succeeding generations through narratives and then confirmed by racial conflicts currently going on. Racism exists and is a foundation for this community's low participation in mental health and related systems of care.

Second, we add to this the stigma that continues to be attached to "mental illness" within our society.

African Americans are not isolated from the fear of carrying and of being labeled "mentally ill" This is double stigma when added to racism and reinforces the perception that being Black and labeled mentally ill is a designation to be avoided.

From an African American woman with depression "The first thing they say is "Oh, she's crazy." Always acting crazy, you know what I mean? You don't wanna be referred to as crazy. You might want to be referred to as mentally ill, you know. 'Cause mentally ill sounds more better than "Oh, I'm crazy!" You know what I mean. Oh, there's definitely a stigma".

The third barrier is embedded in the mental health systems of care. Being Black and labeled mentally ill puts the individual at a disadvantage when trying to access care. African Americans point to the White-dominant attitudes that prevail among doctors and other treating specialists and lack of cultural sensitivity. African Americans report that they receive fewer sessions, are more quickly hospitalized and directed to medication treatments instead of therapy due to racial disparity. They point out that Caucasian doctors do not take into account that African American women are heads of households and as such have obligations to multiple people and cannot spend time or funds in treatment. They report that most treating individuals are Caucasian and this makes them feel uncomfortable.

When asked by an interviewer about trying to contact a helping person in a mental health clinic the individual stated that in the initial phone call he was identified as Black and he believes that his needs were not addressed because of his race; These are things that we, I think, as blacks—we're not told about... If you make a phone call and they discover that you are black, then they transfer you to someone else, and by the end of the day, you don't wanna talk to anyone. You say, Forget it, I'll just sit here and keep it to myself... So we have to get information...by word of mouth from somebody else. We really don't get it from the professionals or the agencies or the people who (handle) it. We just get it from a friend. You know. And hopefully, you had a white friend to tell you".

In a similar situation an individual described the mental health clinic that I worked in as a cold and uninviting place where she felt unwelcome because of her race. This was voiced by a senior African American woman that I was doing an "intake" with. She was clearly uncomfortable during the interview; clasping her handbag tightly in her lap, her posture was stiff and she had been answering questions with only a "Yes' or "no" response. With encouragement and after a cup of tea she relaxed sufficiently to tell me that she had come only because her primary doctor wanted to "rule out" depression as the cause of her severe stomach pain before he sent her for testing. She was, indeed, depressed , but refused counseling and said that she would "take care of it" herself. It turned out that she also had an ulcer.

The fourth issue is the cause of depression. They perceive that the predominant biologically-based view of mental illness is antagonistic to their view of mental illness as primarily due to life stress, to poverty, discrimination and the violence within the African community today.

From an untreated man with depression: "I know a lot of black people that's depressed. Every black person I know is depressed...We're born into a depressed (state). What we live with and adjust to...I have nothing against white people...But what we live through and go through... a white person couldn't handle it".

They pointed to the specific causes of their depression as being relationship-based and due to problems with partners, children, grand-children and friends. The issues that made them feel depressed were deaths through murder, drug overdose, gang violence, physical abuse, incarceration of loved ones. One participant stated:

"Uh, one of the things that affected me is the two children that died so close together, and left me with the one about what I wished I'd had done, and it gets to me, sometimes. And that's really depressing".

Within this community (and other communities where poverty and marginalization take place) the environment is so harsh and hopeless that it is difficult for privileged individuals to conceptualize.

Self-care is an important part of self-esteem and emotional well-being there is little time, money or energy for this in the Black woman's schedule. Self-deprivation is sad and demeaning . The following

quote is one that we need to hear:

"And I think another reason why people get depressed in my opinion, is we neglect ourselves.

Particularly black people, black women. We don't have any good men to rely on. We've had children too early in life. And we neglect ourselves. We're so busy doin' for and trying to do the things that we should do and make up for it, we don't take the time to get our hair done, go to the spa, go get a facial, get a pedicure, ya know."

Living a life of deprivation and abuse that has been endured for generations is what is being described here and the chemical imbalance theory simply does nothing to explain the sadness and hopelessness of these lives. In an environment filled with the sounds of sirens, cries, gun shots and the deafening sounds of silence when someone is being abused in secret we hear that the medical model is another form of oppression and to be informed that you have a chronic brain-based illness is just another degrading experience.

The symptoms of depression are well known to African Americans and they view these symptoms in the context of their difficult lives. They are not denying or ignoring their symptoms.

In one of the studies that used mixed focus group to question African Americans on their perceptions of depression, their use of mental health resources and their traditions it was made clear that the individuals are very aware of what the symptoms of depression are. They identify the following: sadness, being tired and having little energy, irritability and weight loss or gain. Many described headache and body pains and others pointed to increased cravings for drugs or alcohol. Those interviewed believed that these symptoms were to be expected due to their hard lifestyle They pointed to the specific causes of their depression as being relationship-based and due to problems with partners, children, grand-children and friends. The issues that made them feel depressed were deaths through murder, drug overdose and deaths of young children.

How does one cope with depression given an environment that entraps one in despair and deprivation?

The answers from those who were interviewed were strong and clear. They reach out to family and they depend upon their religious institutions to give them strength, care and comfort. The importance of intimate relationships with others and with God was the dominant theme. A significant number of individuals pray during the day, with friends and in their Churches and they ask for strength and for help for their friends and family Many of these individuals also noted that they stay busy and this gives them a sense of being in control of the situation. Black Americans, as per this informative study, say that they have experienced the pain of depression for a long time. African Americans have developed their coping strategies based upon their experiences with racism and discrimination, the stigma associated with mental illness, interactions with a culturally insensitive mental health system and their cultural traditions regarding mental health.

We can learn much from the lived experiences of African Americans in our society.

We can appreciate how they view the majority population and that insight leads to self evaluation and an opportunity to connect with them differently. Perhaps in relating to a Black individual we can ask about their family, their spiritual foundation and ask where they get their strengths.

We certainly can empathize with the difficulties in their lives.

We can learn why they avoid the mental health system and put more effort into building trust.

We can be consistent with them and not promise what we cannot deliver.

We can confirm their own views and acknowledge that the system is insensitive and ask what would make it better for them. We can find alternatives to medication and research ways to provide counseling with people that they can relate to.

We can learn about the importance of intimate caring relationships to strengthen and support the resilience of people in states of emotional pain.

#  Chapter 5 - Youngsters with Mental Illness and Medication in a Broken Mental Health System

Children develop mental illnesses at surprisingly young ages; youngsters at the age of 4 have been reported to be depressed and have attempted suicide. Children, who live in families where there is mental illness, may be at high risk for developing anxiety, for acting out and becoming depressed. The issue of psychiatric treatment for youngsters is a passionately debated one and is covered in other venues. We bring it to attention here due to the fact that children in shattered families tend to be silent about their problems until they are overwhelmed and it comes to the attention of teachers or other care takers. Caretakers need to be aware of the concerns about medication for youngsters especially when the family is trying desperately to cope with another family member who needs help and support. Recommendations by friends, family and professionals should be considered carefully for children in light of recent studies on longer term effects of medication and the importance of comprehensive treatments including therapy. This, undoubtedly is a difficult process given the proclivity of our system to provide medication as a first line solution but it can be an option.

In this chapter we do present one viewpoint on psychiatric treatment of young children because it offers relevant information for families. In this opinion, when children do receive treatment the psychiatric medication may create harmful side-effects and long-lasting problems. This opinion directs attention to this issue and it highlights the pharmaceuticals role in increasing the availability of medication for youngsters for profit. Psychiatric treatment for children is an important issue currently and this debate is open for comments on other sites.

Pharmaceutical companies are aware of the possible cuts in funding for medication that are planned.

They feel the pressure forge ahead with new algorithms accelerated research and new populations to aim at.

The new populations that are potential recipients of new drugs and algorithms are young children and indirectly, the unborn infants of pregnant women. This would stand to reason as these 2 groups have been semi-protected until recently and are an untapped source for research and development of new drugs. Since the 1960's scare due to Thalidomide and infants of mothers who had taken that tranquilizer being born without arms and legs, pregnant women have themselves been leery of medications. However, with the current trend of diagnosing very young children with ADHD, autismspectrum disorder and numerous sensory disruption conditions, women are re visiting the concept of treatment at a very young age. Along with this, the promise of new drugs for anxiety and depression may invite more people, including pregnant women, to try the newer medications. They may be influenced by reports that severe depressive and anxious states have physical effects upon the body and they may fear that the stress of depression and anxiety may harm the fetus.

There is a disturbing case from Texas that involved a 12 year old child, Johnson and Johnson, the drug Risperdal, Texas state officials, the Texas Medication Algorithm Project , Texas state hospital, and the university of Texas. The core issue here is money and promotion of the expensive drug, Risperdal, for children. The case is about payouts and influence and corruption but more than that it is about the damaged done to a 12 year old girl and the possibility of more cases like this in the near future. This case is discussed in several places on line.

A summary follows; In Texas, a 12 year old child in middle school was labeled "oppositional defiant disorder" and placed in special education even though her grades were B's and C's. Her parents, who have 3 other children, and run a small business, were not alarmed-they had no idea where this label would lead. At this time the University of Texas was doing a study funded by a pharmaceutical company to develop an "algorithm" for treating "mental illnesses" and specifically schizophrenia with their psychiatric medications. Court records later revealed that the study and its ties to the University, the State hospital and government-funded clinics in Texas led to a psychological screening at the child's school in which she was identified as "suicidal" referred to one of the clinics. Six weeks later a child protection worker came to the home to take the child to the state hospital Her father absolutely refused at which point the worker took emergency custody of the child and involuntarily hospitalized her. The next months reveal a cycle of psychiatric medications and diagnoses ranging from depressive disorder, mood disorder, psychosis and her medications included Haldol, Geodon, Abilify, Cogentin, Depakote and Risperdal. The child recalls being injected, threatened, being restrained and having her head held down so that she would take the medication and she spent a great deal of her time crying in her bed. Eventually and luckily a complaint against the Texas Mental Health system involved an investigator who began to look into the case (and was suspended several times during that process).

He uncovered documents showing that the drug company was spending millions of dollars to influence State officials and in 2004 he laid out his charges for the New York Times. Almost 6 months later the case went to court and the child's parents saw her for the first time. It took another 4 months before a judge ordered her released from state hospital. The family sought and found a psychiatrist to wean the child off her basket full of medication and it is reported that she was able, in time, to go back to school. Her parents noted that she is still not the child that she had been, the gleam in her eyes is still absent. For more personal information on this case please go to the website.

As a follow up to the above, the Texas program is called TMAP and an internet search reveals that the drug company that was involved in the case settled the lawsuit for 158 million dollars. In 2005, a bill - The Parental Consent Act, was introduced in the House of Representatives that forbids federal funds from being used for any mental health screening of students without parental consent.

Along the way we can expect to find accidents and probably some of them will be fatalities. There are, and will be, problems with algorithms (formulas) and as these are directly linked to diagnoses and selection of medication for the diagnoses this needs to be a topic for scrutiny. There are, and will be, problems with the age ranges of children involved in the research and as one study that will be researched for the next article is going to recruit infants of 18 months of age this is also an area that needs attention. There are and will be problems with drug testing and whether the tests themselves

are valid and reliable.

And, of course, there is the concern that the drug companies have historically found strategies to meet their agendas even with regulations in place. They need constant scrutiny and questioning by parents and professionals.

Within a system of care that is not uniform across states, that is poorly monitored and a diverse mix of private and government agencies and that remains in limbo in terms of many mental health issues it is vital that we keep our eyes and ears attuned to the recommendations that are so freely made on TV and internet. This and even recommendations from physicians needs to be a domain within which parents are involved and are always able to make informed decisions regarding their youngsters emotional health.

#  Chapter 6 - Why Some Communities Avoid Treatment for Mental Illness

By M. Altman MSW

People with untreated serious mental illness comprise one-third, or 200,000 people, of the estimated

600,000 homeless population, and an even higher percentage among homeless women and among individuals who are chronically homeless.

We find certain communities where the residents are not receptive to the bio-psychiatric model or to medication per se for emotional distress. Within this domain there are numerous Eastern cultures that are traditionally oriented towards spiritual explanations and treatments for the symptoms that Westerners call mental illness. Their practices are well documented and can be truly effective. There are organizations within Western countries that view the medical model per se as dangerous, harmful and thus shun psychiatry and medications. One's perspective about the "cause" of mental illness will determine how or if one is open to treatment that our society prescribes.

There is also, and very significantly a large proportion of the community of African American women.

In prior articles the issue of the drug companies targeting young children, teens and pregnant women

as ripe and rich populations for new drugs that allegedly attack symptoms of ADHD such as irritability was brought up. Parents and child care workers were described as fearful of the ramifications of an ADHD or autism diagnosis for their youngsters and therefore prone to await the arrival of the new drugs on the superhighway.

African American women however inhabit a different social and ideological domain and, according to the voices of these women and targeted research they shun the mental health system for various reasons that need to be brought to light. African American women who are in emotional distress have spoken out about the double stigma that they face and how they view the causes of their distress.

In a recent media video we witnessed an African American mother slapping her young son for looting in Baltimore. She was hailed by some who perceived her as the strong Black mother who is head of household and in charge of protecting and disciplining her children. This is one image that we have. The other image, and the one that women of color struggle with daily, is the image of a subservient

Black woman who is called upon to take low level jobs and forgo her education in order to support her kids. Black women report that they face daily discrimination; in their neighborhoods, at work and in the mental health system. The fact that they are stereotyped with this dual image; strong with the family, weak in education, subservient in status because of their race is what they live with on a daily basis. This is a primary cause of their emotional distress according to what they report it is the social and environmental context that underlies their depression, fear, shame and anger. The cause is not a brain disease it is a social disease. To that distress is added the stigma of being "mentally ill" if and when they seek relief. The double stigma is a terribly heavy burden and not one that is openly discussed when most people talk about stigma.

One reason that this is not brought out and up for discussion is that Black women encounter a "White" perspective in the mental health system in terms of the medical model and its view of locating the source of the distress as being within the individual. The African American woman's perspective is quite different in terms of the discriminatory context of their daily lives and they see the cause of their pain as being outside of themselves. The mental health system does not address these core issues and Black women are confronted with a system of care that often dismisses these concerns and prescribes medication. Black women also feel more comfortable and better supported in the religious systems that are a large part of their lives. Here they find empathy and understanding of the multiple sources of degradation that they face on a daily basis.

Black women are driven, like all parents, by fear for their children. The basis of their fear is not a diagnosis of ADHD; it is more likely to be a fear of violence, racism and the terrifying situations that occur in their neighborhoods. Their shame is about being discriminated against and then stigmatized if they reach out for help. Their frustration is about the lack of understanding in the systems of care that they may turn to.

Within the community of women of color who face the double dilemma of racial and social stigma the emotional distress is elevated to a high degree. African American women report that their lifetime of racial discrimination along with abuse and other barriers have enormously effected their self esteem and ability to express feelings and thoughts.

There is a great need for a paradigm shift in the way that mental health services views and treats

Black women otherwise their wounds are rendered invisible and the marginalization of this valuable community continues unabated.

Black women do report that there have been improvements in terms of increasing the relevance and appropriateness of mental health services for radicalized groups. Indeed, specialist services have burgeoned in the past decades and various collectives now exist to try and ensure that psychological needs are met in ways that are more congruent to peoples' values, worldviews, histories and social realities. However, within the mental health system, Black women feel that the profession is itself "White" and treats Black women differently in terms of more recommendations for medication instead of therapy and more hospitalizations when they are in emotional distress

Several recent articles reinforce the fact that Black women see the cause of emotional distress as being located in trauma of abuse, violence in the community and the degrading discrimination that they face on a daily basis. They do feel ashamed when they have depressed feelings and consider that this is a sign of a weak disposition and they seek help in their religious services. Their use of mental health services is low due to the stigma of being "mentally ill" and the lack of understanding about the contextual nature of their distress. Informed sources stress the importance of education within the mental health system as African American women are in situations where there is a great deal of exposure to violence and stress and these factors have a strong impact upon the physical health of the individual.

There are other populations that endure double stigmatization and deserve a voice in the discussion.

They may also not be on the drug consortiums radar as a target group from which profits may be garnered. The LGBT community is 2-3 times more likely than the general population to suffer from anxiety and depression due to the stigma and discrimination that they face on a daily basis. Almost half of transgender individuals have attempted suicide. Gay teens are 7 times more likely to attempt suicide than teens in the general population Many LGBT individuals face discrimination within the health care system as well and research indicates that other barriers include homophobia, lack of confidentiality, lack of training and insurance policies that create loopholes for employers that do not provide coverage for domestic partners. The APA on line provides this information.

According to NAMI the LGBT population is hesitant to use mental health services due to the following; Mental illness is regrettably still stigmatized in our society. So, too, is being lesbian, gay, bisexual or transgendered. A GLBT person with mental illness may be in the unfortunate position, then, of having to contend with both stigmas. It is often the case that GLBT people experience a mental health care system that is not comfortable with or sensitive to issues related to sexual orientation. Therefore this population with its high prevalence of depression and sociality faces barriers to treatment and they remain in emotional pain.

Again, looking cross culturally at other traditional ways of looking at, explaining and coping with youngster's behaviors we have a community in Australia that deals with the symptoms that we call ADHD in a very positive and non medical way.

In South Australia, Ngangkari are often used in mental health and in the prison system to calm someone who is troubled or whose behavior is out of control. Through a combination of coaxing and massage, they say they are able to restore the spirit balance within the body. The concept of repositioning the spirit that has flown out of he body is a comforting one. When a death has occurred the Ngangkari puts the spirit of the deceased into the body of the family member who is grieving and this closeness is a healing process. The Ngangkari use massage to nestle the spirit back into place and they have sacred tools to assist them and these are passed down from generation to generation.

In Australian aboriginal culture there is a special, reserved place for young children who demonstrate "special" traits. These youngsters have behaviors and experiences that in our Western culture we would describe as "hyperactive", "distracted" and delusional". They describe being awake at night and flying around to meet with kindred spirits who search for souls that are lost. Children as young as 4 tell their families that they can see things and hear things that no one else can see and they seem to have a different way of relating to the world and to others. Instead of taking these traits as a negative symptoms the people of this tribe say that they are Ngangkari in training. In Western culture these youngsters would probably be considered to have psychiatric problems but for the Australian aborigines they have a place within society that is respected and they develop and use these skills over their lifetime. Being included within the family and community gives these children the opportunity to help others and to develop a high self-esteem.

In the Aboriginal world view, every event leaves a record in the land. Everything in the natural world is a result of the actions of the archetypal beings, beings whose actions created the world. The ancestral beings are part of the living world as well as the historical past and through paintings, songs, healing rituals and stories their continued presence is celebrated and renewed for each generation.

The Aboriginal perception promotes comfort, resilience, connection with history, community and nature.

#  Chapter 7 \- The Missing

There is an emotion that conflates panic, depression and rage in an overwhelming storm. There is a feeling that interferes with rational thought with decision making and planning. There are times when families are so very distressed that they become both paralyzed and frantically searching without finding the lost part of their lives. The voices of relatives of missing untreated mentally ill individuals speak about this horrendous situation.

When a vulnerable and mentally ill person is missing, the family is truly broken. Many untreated mentally ill persons leave their environments. The reasons, although they may not express them or be completely aware of them are; command hallucinations telling them to go, paranoia about the home or family members, fears about harming a family member, being terrified of being locked up, confusion about who they are and what they are doing, searching for something precious. The situations that provoke leaving are often the following; release from jail or hospital without a plan or medication, an argument at home, the need to be alone and without being judged.

Families become guilt-ridden and blame themselves while experiencing enormous fear and confusion about what to do. To compound this authorities will not disclose information and are often reluctant to begin a search after knowing that the person is "mentally ill" and when found the person usually refuses to return home or to a program. The program if there is one has usually given away the individual's bed.

When Carla Clark's cell phone rang, she assumed the news was bad. The phone number displayed on the caller ID belonged to the probation officer for her daughter, Melissa.

It was the last Tuesday of December, the day Melissa was scheduled to be taken from Cook County Jail to a treatment program for people battling mental illness and substance abuse.

Less than an hour after she arrived at the facility, Melissa took off, the probation officer said. No one knew where she was, and a warrant was to be issued for her arrest.

"I felt like I had been kicked in the stomach," the mother said.

Melissa's flight from treatment was the latest in a long string of heartbreaks for the mother as she tries to help her only daughter, whose bipolar disease and schizophrenia have turned her into her own worst enemy.

But as her case illustrates, solutions often don't come easily for people who battle serious mental illnesses. Ten hours after running away from the court-ordered treatment, a disheveled and disoriented Melissa landed at her mother's downtown condo, putting Carla Clark in the gut wrenching position of having to turn her in. Melissa is now back in County Jail, where she awaits a hearing Friday.

In the past, M, 22, has refused to take medication and has been difficult to manage. She has wandered the streets, committed petty crimes, overdosed on heroin and been assaulted by drug dealers. After being arrested in the Whole Foods in September 2010, she joined the sizable mentally ill population in Cook County Jail.

This miserable mother meanwhile, described herself as "worried to death" Said the mother: "treatment is the only way her mind is going to be clear enough to make good decisions."

The facts about mentally ill individuals who wind up on the streets are as follows:

1. They are marks for thieves and other criminals who live there. . . . Those who receive social security disability checks become targets for muggers. . . . There is a hierarchy among the shelter clients, and the visibly mentally ill are the lowest caste, untouchables among the outcasts."

The stories bear out the studies. For instance, Albert Blanchard, a homeless man with a long history of schizophrenia and homelessness, was set on fire as he slept on a sidewalk in downtown Nashville.

His sister noted that "Albert's paranoia would not allow him to stay in one place for long. He chose to live on the streets to keep the people the voices warned him of from finding him." As a result of the attack, Albert spent more than six months in the hospital and had eight separate surgeries.

2. Women are targets for sexual assault

The consequences of impaired thinking are often direr for women with untreated mental illness than they are for men. A 1995 study of the incidence of rape among women with schizophrenia reported it to be 22 percent, with two-thirds of those having been raped multiple times. A 1989 study of homeless women in Baltimore found that nearly one-third of the women had been raped A 1988 report on homeless women in San Francisco noted the women were being raped and sexually assaulted at an alarming rate, with some women being raped as many as 17 times. To protect themselves from attack, homeless women were known to wear 10 pairs of panty hose at once and bundle up in layers of clothing Rape also exposes these women to deadly infection with the HIV virus that causes AIDS, especially since most of the men committing the rapes are drug addicts among whom HIV infection is common. No study has been done to date of the HIV infection rate among homeless women who have a severe mental illness. A 1993 study of HIV infection among psychiatrically ill men in a New York City shelter, however, found that 19 percent of them were HIV positive. Clinical AIDS will, therefore, become an increasing problem in the near future among the homeless psychiatrically ill.

3. They often die alone and the family continues searching.

There is evidence that those who are homeless and suffering from a psychiatric illness have a markedly elevated death rate from a variety of causes including murder. This is not surprising since the homeless in general have a three times higher risk of death than the general population and severely ill individuals have a 2.4 times higher risk of death during any year. As part of a 1992 study in England, for example, investigators collected data for 18 months on 48 homeless people who also had a severe mental illness. They found that three people had died from physical causes (i.e., aortic aneurysm, heart attack, and suffocation during an epileptic fit), one had died in an accident, and three others had suddenly disappeared without taking any personal belongings with them. Depending on whether or not the missing participants were alive, the 18-month mortality rate was a minimum of eight percent and a maximum of 15 percent.

4. Homeless people with untreated brain disorders frequently suffer fatal accidents caused by their impaired thinking.

A 1990 study of homeless people published in Hospital and Community Psychiatry found that 43 percent of the cases showed the marked disorganization of mental illness and poor problem-solving skills (H.R. Lamb & D.M. Lamb). In an additional 30 percent, the subjects were not only disorganized but too paranoid to accept help. For example, two of the people had a place to live, but were too paranoid and fearful to stay there.

One Miami police officer commented: "Seeing another human being living like an animal in America, it just shouldn't be like that. It gets frustrating not being able to do anything to help."

A father weeps for a mentally ill son who is on the streets.

"There is a sense of helplessness, alarm and fear when the person does not respond to your outreach and your efforts are responded to with anger and suspicion. You know something is terribly wrong and at this stage, without information, all you can do is try to make contact and watch the frightening process unfold."

This young man, diagnosed with paranoid schizophrenia is, as his father describes, at the mercy of voices that tell him to "starve and die". The last time that he found him, he had been walking a downtown area where the homeless stay and he found his son in a dirty alley, with only a thin tattered jacket to protect him from the cold. His son was curled into a fetal position, pale and emaciated and woke up to gaze in an unfocused way at his sobbing father. The father called police who came and asked him if he needed "help" He managed to shake his head no. They asked him if he used the local shelters and he nodded "yes". He also indicated that he had no "plan" for self-harm, although his father knew that he had tried to kill himself in the past. Still, that was considered "ancient history" and it didn't count.

When his father walked away he said that if felt like he was physically torn apart. He returned home in extreme depression. At the dinner table an empty chair stood out like a black hole in space, a cruel reminder that his child was cold, hungry and alone. That night he had nightmares and finally got up to drive back to the alley with food in a paper bag. But his son was gone....

#  Conclusion

"Gone but not forgotten"....would be the phrase used by families of untreated mentally ill loved ones who are missing or who continue to struggle in emotional pain. Gone in some ways but they exist as constant reminders of the struggles and the love that endures and many times strengthens the family bond. The bond becomes a connection that cannot be ruptured because the loved one is so vulnerable and they need to be cared for, respected, loved and protected and because that is what families do....they give life meaning and value.

It is difficult for family members to put their feelings into the appropriate language to explain and to express their situations. They take that step in order to inform us and to motivate us towards reform and understanding. The words that they use are important in this effort however one must see and feel the pain of their loved ones in order to begin to cross that threshold into full understanding.

In the eloquent words of a young lady with mental illness; "All my life I have been running from

messages from the outside world that define how I see myself....Early on it was all the messages of shame and otherness. Their cumulative messages become truth and truth becomes my skin. Shame becomes an indictment of who I am. I become shameful. My body is bad. I am bad. I learn to live the life of a mental patient"

And the voice of her mother;

"I watched while my daughter was shuttled from one institution to another and as she became more confused and depressed every time they transferred her. She was on so many legal psychiatric holds I couldn't keep track of them. My daughter was 15 when she got sick and tried to kill herself. I know she heard voices and she believed that the world was going to end because of something that she did. She told me that and told the doctor's that she wanted to die to save the world. That never changed even with all the pills and ECT they gave her she got worse and worse. I was so heartbroken to see my beautiful, smart girl who couldn't even talk to me at the end. She was on suicide watch when she hanged herself and she did it in-between the 15 minute checks. I don't know how she could do that to herself and to me. I've cried every day since she was 15. I ask myself "what did I do wrong as a mother?" I pray and I ask God for guidance. I keep my peace when I am with the people at work because when they talk about suicide or depression and such they think its all fake. They don't understand. I keep my feelings inside. I don't blame anyone but me for what happened to my child"

(Contributor asks to remain anonymous).

Perhaps the tragic death of Robin Williams will open the door even further so people may finally begin to understand how serious mental illness breaks into homes and steals the most valuable thing people can ever have: their happiness. This poor man with everything going for him, including a brilliant mind and marvelous career, wasn't able to defend himself against the sirens' song of deep depression. Perhaps his death will make people understand that despite the noble idealism of "individual rights," the hard realities of serious mental illness often warrant action by good people to get treatment for others for reasons of compassion and the greater good.

One parent asked a psychiatrist the ultimate question; "what causes my son's mental illness?" and he responded "Change, he said: "The stress of daily living.''

In truth the cause is still unknown and "stress" is not an answer for families who must endure complex traumatic situations on a minute by minute basis. Yet chasing the cause continues to take priority over chasing the care for the mentally ill and their families. As human beings we need to know something and for now what we do know is that reducing the many barriers to treatment will enable us to persist in the struggle to give families and their loved ones back their dignity, their hopefulness and the joy of daily life.

What do the authors and readers gain from reading these words? We achieve a better understanding of what the families of the untreated mentally ill experience on a minute-to-minute basis. We can almost see, hear and feel their pain, their hope, their frantic search for help. Perhaps this raises our anxiety or makes us sad or angry. Hopefully it motivates to take an active part, one at a time or in groups to improve the situation. We also gain insights into what families observe as early signs of emotional deterioration; the changes in movements, verbalizations, patterns of eating and sleeping.

This is critical information in terms of trying to intervene early in the process. We also have new concepts about resilience and how to reach out to others for the kinds of emotional support that will enable us to continue in all of our efforts.

We can also appreciate the fact that people do return to satisfying functioning even though the way that they view life and function within in is different from before.

"We are climbing mountains, planting gardens, painting pictures, writing books, making quilts, and creating positive change in the world. And it is only with this vision and belief for all people that we can bring hope for everyone."

"My new life barely building, this beginning of hopeful feeling,

Of possibility I couldn't even exhaust the abilities

Of grace indeed that makes this place I see mean I can yet hold tight to face my dreams

And making it all work out, a job, home, and friends I had my doubts.

117

Then on this day the prodigal son showed the way I came to my senses

And realized, "I'm making it."

"I'm doing this – independence is just pushing through the mist."

And the fever of fear broke it's hold on me once I stepped out of darkness so bleak

I didn't know I'd become blind till the moment I was able to see.

(Corinna West with permission)

#  About the Authors

Author Dr. Stephen Seager is a board-certified psychiatrist, a former assistant professor of psychiatry at UCLA School of Medicine and a multiply published author. His experience-based work on the front lines and informed opinions have been featured on national television and radio, including Oprah, GMA, NPR, and Larry King, among others.

Dr. Seager's film Shattered Families is in production. Dr. Seager is a passionate and active advocate for mental health reform.

Psychiatrist Stephen Seager who works on the front lines at-Gorman State; one of the nation's largest forensic mental hospitals, is dedicated to treating the criminally insane. Unit C, where Dr Seager was assigned, was reserved for the "bad actors," the mass murderers, the serial killers. Behind the Gates of Gomorrah affords an eye-opening look inside this facility.

Margaret Altman is a semi-retired LCSW and has worked in psychiatric and medical hospitals as well as the L.A Jail and private practice for over 35 years. She specializes in acute mental illnesses and crisis intervention with a focus upon family dynamics and childhood trauma. Margaret's book "Developing Your Child's Emotional Intelligence" is on Amazon, articles are on Psych Central Pro and Psychology Today sites. This author is an involved advocate for mental health reform with an open-minded and inclusive approach to treatment strategies.

