Blog Posts

A Better "MEDICAL MODEL" could sure reduce institutionalization

4/6/2024

Val's Take

The Psychotropic Medications of the 1950s and 1960s along with NEXT GENERATION Medications---
- have been a MIXED BAG
- and instituted a BACKLASH in Mental Health AGAINST the Medical Model

The DSM 5 is an embarrassing list of categories with subjective symptom clusters that often don't track brain scans or the research.

Having said all that, research of the last 10 years is making REAL BREAKTHROUGHS:

Discovery of lymphatic vessels in the brain.
Linking Maternal Immune Activation with Neuro-Developmental and Psychiatric Disorders as well as "Hyper-Connected" Brains
Recognizing the Metabolic aspects of Neuro-Developmental and Psychiatric Continuum and the role of Mitochondria and ATP.

New insights into the role of mitochondria in autoimmune diseases (2019)

Mitochondrial DNA (mtDNA) normally stays within mitochondria, energy-producing structures inside cells. However, it can be released from the mitochondria into the cell in response to stress. When this happens, the mtDNA can trigger an overactive immune response, as occurs in autoimmune diseases.

"In most cells, mitochondria (green) form complex tubular networks that help them distribute energy throughout the cell. Disruption of these mitochondrial networks is a hallmark of many human diseases."

Photo credit: UC San Diego Health Sciences

Video reports UC San Diego research
Biomarkers for Suicidal Thoughts in the Mitochondria

When People Complain to me of the Medical Model -- I usually say what medical model -- It's a sham medical model at best

Shared Genes & Psychiatric Disorders

Developmental Stage-Dependent Changes in Mitochondrial Function in the Brain of Offspring

Following Prenatal Maternal Immune Activation (2023)

As mentioned above, prenatal activation of the maternal immune system has been connected with both increased risk of ASD [Autism Spectrum Disorder] and with mitochondrial dysfunction.
It has been demonstrated that the mitochondria have a noteworthy relationship with the immune system, as they can impact the immune response and vice versa.

What's "REASONABLE" when the system(S) to address Neuro-developmental & Psychiatric Disorders are already OVERWHELMED & RElying on A scientifically invalid DSM

2/22/2024

Val's Take/Conjecture

"University Teaching Hospitals" are an important connection between RESEARCHERS and CLINICIANS.

One of the scariest things to observe in Mental Health is the LARGE DIVIDE that has grown up between the RESEARCHERS and the CLINICIANS.

Generative AI in Healthcare

Is this an Olmstead Issue?

So Olmstead is about preventing the unnecessary institutionalization of people with disabilities.

Further, it is currently understood to include the risk of institutionalization of people with disabilities that is inherent in HOMELESSNESS.

OVER10 Years After the National Institute of Mental Health Called Out the DSM 5 --- Where Are We?

NIMH's idea which sounded good at the time and probably is still good in many respects was the RDoC Program.
- The DSM was not tied to the underlying biology BUT
- The RDoC Program and its "MATRIX" would be.

In the intervening 10 years, we've learned a lot more and seen the emergence of:

The Microbiome
Immuno-Psychiatry
Metabolic Psychiatry
Neuro-Endocrine Psychiatry
Maternal Immune Activation
A Neuro-Developmental-Psychiatric Continuum

The number of variables is staggering.

I do think we are reaching our limits to process information. There is a need to expand those limits to achieve more effective individualized medicine.

AND

The largest institutions for people with mental illness are JAILS & PRISONS.

Even if we don't readily have available the absolute answer --- If we had a mental health profession that was MORE AWARE of its knowledge limitations ---

we might have the INTELLECTUAL MATURITY to get more people out of jails and prisons.
and provide the ALTERNATIVES currently necessary.

Insanity

Science Up

Denver Mayor Johnston's numeric goals, SUPPORTIVE HOUSING and the state

2/16/2024

Val's Take

Olmstead Plans need Reasonable, Measurable, and Numeric Goals.
- If you don't have that --- that is one of the first tip offs that you don't have a legally compliant OLMSTEAD PLAN.
- COLORADO DOES NOT HAVE A FEDERALLY COMPLIANT OLMSTEAD PLAN and MOST STATES DON'T.
  - It appears Minnesota's Olmstead Plan has Numeric, Measurable Goals --- after Federal Judge Donovan Frank threw more than one hissy fit.

Johnston is a mayor, a former legislator --- he's largely focused on the most pressing problems and set Numeric Goals and gone from there.It hasn't always been pretty--- but things don't seem STUCK in ANALYSIS/PARALYSIS.

The grand OLMSTEAD Soviet-Style Plan hasn't really worked over the past 20 years since Olmstead was decided.States by and large are OVERWHELMED with the MAGNITUDE of the ISSUES ---

States try to stay as VAGUE as possible so they are NOT ACCOUNTABLE
& Generally do "some good things."

The Disability Community often doesn't feel like it can look Olmstead --- this gift horse --- too closely in the mouth --- and the US Department of Justice files "some cases" (including in Colorado) ---

BUT WIDESPREAD NON-COMPLIANCE IS THE NORM.

We need STATE NUMERIC YEARLY GOALS for SUPPORTIVE HOUSING

I think the State needs an "Objective Measure" for that --- Medicaid Long Term Care might be such a measure.
Further, partnering with municipalities probably makes a lot of sense.
Further, there are various funding streams this could come out of.

Homelessness, Criminal Justice, IDIOSYNCRATIC BRAINS, Olmstead and the Prodigal Son

12/21/2023

One of the things that is happening with the recognition of:

the prevalence of Neuro-Diversity in Homelessness and Criminal Justice, and
the IDIOSYNCRATIC nature of Neuro-Diversity in which brains differ from the NORM but in IDIOSYNCRATIC WAYS
we're called on to invest in highly person-centered INDIVIDUAL supports
- that requires us to really understand the person and his or her strengths and challenges
  - that is a form of love and an investment of time, energy and resources --- that amounts to love
  - that we may not really be feeling as a society.

The only problem is --- lesser strategies often fail.

Abba Eban was a South African-born Israeli diplomat and politician, and a scholar of the Arabic and Hebrew languages. --- Wikipedia

State officials in Colorado and around the Country may finally come to Olmstead Compliance after much passive resistance.

It could be in their own best interest to collect the data to make the case for more Federal assistance, especially around Supportive Housing and integrating neuro-diverse folks into the work force.

Which son is the true Prodigal Son in Luke 15:11-32?

Two-Minute Museum
Rembrandt's The Return of the Prodigal Son

Aurora Mayor Mike Coffman who is now calling for a "Work First" solution to Homelessness is more sophisticated than he lets on.

He knows that "Housing First" is NOT SUFFICIENT and he has said as much --- recognizing that mental health and substance treatment were big parts of the equation --- but municipal officials don't have the resources for that.

Further, I don't see how we effectively address Homelessness or Criminal Justice unless we do a better job of INTEGRATING Neuro-Diverse folks into the work-force.

Employment of people with disabilities or perceived to have disabilities is an Olmstead Issue.

A Strict Constructionist Supreme Court and Olmstead

12/10/2023

Val's Take

In the US Supreme Court's decision denying VETERAN'S DISABILITY BENEFITS due to late filing even under extremely compelling facts involving schizophrenia, bipolar disorder and tardive dyskinesia ---

The Supreme Court may be signaling that they are not going to play favorites --- or they at least want to be perceived that way;
"Dobbs" (the Supreme Court's 2022 decision overturning Roe v. Wade) was not an anomaly --
and strict constructionist views (both Constitutional and Statutory) are going beyond "THE RIGHT TO PRIVACY."

I could be WRONG --- but I don't see the current Supreme Court overturning Olmstead. YET.

BUT the little dance that advocates and states are required to do under OLMSTEAD is PROBLEMATIC.
Further, it is NOT CLEAR what the current Court would do with current US Department of Justice Guidance on OLMSTEAD.

I think most everyone likes OLMSTEAD IN PRINCIPLE --- just ask STATE OFFICIALS ---

BUT I think People with Disabilities Need MORE ACCESSIBLE ACCOUNTABILITY and
STATES need MORE MONEY and TECHNICAL SUPPORT from the FEDS even as we're maintaining FLEXIBILITY.

Back in 1999 when Olmstead was decided --- I don't think people were necessarily ready to get rid of the Medicaid Rule Prohibiting Medicaid Funding of "Institutes of Mental Disease."

BUT they also often hadn't been ready to acknowledge the numbers of people with brain injury, neuro-developmental disorders and psychiatric disorders in Jails and Prisons.
- That has changed a lot, especially in the last 10 years.

Further, PERMANENT SCATTERED SITE SUPPORTIVE HOUSING is widely recognized as a VIABLE HOUSING & SERVICE MODEL for many people in a way that it wasn't 20 years ago even if some professionals knew about it.

SCOTUS’ First Decision of the Term Is a Unanimous Blow to Disabled Veterans (2023)

Why did the liberals co-sign Justice Amy Coney Barrett’s harsh opinion?

The Supreme Court's opinion in Arellano v. McDonough

What are some POTENTIAL OUTCOMES of INDIVIDUAL OLMSTEAD COMPLAINTS in the NEAR TERM?

Making A Record
Public Education
CREATIVE PROBLEM SOLVING

I think if the FEDS were to get rid of the IMD Rule -- they need to STATUTORILY require States to develop Comprehensive Plans of Care, Placement and Housing for People with Disabilities who are Institutionalized or at Risk of Unnecessary Institutionalization with:

Measurable Goals
Reasonable Time Frames
and Funding to Support the Plan

Late Diagnosis of Developmental issues and Failure to Accommodate executive Functioning challenges raises risk of institutionalization

10/10/2023

Conjecture

CMS (the Centers for Medicare & Medicaid Services) and others have championed Physical and Mental Health Integration --- one of the other important components to that is DEVELOPMENTAL HEALTH.

We currently have a sizable number of people who are getting a LATE DIAGNOSIS of a NEURO-DEVELOPMENTAL DISORDER such as ADHD and/or AUTISM that come with significant EXECUTIVE FUNCTIONING CHALLENGES.

I would submit that LATE DIAGNOSIS of NEURO-DEVELOPMENTAL DISORDERS is INCREASING INSTITUTIONALIZATION of people with Neuro-Developmental & Psychiatric Disorders insofar as NEURO-DEVELOPMENTAL and PSYCHIATRIC DISORDERS appear to be on a CONTINUUM.

Further, CHRONIC STRESS resulting from UN-ACCOMMODATED EXECUTIVE FUNCTIONING CHALLENGES is increasing the burden on individuals, families and the communities in this country as well as other countries.

In some ways --- this may not be that new --- we just didn't recognize it.

In the 20th Century --- SMOKING EXPLODED --- and a population that had significant Neuro-Developmental Disorders was perceived calmer and more stable in some respects --- even as large numbers of people were dying of heart disease from smoking.

Further, smoking during pregnancy multiplies the risk of ADHD in the child and that appears to go to the 3rd Generation and maybe beyond.

We don't have the same level of smoking anymore --- but the current "Mental Health Crisis" is spiralling out of contol without better CONCEPTUALIZATIONS and TREATMENTS.

Further, this isn't just related to our "Mental Health Crisis" --- it also seems to be related to our CHRONIC DISEASE EPIDEMIC where people with ADHD and/or AUTISM seem more vulnerable to these diseases.

Additionally, our MODERN ALIENATED, INDIVIDUALIST WORLD VIEW has not always been helpful in understanding this --- if we think this is just about the "LIFESTYLE CHOICES" of the INDIVIDUAL --- IT'S NOT.

Further, it is not just about the LIFESTYLE CHOICES OF THE PARENT.

BUT LIFESTYLE CHOICES going forward do need to "ACCOMMODATE" and/or ADDRESS these DEVELOPMENTAL DIFFERENCES.

Our current go to of a MENTAL HEALTH PROFESSION that thought its mission was to help people change is a MIXED BAG --- it is BOTH HELPING AND HURTING.

Further, when I started as a mental health advocate in 2007 --- the Mental Health Centers didn't think it was their responsibility to deal with DEVELOPMENTAL DISORDERS.

On the other hand, individuals have been "UNCONSCIOUSLY MASKING" for as long as they could and many of these "HYPER-CONNECTED BRAINS" --- had a hard time understanding why they would have EXECUTIVE FUNCTIONING CHALLENGES and so did everybody else.

You can start to see why this isn't really working.

Now that is slowly changing, but people with these "DEVELOPMENTAL DIFFERENCES" have to be part of the process of constructing appropriate supports going forward.

The Impact of Systemic Inflammation on Neurodevelopment (2018)

Cytokines and neurodevelopment

In the past several decades, inflammation has been increasingly recognized as an important contributor to central nervous system (CNS) injury in both the developing and adult brain [1,2] (Table 1).

The brain is particularly vulnerable in utero as well as during infancy and early childhood, and insults that occur during these critical periods have the potential to cause long-term damage.

Several neurodevelopmental disorders have been linked to early life immune activation and inflammation, including autism spectrum disorders (ASD), schizophrenia, cerebral palsy, epilepsy, cognitive impairment, and depression

Looking to Collaborate with Atlantis

8/11/2023

Val's Take

So the first thing I should say is that Mike Oxford with Atlantis gave me a little TUTORIAL on OLMSTEAD in our conversation in late July.
"Hey, I already know a lot about Olmstead --- Buddy" (and actually I do know a lot --- But I don't know everything).

History of Using the ADA's "Integration Mandate" in the Context of LONG TERM CARE

Mike credits legendary Disability Rights Attorney Steve Gold with being the first to use the Integration mandate in the context of LONG TERM CARE --- to get some residents out of nursing homes back east.
That rationale was ultimately used in Olmstead which involved a Mental Health Institute in Georgia.

Further --- Steve Gold served as an attorney for Atlantis and ADAPT (begun in DENVER).

Interim Director of Atlantis --- Mike Oxford

As far as I know, the US Department of Justice (DOJ) was the first to use Olmstead in a LARGE WAY in the context of INCARCERATION.

This involved a 2010 Settlement Agreement with the State of Georgia to provide housing and services for THOUSANDS of GEORGIA INMATES with DEVELOPMENTAL DISABILITIES (DD) and/or SERIOUS MENTAL ILLNESS (SMI) upon release.

Attorney Steve Gold: A Leader in Fighting for Disability Rights

Supportive Housing is a big Key to keeping people with disabilities out of institutions

8/7/2023

Nebraska is one of the states that has incorporated the Supreme Court's Olmstead decision into State Statute.

Originally when I was thinking about a "STATE STATUTE" ---- I was thinking something very broad to reflect the broadness of the Olmstead decision itself.

I think the broad application of Olmstead can paralyze States and for that matter Advocates.

There is much more a realization in 2023 than there was in 1999 that SUPPORTIVE HOUSING is a BIG KEY to keeping people with disabilities out of INSTITUTIONS.

For some people that HOUSING needs to be PHYSICALLY ACCESSIBLE often for a wheelchair --- but potentially other issues as well.

For people with "COGNITIVE DISABILITIES" --- SUPPORTIVE HOUSING in "MENTAL HEALTH" ---

Is often SCATTERED SITE HOUSING + ASSERTIVE COMMUNITY TREATMENT (ACT).

One of the things that Mike Oxford -- Interim Director of Atlantis pointed out to me was that the Colorado Dept. of Healthcare Policy & Financing has beefed up CASE MANAGEMENT for people TRANSITIONING OUT OF NURSING HOMES.

THAT'S A GOOD THING
There had been some HORROR STORIES involving people transitioning from the Nursing Home to the Community without proper supports.

Horror Stories of Homelessness --- It Doesn't Have to be This Way

When we think about people who are HOMELESS or BEING RELEASED FROM INCARCERATION with "NEURO-DEVELOPMENTAL DISABILITIES" and/or "PSYCHIATRIC DISORDERS" who qualify for MEDICAID:

WE PROBABLY NEED BEEFED UP MEDICAID CASE MANAGEMENT.

We have FOCUSED on "MEDICATION ADHERENCE" for several decades now in Mental Health and that has not resolved our Mental Health Crisis.

Two BIG CHALLENGING REALITIES:

The medication is often not as good as we would like.
- Can have many NEGATIVE SIDE-EFFECTS --- especially the current generation of medications that WORK ON THE BRAIN GLOBALLY.
- Genetic Testing may be in order for some people as well as
- Paying for a Neuro-Pharmacologist
A lot of this is DEVELOPMENTAL and people have gotten WORSE by not ACCOMMODATING their DIFFERENCES in:
1. Executive Functioning, and
2. Energy

The FAILURE TO ACCOMMODATE has been on MULTIPLE LEVELS:

The Person,
The Family
The School
The Employer, and
The Society

Have not really been aware of these EXECUTIVE FUNCTIONING and ENERGY ISSUES nor how to accommodate them.

THAT IS CHANGING.

The NEED for "SUPPORTIVE HOUSING" does not exist in a vaccuum and is related to many other VARIABLES.

Translational Research & Medicine
Public Education regarding Neuro-Developmental Differences involving EXECUTIVE FUNCTIONING & ENERGY
ACCOMMODATIONS for EXECUTIVE FUNCTIONING & ENERGY DIFFERENCES/DISABILITIES that are available in:
- EDUCATION, and
- EMPLOYMENT

Additionally, many people with "HYPER-CONNECTED BRAINS" do have "SPECIAL TALENTS" that should be DEVELOPED to benefit the person as well as the community.

The Complicated Relationship Between the FEDS and the STATES under Olmstead

5/7/2023

It's very hard to see how we FUND the level of support needed for Cognitive Disability in the US (and for that matter around the World) ---

If we don't get some better understandings and treatments.
- There are ACCESS ISSUES --- BUT THAT IS HARDLY THE ONLY PROBLEM.

There has been a lot of cachet around the brain and all things neural ---

BUT the more we learn about "PSYCHIATRIC DISORDERS"
- The more they start to look like other disorders and diseases we're more familiar with.
  - It is the BRAIN -- but it's not just the brain.

Further, the more you look at other disorders and diseases --- the more you see that there are some "PSYCHIATRIC COMPONENTS."

Once you get to "DISABILITY" that is resulting in "UNNECESSARY INSTITUTIONALIZATION" ---

If you're in the US --- that's an OLMSTEAD ISSUE.

One of the reasons why COGNITIVE DISABILITY is such a HUGE PUBLIC POLICY ISSUE is because FAMILIES can often not afford the SUPPORT needed.

Further, if you've got a Health Care System that is arbitrarily focused on people with IQs below 70 and Neuro-Developmental DIFFERENCE/DISORDER/DISABILITY ---

What happens to those people with an IQ over 70 and a Neuro-Developmental "Disorder" -- ?

Well, they are often not identified.

RESEARCH and TRANSLATIONAL RESEARCH and MEDICINE are generally FEDERAL ISSUES.

The responsibilities for services for people with disabilities is generally a shared responsibility under Medicaid.

The responsibilities on the State to prevent UNNECESSARY INSTITUTIONALIZATION OF PEOPLE WITH DISABILITIES under Title II of the Americans with Disabilities Act and the Olmstead decision and subsequent caselaw and guidance run beyond Medicaid.

Under 504 of the Rehabilitation Act there is to be no discriminaton based on disability for programs receiving federal funding.

Disability Housing under HUD (the US Department of Housing & Urban Development is NOT an ENTITLEMENT.

The Medicaid's prohibition against FUNDING INSTITUTES of MENTAL DISEASE without MORE was well intentioned ---

Unfortunately, in many cases it gave people with "Mental Illness" and their advocates a PYRRHIC VICTORY --- rather than a TRUE VICTORY.

American Society for Biochemistry and Molecular Biology

PTSD Biomarkers Found in Blood

Neuroscience News
March 27, 2023

"A new study found that people who are currently suffering or face a high risk of post-traumatic stress disorder show particular patterns in four biomarkers measurable with a simple blood test.

"The findings suggest these biomarkers could be used to predict a person’s likelihood of developing PTSD, diagnose the disorder or monitor the response to treatment."

Kings College London

Study Maps Out Links Between Psychosis and Our Immune System

Neuroscience News
March 27, 2023

A victory in which the results of the casualties incurred are so devastating that calling it a victory is arguable.

Olmstead, Cognitive Disability and the Running of the Bulls in Spain

5/5/2023

It's easy to make fun of the video to the right --- especially when it comes to "PHYSICAL DISABILITIES."

When it comes to "COGNITIVE DISABILITIES" --- I think we're often talking a "MIDDLE OF THE ROAD" APPROACH when it comes to the "BIOLOGICAL BASIS OF BEHAVIOR"---
- And a lot of what I am proposing on this website --- is that the ROUGH MESSY APPROACH we've been taking is more and more obviously OUT-DATED.

I think the INTELLECTUAL EVIDENCE for this --- in some ways MATHEMATICAL, LOGICAL and even ALGEBRIAC --- is there ---
- Robert Sapolsky at Stanford has done an excellent job of collecting the EMPIRICAL EVIDENCE and making this case in his book "Behave: The Biology of Our Best & Worst Selves"
  - I think there is also a biology to our boring and meh selves --- but its not as interesting.

I've made this point before that some of those SOFT SOCIAL CONCERNS --- are turning into SOME HARD BIOMARKERS.

Further, those BIOMARKERS can be EXTREMELY HELPFUL to INDIVIDUAL TREATMENT.

Are we just talking about 4 BIOMARKERS for PTSD --- probably not.

Medical Dialogues
Markers of PTSD in the Blood (2023)

Channel 9 Next

CO Lawmaker Argues People with Disabilities "ASSUMED THE RISK"

When we start bringing in the Broad Categories of Factors that impact HUMAN BIOLOGY and in turn HUMAN BEHAVIOR --- that includes:

the Systems of the Body
the In Utero Environment
the Microbiome
the Physical Environment which can impact our biology, and
the Social Environment which can impact our biology

This should be greatly expanding what we mean by Mens Rea in the Criminal Law.

I think it could also greatly expand what we mean by "UNNECESSARY INSTITUTIONALIZATION" under Olmstead and Title II of the Americans with Disabilities Act (ADA).

There is already a LANDMARK OLMSTEAD SETTLEMENT AGREEMENT out of Georgia from 2010 that was intended to be a US Dept. of Justice TEMPLATE FOR THE NATION.

focused on providing appropriate housing and services for thousands of inmates with "Developmental Disability" and "Mental Illness" upon release from incarceration.

In 2023, "Mental Illness" in many cases is looking like "DEVELOPMENTAL DISABILITY" with an IQ over 70.

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