Forensic Mental Health - Part 1: It's Not What You Think

I want to use this entry to clear up a couple things about forensic mental health.  I believe there is a lot of misinformation and misunderstanding about a couple of concepts: being found Incompetent to Stand Trial (IST), and being found Not Guilty by reason of Insanity (NGI).  I became well acquainted with, and well versed in, both topics during my time working at a state hospital.  I will speak to the application of these laws in my state.  

I like to read the comment sections of news articles.  Maybe I’m a masochist, but that’s a topic for another entry…not to mention my therapist!  At any rate, I find the lack of knowledge on this topic alarming.  As a member of a society, I want to know what a law means and how it is applied.  Remember our stages of moral development?  We can’t live by rules and laws we don’t understand.  So for these two topics in particular, here goes…

Incompetence to Stand Trial:  A person is arrested and accused of a crime.  They are, according to the 6th amendment of the US Constitution, afforded the right to a fair trial.  This means two things under IST law: If the person is 1) unable to understand the nature of the criminal proceedings, or 2) unable to assist his or her attorney in a rational manner, they can be found incompetent to stand trial.  Either or both of these conditions MUST be due to mental illness.  In either case, the person’s symptoms prevent them for understanding what is going on in court.  They have to be able to work with their attorney.  The 6th Amendment of the US constitution affords the right of the accused to know the nature of the charges, and the evidence against the defendant.  A person can’t do this if their mental illness is keeping them from understanding this information.   It is usually the judge or the public defender who will raise the issue of the defendant’s trial competence.  At that point, the defendant is transferred to the State Hospital.  By law, they have 3 years in which to become competent to stand trial.  Should they become competent, they will be transferred back to county jail to await trial.  During the time they are hospitalized, they will receive treatment for the mental illness, and education about their diagnosis, treatment, and the court process.  If the 3 years go by and the person has not regained competency, usually one of two things will happen: If the crime is not serious and the time they would have been incarcerated had they been found guilty is less than the time they have spent in the State Hospital, the prosecuting attorney may decide to drop the charges.  If this is not the case and the charges are for a violent crime, the patient will often be put on a conservatorship.  This means they will be assigned to a county mental health worker.  Often, especially if the charges are for a violent offense, the person will be confined to the State Hospital indefinitely, until such a time they regain competency to stand trial.  Read that again: They will be confined to the State Hospital indefinitely.  Being found IST is NOT a Get Out Of Jail Free card. 

Tomorrow's post will be about what happens when a person is found Not Guilty by reason of Insanity.  Stay tuned to find out just how hard it is to be released from a State Hospital!

No Laughing Matter: A Rare Entry About Politics

Friends, 

Today’s blog entry is going to be directly anti-Donald Trump.  Insight Outside In is intended to be educational, informational, and a medium to share my own experiences in mental health.  For the most part, I try to keep politics off the blog.  My goal is not to alienate anyone, but I’ve had something circling in my brain that’s been bothering me about recent political events.  A number of things I have found problematic, I have been able to identify and address either in my own processing, or discuss within my own circle of friends and family.  I haven’t been able to put my finger on it until earlier today.  I was browsing a social media site, and came across a series of tweets by a gentleman named Jason P. Steed, an attorney from Dallas, Tx.  I am, with permission, sharing them here with you.  I am sharing them all together in sentence form instead of the series of 140 character posts of the cited content.  Content is unchanged, except for where changes in punctuation serve to convert the text from a series of tweets to paragraph form.

“I wrote my PhD dissertation on the social function of humor (in literature & film) and here's the thing about ‘just joking.’  You're never ‘just joking.’ Nobody is ever ‘just joking.’ Humor is a social act that performs a social function (always).  To say humor is social act is to say it is always in social context; we don't joke alone. Humor is a way we relate/interact with others.  Which is to say, humor is a way we construct identity - who we are in relation to others. We use humor to form groups and to find our individual place in or out of those groups. In short, joking/humor is one tool by which we assimilate or alienate.  IOW (In other words), we use humor to bring people into - or keep them out of - our social groups. This is what humor *does.* What it's for.

Consequently, how we use humor is tied up with ethics - who do we embrace, who do we shun, and how/why?  And the assimilating/alienating function of humor works not only only people but also on *ideas.* This is important.  This is why, e.g., racist "jokes" are bad. Not just because they serve to alienate certain people, but also because they serve to assimilate the idea of racism (the idea of alienating people based on their race). And so we come to Trump.  A racist joke sends a message to the in-group that racism is acceptable. (If you don't find it acceptable, you're in the out-group.)  The racist joke teller might say ‘just joking’ - but this is a *defense* to the out-group. He doesn't have to say this to the in-group.  This is why we're never ‘just joking.’ To the in-group, no defense of the joke is needed; the idea conveyed is accepted/acceptable.  So, when Trump jokes about assassination or armed revolt, he's asking the in-group to assimilate/accept that idea. That's what jokes do.  And when he says ‘just joking,’ that's a defense offered to the out-group who was never meant to assimilate the idea in the first place.

Indeed, circling back to the start, the joke *itself* is a way to define in-group and out-group, through assimilation & alienation.  If you're willing to accept "just joking" as defense, you're willing to enter in-group where idea conveyed by the joke is acceptable.  IOW, if ‘just joking’ excuses racist jokes, then in-group has accepted idea of racism as part of being in-group.  Same goes for ‘jokes' about armed revolt or assassinating Hillary Clinton. They cannot be accepted as ‘just joking.’  

Now, a big caveat: humor (like all language) is complicated and always a matter of interpretation. For example, we might have racist humor that is, in fact, designed to alienate (rather than assimilate) the idea of racism. (Think satire or parody.)

But I think it's pretty clear Trump was not engaging in some complex satirical form of humor. He was "just joking." In the worst sense.  Bottom line: don't accept ‘just joking’ as excuse for what Trump said today. The in-group for that joke should be tiny. Like his hands.”

Mr. Steed very eloquently stated what I have been feeling: the jokes are designed to make us who disagree feel like outsiders.  This is always unsettling.  Human beings are pack animals.  We need to belong.  Regardless of what a person’s specific opinion is, they are likely to feel strongly about it and confident in their belief.  

We look to leaders to guide us.  They are in a position to be role models.  Whether it’s a teacher, religious leader, a coach, a celebrity or a politician, people are listening.  I am all about personal responsibility.  If a role model advocates my causing harm to someone else, it is still up to me to know right from wrong, and not hurt another person.  But not everybody is going to think or feel the same way I do.  We trust our leaders not to steer us in the wrong direction.  This is responsibility that we give to them.  I feel this responsibility as someone who blogs about mental health.  I do my best to give accurate information, and state wherever appropriate ways for someone to be safe.

Getting back to Mr. Trump: stating that he was joking when he called for harm to come to another presidential candidate, or their hypothetical Supreme Court nominee, is reckless.  He has assumed a leadership role by accepting his party’s nomination, and is soliciting your vote and mine.  I believe he has betrayed us.  Saying he was just joking is how he goes about denying any responsibility for what may come of his words.  Whichever way a person may, in his opinion, misinterpret his joking has the potential to cause harm.  If a person takes him seriously, another human being’s life is endangered.  For the rest of us who don’t see the humor, we are the outsiders.  This is not a position I am second-guessing whatsoever.  I am perfectly happy not to be supporting him.  But at a deeper level, calling it a joke is designed to discount our feelings and experience, and therefore, our basic humanity.  I don’t want IOI to turn into a political blog, nor will I allow it.  But especially after reading the words of Mr. Steed, I felt compelled to share them with you, and say something.  

As I wrote in an earlier entry about media saturation, I encourage you to take care of yourself, and monitor your own exposure.  I get to where it’s too much, and I have to change the radio, or turn off the TV.  No matter your political affiliation,

Be well.

Trauma, Part Two: Therapy and Helping the Trauma Survivor

Yesterday I wrote about Post-Traumatic Stress Disorder.  I described the symptoms, and how some of them may appear.  Today I am writing about some of the different treatment modalities for PTSD.  This list is not meant to be exhaustive.  I always encourage you to work with your mental health professional to decide what will best help you in your situation.  This entry may also be useful to someone with a loved one who has experienced trauma.    

In an earlier entry about finding a mental health professional, I mentioned that it is not uncommon for a therapist to want a new patient to see a medical doctor, if they have not seen one recently.  The therapist may also want to refer a client to a psychiatrist for a medication evaluation.  If you go to see a therapist to deal with trauma specifically, this may still be the case.  Certain antidepressants may help with symptoms of anxiety.  This can help reduce symptoms to a more manageable level while they are getting therapy.  It all works together.  Therapy for trauma may be more effective while the patient is on antidepressants, and the antidepressants will help the patient get more out of the therapy for the trauma.  There are several different methods of therapy that are effective for helping a person deal with trauma.  Here are descriptions of some of these methods.  Your mental health professional will work with you to find the best treatment for your specific situation.  This list and the accompanying descriptions are not meant to be exhaustive:

Exposure Therapy - Exposure Therapy involves recalling the traumatic experience and, things associated with it, repeatedly.  While this may sound frightening, the goal is to help the patient be able to remember the event without experiencing PTSD symptoms.  This is often done by having the patient describe the event to the therapist multiple times, over a period of time.  This helps the survivor to lessen the avoidance of reminders of the trauma by making them feel less sensitive to them.  Think of it this way: the first time you watch a scary movie, you jump out of your skin when the killer jumps out at the unsuspecting victim.  Then next time you watch it, the scene may still be suspenseful, even scary, but it loses some of the shock value.  Every time you watch that scene, it gets a little less frightening.  It’s the same concept with exposure therapy.  Talking about the experience multiple desensitizes you to it, until you get to the point you can go make more popcorn during that scene.

Cognitive Therapy - During Cognitive Therapy, the therapist will work with the client to help change the thoughts about the traumatic event to make them less distressing.  The client learns to identify the thoughts which are upsetting, and begins to change their perspective.  An example may be that a person may experience guilt for not fighting off an attacker during a mugging.  However, during cognitive therapy, the focus will be placed on the fact that attempting to fight the attacker, the client may have been stabbed, since the attacker had a knife.  The therapist will work with the client to focus on the fact that they were not harmed physically during the mugging, instead of focusing on the guilt of not fighting back.

Group Therapy - Some trauma survivors benefit from group therapy.  Group therapy is designed to bring people together who have had a similar experience.  Trauma survivors may feel alone in their victimization.  This may foster feelings of shame, which make healing more difficult.  Group therapy allows survivors to talk about their experiences with a therapist as a facilitator.  Sharing with one another helps to reduce isolation.  It can also facilitate hope as survivors see others recovering after a similar experience.  Group therapy may also be used with a group of people who have all experienced the same traumatic event.

Brief Therapy - Brief therapy uses a set number of sessions, usually between 4 and 8.  A specific goal is established, and the sessions are used to move the client toward that goal.  Brief Therapy will often use some of the same principles of Cognitive Therapy.  The focus will be on the stated goal, and how to get the client to that goal.  

EMDR and Hypnosis - EMDR, or Eye Movement Desensitization and Reprocessing, and hypnosis are sometimes used in trauma recovery.  According to the EMDR Institute Inc (www.emdr.com), the purpose of the treatment is to help the brain to process information about the trauma, and move toward healing. Hypnotherapy is sometimes used to help the client have controlled access to the memory of the event.  Through this process, they are able to recall the event, but the memory will be less distressing.  EMDR and Hypnotherapy should only be attempted with a professional who is certified in the particular method.  

If someone you love has experienced trauma, it can make you feel powerless.  It’s hard to see someone go through an event, and then continue to experience symptoms.  Remember that you are only one person, and there is only so much you can do.  You may be able to help them meet day to day needs.  They may ask you to just listen, or to keep them company.  If you see the person experiencing distress, you can encourage them to seek professional help.  Knowing the symptoms of PTSD will help you to know what to look for.  Just remember that you can only provide assistance when it is not causing you harm or distress as well.  Take care of yourself in the process of taking care of another so that you both achieve wellness.  That’s my goal for this blog, to always help you to…

Be well.

I'VE GOT MAIL!

Friends, 

I realize posting a comment on a blog, even anonymously, may not be right for everyone.  Now you can contact IOI directly: Email me at InsightOutsideIn@gmail.com

Be well!

Trauma, Part One: Definitions and Diagnosis

Any time I write about diagnostic criteria, it is for information purposes only.  I cannot diagnose nor treat anyone over a blog.  If you experience symptoms I discuss on Insight Outside In and are not seeing a mental health professional, I encourage you to access services available to you.  I am happy to answer questions within my scope of knowledge and ability, given the limited nature of this medium.

All right, this one’s a biggie, get comfortable: I am writing about trauma today.

If you personally have an active diagnosis of Post-Traumatic Stress Disorder (PTSD) or have experienced trauma that still causes you distress, you may want to skip this one.  Always do what you can to keep yourself safe.

I’m going to break this up into two entries.  This one will talk about what PTSD is from a diagnostic standpoint, according to the DSM-5.  In my next entry I’ll write more about treatment, coping strategies, and helping a loved one with PTSD.

There are five different criteria for a person to be diagnosed with PTSD.  First, the person has to have had a traumatic experience.  According to American Psychiatric Publishing, the DSM-5 defines a traumatic experience as “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 (not through media, pictures, television or movies unless work-related).”

Next, the person will reexperience the the trauma in one or more ways:

• Thoughts or perceptions
• Images
• Dreams
• Illusions or hallucinations
• Flashbacks
• Distress related to cues that symbolize some aspect of the traumatic event

The third criteria is that the person will avoid stimuli associated with the trauma such as:

• Avoiding thoughts, feelings, or conversations about the traumatic event
• Avoiding people, places, things, or situations which remind them of the event.

Fourth, the person will have negative changes in thinking and mood, including two or more of the following:

• Irritability, angry outbursts
• Reckless or self-destructive behavior
• Hypervigilance - the person may be jumpy, or seem more alert to the possibility of threats.  Their senses may seem heightened since their brain is staying in fight-or-flight mode.
• Being easily startled
• Trouble concentrating
• Problems with sleeping

These symptoms must have persisted for at least a month in order for the diagnosis to be PTSD.  They must cause the person distress or interfere with functioning.  Also, the symptoms cannot be better accounted for by a medical condition or substance use.

So, to sum up: 

A person experiences something traumatic.  They start reexperiencing the event by way of things like flashbacks, hallucinations, or nightmares.  They start avoiding things or situations that would remind them of the trauma.  It starts affecting their mood, making them nervous, distracted, irritable.  

These are not things that a person just gets over.  I think that telling someone that they need to “get over it,” or “stop feeling this way” cause more harm, and can exacerbate symptoms.  Tomorrow I’ll write about what can help someone who has experienced trauma, both professionally and personally.

Be well.

Sorry to Tell You, This One's About Apologies

I can’t run a blog about mental health without spending a good bit of time talking about relationships.  Our relationships with others start shaping our personalities from the time we are born.  As we go through life, our personalities affect how we will relate to other people.  A couple weeks ago I wrote about mistakes, and how working through mistakes can strengthen relationships.  Today I’m writing about apologies.

I think a common experience of childhood is being told to apologize to someone.  If you recall the entry about moral development, perhaps you’ll recall that children make moral decisions for one of two reasons: to avoid punishment, and then to earn reward.  It isn’t really until adolescence that a person will start to see themselves as a member of a society.  The person will not fully grasp the consequences of their actions on an altruistic level, they will at least understand the need to maintain relationships in order to function in life.

It’s not possible to have relationships without conflict.  If you know of a relationship in which the parties say that they never disagree, there’s a problem.  It’s a loss of individuality, but that’s a topic for another blog entry.  In my entry about mistakes, I talked about how mistakes can be learning experiences that can help relationships to grow.  Now I’m going to take it a step further, and talk about how.  

A true apology must involve taking responsibility.  This can’t be the non-apology of “I’m sorry you got your feelings hurt.”  Even if I had absolutely no intention of causing harm, the damage is done.  The person doing the apologizing can phrase it as, “If I’d known…I never would have…” For example: “If I had known your goldfish had drowned, I never would have made a joke about fish drowning.”  It’s part of our experience as human beings to want to be heard and understood.  

It’s tricky when we don’t feel we have done anything wrong.  When this is the case, it’s easy to fall into the traps of the power struggle, and the non-apology.  Neither of these, however, maintain, build, nor support healthy relationships.  

Next comes acknowledging the harm that’s been done.  Whether we intended to do harm or not, it needs to be acknowledged.  This is the heart of the apology.  It’s how we communicate that we are hearing and understanding the other person’s experience.  If you’re not sure what the other person is feeling, ask!  Let them know that you are trying to understand how they are feeling so that the two of you don’t end up in the same conflict again.  Try not to parrot back to them what they’ve said.  Let’s avoid, “I was hurt when you said fish can’t drown.”

“You were hurt when I said fish can’t drown.”  Take it one step further: “I was hurt when you said fish can’t drown.”

“So when I made that joke about fish drowning, that upset you because Fluffy the Goldfish did drown.  I’m sorry for upsetting you.”  

So now we have taken responsibility, and acknowledged the harm we have done.  But if anything is going to change long term, we must learn from the experience.  We have to be willing to let our guard down, and accept this place of vulnerability.  It never feels good to know that we have harmed someone we care for, but when it comes to relationships, it’s inevitable.  Once it happens, we can’t take it back.  But the best way we can show that we truly regret the consequences of what we have done is to learn from it.  We learn about the other person.  We learn about their point of view.  We learn about their needs, how they communicate, what they expect, and their priorities. 

We continue to put weight and meaning behind our apology as we move forward by doing better.  We allow ourselves to learn from the experience.  Ideally, this happens not just on a small scale with the person with whom we originally had conflict, but across other relationships as well.  In the entry about mistakes, I wrote about someone in my life who needed better communication from me.  This has taught me to be more aware of my level of communication in other relationships as well.  It has also taught me to listen more carefully to what the person in that particular conflict is saying.  That whole situation could have been resolved so much sooner if I’d been listening, instead of just being defensive.  So part of my apology involves doing what I can not to hurt that person the same way again.

Conflict and mistakes are part of relationships.  They also have the potential to be learning experiences.  An apology is not always going to be a cure for what has gone wrong.  There are times when a relationship may not be salvageable.  In these cases, the best we can do is learn from the experience as we move forward.  So if anyone’s goldfish has in fact drowned and you were upset by my use of that as an example, I am sorry. 

Be well.

I'm home

Hey there, IOI!  I've missed you.

It's been a great week.  I got to spend time with family and friends, as well as get to know a new city which I really enjoyed.  This week gave me ideas for some new topics, and I am really excited to get back to writing.  

For right now, I am catching up on sleep and laundry.  My goal is to get a new entry posted this weekend.  What's new with you?

Be well.