Dismantling state-level psychiatric centres: instituting full community access and integration

This paper presents a long-overdue proposal to the New York Office of Mental Health (NY-OMH) to close state psychiatric centers and discharge all remaining patients into the community. From long-term care and extended service units to admissions and adult, children, and adolescent services provided by inpatient treatment wards, this is a call for the complete discontinuation of state-level care and treatment centers in the United States. No question, society has arrived at a crossroads in determining the future of mental health treatment. Consumers and practitioners both acknowledge that the current mental health system does not address gaps in mental health care and treatment. Instead, the system is still informed by the era of institutionalization and does not facilitate access to services at the local level where the potential need for connectivity and person-centered care is greatest. This recommendation challenges the ongoing denial of full community access to and integration of mental health care in the United States and aims to disrupt the increasingly insidious neo-institutionalization. Access to mental health treatment should be the first priority in addressing mental health crises for consumers who have historically fallen through the cracks of the system. The implications for psychotherapy and the treatment of mental health conditions post DSM-5 are clear. Mobilizing the perspective of a peer diagnosed with a mental health condition, I propose to create and establish new practices and regulations to guide the revision of the system of care and public health policy in the United States.


I will never forget the words my psychiatrist in the community hospital in which I was receiving treatment for first-episode psychosis: “You’re not going to like where you are going….” (Personal Communication, 2008). My doctor was referring to the local state hospital in which I was pending immediate transfer for “unresolved psychosis” for “ongoing” care. I am a consumer of mental health services who has been hospitalized in a state psychiatric center in New York State. I am also a social worker, a disability rights advocate, and therapist for mental health treatment. This presentation will offer facts, data, and professional analysis based on years of clinical practice. In addition to clinical experience and research, I will incorporate the peer perspective stemming from my own experience and the shared experiences of peers in the United States. Utilizing peer-informed literature written by consumers of treatment in New York State and from other state-run regulatory bodies in the United States hiring peers, this paper presents a new perspective on uses of long-term hospitalization at the state level. The argument builds on existing research suggesting the state hospital system needs to be expanded and reformed. Instead of supporting this claim, I turn this fallacy on its head by reexamining the data already presented by supposed independent researchers contracted by the state governments from which they receive funding, which provide data and analysis of trends in modern mental health within the same system in which they serve.

In the research report written by Parks & Radke (2014) state psychiatric hospitals are a vital part of the continuum of care and should be recovery oriented and integrated with a robust set of community services, the authors lay out a set of recommendations on how to reform and revamp the existing state-run mental health system. The central arguments proposed then were not exactly new, nor a radical departure from standard practice in psychiatric medicine during the 1980s, shortly after the beginning of deinstitutionalization when clinicians were forced to accept that patient involvement in their own care should be central in the recovery progress. This notion, radical then, was driven by the peer movement and disability rights advocates passionate about changing clinical practices at the ground level. On a more global level, the report hammers existing roadblocks in the culture and environment of state psychiatric hospital facilities posing as barriers to providing effective care given new recovery-oriented; trauma-informed; culturally and linguistically competent regulations for best practice. These include patients receiving treatment in the “least restrictive environment possible” Parks & Radke (2014) and other peer–driven, recovery-oriented practices, such as including recovery specialists as equal members of the treatment team.

Unfortunately, when considering praxis in contemporary state-run facilities day-to-day operations, theory is not congruent with practice on the units and wards where patients live out their lives when treatment fails them in the community hospital. The very language, “when treatment fails,” is the point of departure for this argument, which questions the complicity and ethics of practitioners who consign their patients to the categories of “failed” or “untreatable” (Guttman, 2018) instead of an immediate revision or urgent critique of the praxis existent in available mental health treatment. The first step to providing the least restrictive measures possible in treatment is dislodging the use of restraints, including seclusion practices that isolate patients from their community members on the unit. In reality, from both professional and lived experience, state-operated units are smaller, more confined, overcrowded, and jail-like in architecture and lay-out of services in the wards. In addition to the aesthetics of institutionalization and the confining environment of the hospital, the restrictions placed on the patient living away from the community-at-large in a locked hospital, usually hundreds of miles away from family and friends, is antithetical and a sharp departure from the words and language used in the report by Parks and Radke (2014). It is, instead, the very reason why this presentation seeks to reevaluate so-called reform in today’s mental health system.

Research supporting the further expansion of the state hospital system continues to acknowledge the lingering debate about whether patients can be better served in the community in place of in-voluntary treatment in long-term state-run units. Given this debate still persists, government stakeholders and decision-makers need to give more consideration to both sides of the argument and truly look at the facts. Instead, revenue, insurance, and cost-based analyses of the situation continue to be firmly in the hands of the people that keep the system running. This presentation is instead independent of OMH, DOH, and other federal commissions that hire researchers based on trends in funding. At the crux of it, both sides of the community versus in-patient debate realize the risks and benefits patients must be evaluated at all times to determine if this same treatment in the state hospital can be safely provided in community settings.

One day, state psychiatric centers and mental health hospital networks will be just relics, anachronistic holdovers of modern medicine and the sins of psychiatry. Where the last great psychiatric cathedrals now stand is a carefully laid out and organized system of hospitals. These hospitals continue to symbolize the harmful power that housed an entire population of “sick” people gone “mad” in hallways of the living damned. Hallways of “treatment” rooms in which medical interventionists forced medication, shock treatment, and lobotomies upon patients. While the mentally ill suffered and were exploited by medical testing, more insidious and covert forms of treatment were also administered. Indeed, lobotomies were supplanted by shock treatment and, the final abuser, the pharmaceutical companies. All of this set the stage for a canon of psychiatric atrocities as the 21st century unfolds.

Today the legacy of state psychiatric center in the United States is being challenged by former patients, psychiatric survivors, and peers whose goal is to liberate medicine from psychiatry. This movement began in the 1970s and will reach its crescendo when the last patient is discharged and walks free past the gates of these institutions.

Still, research funded and disseminated by organizations like the Treatment Advocacy Center (TAC) and other reports which inform the emerging trends in state funding continue to be off the mark. Indeed, forced treatment and assisted out-patient care needs to be continuously reevaluated and reconsidered in the context of new emerging treatment options available for consumers which could benefit from release from psychiatric hold and deferred recovery due to problems rooted in access and connectivity to care. However, the reports generated by TAC and other advocacy organizations which put “treatment” ahead of the needs and voices of the consumers truly requires more careful consideration on the part of lawmakers, and stakeholders making decisions on how day-to-day operations are carried out by practitioners in state-run units than simply blanket appraisal and adoption of their recommendations. These are recommendations which continue to ignore the reality of life on the unit, and condemnation to extended and “on-going” treatment without consent and, even worse, effectiveness in avoiding re-hospitalization and certainly not expedited discharge to the community.

The writing in this presentation, its contents, and history began as chatter, “shop talk” among peers in community mental health center. But talk disseminated quickly, moving among the ranks of the peer movement to the level of the czar. The czar, leader among the peer movement, must finally end an era of institutionalization. The specter haunting consumers of mental health treatment even today, disguised as Neo-institutionalization and passed off as treatment to patients in the state hospital system must be stopped.

In no uncertain terms, the czar must stand before the state government in New York State and United States federal government Department of Health (DOH) and set the deadline for New York State and all state-run psychiatric center to comply with ward-closure teams, and sign off on the discharges of all patients in the state hospital system. Indeed, under “article zero”, a future Office of Mental Health regulation, ward closure teams will be charged with the organization, dismantlement, and discharge of patients in state-run long-term and extended care units across the United States. A grand consortium of peers, social workers, and psychiatrists will be assembled once article zero is written into law.

Re-integration, access to the Services, and the makeup of the ward closure team

As with all things absolute, an exception to the rule always exists. For all that rule, including the czar, peers themselves must answer calls from all victimized people who demand and deserve justice. This is a justice as visible and clear as day to patients as the same euphonious chatter from the community center we peers would commensurate years ago and long before the last discharge. Until everything changes, and patients can see the specter rise in the gaze of their abusers, power and privilege will be restored in the hands of the consumer. Without question, full integration and access to mental health services resides in the community. To fully integrate services and consumers into the network of already available mental health programs, remaining patients in long-term state psychiatric centers must be discharged and released from the eternal holding pattern to ultimately integrate and help consumers gain access to community resources, and most importantly, to allow them to live amongst other people outside the gates of the institution. Therefore, phase one of the ward closure team manual for community access will target the release, discharge and reintegration of patients into the community. Later phases will target the establishment of reliable systems of care in which chronic and high-risk patients will have reliable access to services and programs that will benefit this group in lieu of hospitalization.

Phase one theoretically begins in local state governments and municipalities that govern the regulation of mental health treatment. In New York, this would be the Office of Mental Health. The OMH commissioner must ultimately approve this document and other similar research related to the mass-organized discharge of patients in psychiatric centers. Thus, the Office of Mental Health must approve funding for ward closure teams to infiltrate state psychiatric hospital systems at all levels that impact discharge planning and community reintegration. In theory, each freestanding unit in all state hospitals will work side by side with its assigned ward closure teams. Social workers, psychiatrists and all inpatient staff charged with the successful discharge of its patients must partner with the ward closure teams until the final discharge from the hospital in which the final patient reenters the community.

The crux of phase one is the funding needed to staff the ward closure teams across New York State. Each team will serve as an interdisciplinary reflection of the treatment gaps identified at each hospital’s locale. This means that prior to each ward closure team beginning its work in a unit, the hospital will send a memorandum of requirements to the office of mental health, which will inform the makeup and composition of the teams assigned to each hospital and community. Thus, needs related to transportation and rural concerns will be managed by ward closure teams specialising in the needs of rural communities and their mental health systems. More urban-based communities with complex spatial and access issues will be staffed with workers adept at handling the mental health concerns of patients in urban settings.

Implementation: the methodology, phase I and II

The planning involved for both the ward closure teams and the existent treatment teams in the units surpasses the assessment of the composition of the community. Indeed, ward closure teams will be required to have a full understanding of local existing services in the community and will work side by side with treatment teams in the units to identify issues foreseen prior to each discharge. Hence, issues of adherence will be measured against connectivity issues in the communities’ existing health care networks. Other issues, such as medical comorbidities, will necessitate ward closure teams to acquire a full understanding of existing health networks that serve clients with complex medical and psychiatric issues and other complex case management services, which freestanding clinics do not traditionally provide. Thus, diagnostic and public policy stakeholders of health and medicine and public policy stakeholders of health, medicine and chronicity will be counterbalanced with Assertive Community Treatment (ACT) teams and other mobile units, such as care managers, which go into the community, complete home visits and supply case management services to users dependent on the system of care, i.e. the certification and recertification of benefits to continue services without interruption.

To achieve the desired goal, the next major step of phase one will occur just after the assignment of ward closure teams to respective communities and psychiatric centers. At this point, the teams will infiltrate and gain access to inpatient services and begin working side by side with hospital staff to identify concerns prior to discharge. This will be a process in which patients will work with both the ward closure teams and their treatment teams in the community so that postdischarge services can be matched with the needs identified by both long-term clinicians and the new closure teams to achieve the primary goal, which is complete access and the integration of patients into the community and the end of institutionalization.

To achieve this aim, the plan and each of its phases require not only community support and support from stakeholders regarding mental health and public policies but also the shared dream and goal of creating a society without walls or restrictive barriers for patients with chronic and long-term mental health conditions who are typically assessed and slated for long-term, ongoing, round-the-clock care that a state institution provides. Thus, the vision and scope of this proposed plan and the prospective teams charged with implementing the final solution and ending the era of Neo-institutionalization is clear: full community access to and the integration of all community mental health programs as well as the elimination of a level of care that is both dated and obsolete in the context of the full meaning of deinstitutionalization.

The end of Neo-institutionalization

Mental health is a community and public health need, and after implementing the proposed plan, the fallacies and misnomers of the old system shall never again point towards institutionalising people and sending the ‘problem’ patients to long-term care units far from the community and its resources. Access to services must be provided, and new pathways must be engendered so that consumers can gain access to the many lines of care already provided by the systems of care in New York State and by all regulatory bodies with a vested interest in mental health treatment.

Neo-institutionalization is complex and insidious, and it must end. Therefore, the focus of the ward closure operations manual is twofold. The first wave of operations targets state psychiatric centers based on a global assessment of outlying communities and on the express needs of the consumers being discharged. The second wave targets the overhaul of treatment silos and installations already in place in the community that need more integrated access for consumers. No question, the resources already exist in the community, and this document proposes how to reconfigure existing structures that provide mental health treatment to serve patients.

The success of the second wave depends on the elimination of freestanding treatment silos. This means that all treatment programs that discriminate and choose to openly serve only subgroups or ‘high-functioning’ patients will be given a mandate by the office of mental health to broaden their scope of services, or they will be subject to a loss of licensing and funding. An example of a program that only serves a small niche of ‘qualified’ patients includes outpatient settings that refuse to accept state-sponsored insurance for patients who are disabled and reliant on Medicaid and other service dollars. Conversely, treatment centers that offer services to all patients or that are cited for restructuring and successfully reconfigure their clinics, group practices and day treatment centers will be awarded funding to commit to on-site projects and community outreach projects to further extend services to the community.

The next segment of the phase is an ongoing community mental health surveillance and hygiene study that continues throughout reintegration and that will expire after the final discharge from the locale’s state psychiatric center. Under the assumption that the influx of thousands of newly discharged chronic patients will test the limits of the community’s local emergency rooms and community hospitals’ abilities to provide services and will largely increase the census of mental health treatment at health centers, this surveillance and hygiene study will bridge the existing gaps in each community during the critical phase of mass-organized discharges from state psychiatric centers. The study will be monitored and fed into a state-wide planning commission for full community access to and integration of mental health care. Next, a broader approach, including at the global level, can be implemented and used as a model for other state regulatory bodies interested in eliminating the dated level of care and the deferred recovery of patients.

Structural adjustments to the system-of-care and organizational shifts in programs to promote full integration and access

The planning and hygiene study will ultimately be analysed and measured against the restructuring efforts already underway in the community. The gaps in care identified based on the hygiene and surveillance study will be seriously considered, and once verified, local community mental health care planners, managers and stakeholders will be charged with identifying solutions to the problems. Given the latitude required to make changes at the local level, the recommendation is that county community mental health departments and Single Point of Access (SPOA) committees spearhead the final structural adjustments to the mental health care system. Ultimately, the Office of Mental Health will begin drafting new regulatory codes that promote and encourage the end of Neo-institutionalization. Thus, codes will be established that discourage extended hospitalizations and ongoing treatment plans without an end. While not forbidden, these treatment pathways will generate red flags at community mental health offices and in the OMH headquarters in Albany New York, and these programs will be monitored for future compliance with integration and access practices.

This proposal is essentially a recommendation and call for regulators at the state and federal levels to revamp and to raise the bar to promote the best practices amongst practitioners and public health stakeholders of mental health care. Research suggests that the delivery of mental health treatment must go on without interruption from either hospitalization or from falling into a gap in available treatment at the local level. Given that many community treatment settings are either inaccessible or do not target the provision of resources for patients to continue recovery on their own terms and in their own communities, it can be assumed that the next logical step in creating a culture equipped and prepared to address mental health care crises will require practitioners and law bodies to pay close attention to this recommendation with due diligence. The rollout and the implementation of ward closures in the United States and anywhere that patients are in a psychiatric holding pattern without hope of accessing services in their communities is urgent.

Revamping best practices for chronic mental health disorders in the community context

In the throes of madness, people need some form of peace to hold on to like an anchor while discovering their innermost serenity. The state hospital center offers no such peace. Even in someone’s most tormented nights consumers armed with the right skills, resources, and support can identify a technique to self-manage their internal chaos and external dysfunction. This section of the presentation is intended to arm readers with the tools necessary to self-manage their own frustration tolerance throttle. In plain English, this section of the presentation is intended to provide trauma and peer informed training material to practitioners to help patients regulate their thinking and feelings while tuning into his or her own mental status and internal barometer for healthy living after discharge from the state hospital center. Consumers should feel empowered to always live peacefully and independently, regardless of their chosen path to serenity and peace, even when the world before it becomes too chaotic to live without medical or psychiatric intervention.

A few additional caveats should be kept in mind before applying theory to practice. The first, when dealing with the interpersonal world, no level of calmness and serenity can prepare you for what someone will throw at you when they are in crisis and mishandling a situation. In cases like this, you may not have to dig deep into your psychological profile to unhinge your frustration; but instead, you can remind yourself that other people’s problems are their own. Feeling or thinking for them will only make their jobs more complicated and difficult to manage independently without you in the future. The second and last caveat: Sometimes you should be, or need to be, anxious. Our anxieties are signals that tell us we need to make changes in our lives. If you cannot locate the deep-seated issue, and you know something has to give, sometimes just going ahead without digging too deep into your subconscious or psychological wellspring might provide you with a fast and very much needed change to feel better in the next few moments. The most ornate and complex set and manifestations of symptoms exist in the schizophrenia and related psychosis family of mental health diagnoses. Symptoms are labelled differently to address and explain the experience of the symptomatic person. To identify which is a negative and which is a positive symptom, i.e., disorders akin to Schizophrenia and related psychosis, practitioners and peers interested in learning about their recovery must differentiate their experiences between an added feature to his or her presentation or an internal sensation or belief at work in your thought process. One example is thought broadcasting. This is a positive symptom in which a person believes his or her own personal thoughts are available to other people seemingly anywhere in the world. It differs from telepathy in that these thoughts are not transmissions per se but a vast web of shared knowledge amongst the people listening or accessing the information being broadcasted.

Repositioning symptomatology Post DSM-5

Paranoia is disabling. It limits us by cutting off our world and making us feel too uncomfortable to explore and live our lives without fear. No reason exists to live with paranoia. Paranoia is fear, and fear stops us from celebrating every moment of our existence. So, how do we stop it? Eliminate it? The most important place to begin is with assessing what you are afraid of and categorizing it into three domains of fear. The categories include: 1) letting our small critical thoughts snowball into major fears; 2) eclipsing hopes and limiting our future-oriented thinking; 3) combining our fears or apocalyptic projections.

We are critical because we care. We want to manage our lives effectively and precisely. But these small critical thoughts can snowball into major crippling fears that stop us from getting out of bed or being social and making new friends. Why let that happen? Check in with yourself. Self-monitor and find an internal balance with your thoughts. Ever look forward to something? Future-oriented thinking keeps us motivated and happy about time elapsing, or in plain language, experiencing every moment of every day. Paranoia stops us from experiencing our days because we become so pained that we stop and detach; we do anything to stop the internal fear from strangling other aspects of our lives. The worst thing you can do to make paranoia worse is to combine fears. A hurricane is bad news, but flooding due to high winds and high water is even worse. See what I mean? Don’t do it!

Implications for treatment for first episode psychosis, delusional symptoms, and thought disorders

Delusions put the crazy in madness and mental health disorders. This means, simply, when we think he or she is “out there” and “nuts”, we are referring to the delusional systems within a person’s larger set of symptoms. Delusions carve out the imaginary and marry it with our orientation in various ways that complicate and distort our reality and sense of self. When we say someone is delusional, clinically we mean someone’s ideas and the beliefs they hold about their world are more than just unusual, they are a departure from reality: what is happening internally is not congruent with the external world. Usually, with most mental health disorders featuring psychosis, delusions are more abundant than one isolated, disordered thought. Delusional systems are either fixed or solvent. This means that no matter how a person’s recovery progresses and how much the external world changes, the delusion persists. This post targets how delusional systems are born and evolve in the person experiencing an altered realty and what the implications are for practice and treatment.

A delusional system is not complex when first born. In fact, it may be as simple and benign as a newly formed idea or routinely repeated habit executed internally by a person trying to complete their Activities of Daily Living, (ADL’s)or go to school or work. For example, a person might be cleaning wax from their ears when a switch flips in the brain and slowly, seemingly organically, the thought transforms. Suddenly, and conversely over time, the person cleaning the ear is no longer purposefully removing wax, he or she is doing something much different and likely more malignant in design than when the idea was first executed by the brain. In my own experience, when I first experienced the birth of a delusion it was my relationship status with a friend and, ultimately, my marital status. At one moment I knew myself as single, then over time and yet suddenly, I knew of myself as married with a kid on its way, depending on the health of my friend’s womb and a piece of fruit on my windowsill that I connected to the health of her uterus. This is an example of how one distorted thought can evolve into a complex system with both fixed and solvent features.

How a delusional system develops directly informs how clinicians should take it apart in treating the person with altered realities. Since delusional systems develop over time and are realized suddenly by the person experiencing the change in their external world, the clinician must identify where and when the “break” or shift occurred and what that meant for the person experiencing the shift in reality. For example, if a person, over time, thinks a microchip is implanted in his or her brain, the clinician must identify when the break originally occurred for the person and what it means to experience the symptom. This means, similar to performing a math equation, that charting the clinical picture’s distance from the shift in reality in terms of each aspect of their mental status (e.g. time, place, judgement, insight etc.) is the first step in unwinding the delusional system’s content and breaking fixed-thought structures into less toxic and maladjusted patterns.

I’ve experienced this symptom first hand during my final days in the community before I was hospitalized for full onset of first episode psychosis. This symptom is not so much scary as confusing and disorienting to experience. I was driving down a major interstate when I first heard my thoughts and believed they were being listened to by friends and family, who were hundreds of miles from me in reality. However, when experiencing the symptom firsthand, I felt as if my family could personally hear my thoughts immediately and without regard to space or time and the even the beginning of their response to my transmission if my imagination or subconscious really had a choice about things. In this sense, voices and delusions collide together to make this feature of psychosis even more difficult to experience without breaking from reality. The break is not a sharp departure in orientation but, rather, noise and interference of thoughts; the addition of these positive symptoms and the space needed to hold on to these overly complex delusional system takes time to process information effectively as it occurs. This is why very psychotic people speak slowly, and their reaction time is longer; there is so much more to process to maintain even basic life functions. So much is happening or not happening in the person’s speech and language centers in the brain that the person experiencing the symptom must sort out the overabundance of stimuli in order to stay connected to the world without getting lost in internal preoccupation.

In order to broadcast thoughts, the person transmitting must be listening. Since thought broadcasting is a symptom and not existent under normal circumstances, the person must acknowledge that it’s happening as it is happening. Thought patterns that are too involved and overly complex are even more diffused and difficult to decipher as either real or a symptom of illness. This is why, as this symptom progresses, people get increasingly lost in internal preoccupation and are unable to come out of their heads per se and spend their time just listening to or even responding to his or her internal thoughts externally or aloud. This is when you typically hear of people responding to their voices. When this happens, it becomes extremely problematic to not attract attention or appear bizarre to others. Since this also occurs late in the progression of the diagnosis, people experiencing the symptom are usually already in the hospital. Without experiencing this symptom, it is hard to believe it can happen to a person. I thought I had extra powers from a government experiment and needed to use them in order to solve the mysteries already at work from a growing delusional system. In my case I was driving. You may be walking the dog. Just be safe in any event and remember safety is first and foremost the goal when you begin experiencing something so otherworldly and yet so personal that it breaks the very conventions of time, space and communication between people subject to physics and human anatomy.

The partnership between health and healing: peer informed recommendations for living with a mental illness.

The final night I was hospitalized in the Community Hospital, I heard screaming all night long from my neighbor’s room on the unit. She was carrying on like a child. The screams resembled those of a baby’s cries. I kept pressing the button next to my bed to summon the staff, but nobody arrived until the next morning. Given the sleep deprivation and my compromised mental status, I was delirious at this point. By the time the staff from the unit was in my room addressing the situation, I was feeling so nauseous from the noise all night that I leaned over and vomited on the social worker and lunged towards the psychiatrist for help. I was immediately placed in the Quiet Room to be monitored and assessed for safety every 15 minutes until I was stabilized. About an hour later, the doctor came into my room and advised me that I would be transferred to another hospital and that I would be staying there for a very long time. We all have limitations. Some of them are more visible to the naked eye; others are more covert and hidden away from the public but still an internal struggle we battle every day. As a therapist, I have the opportunity to listen to other practitioners talk about their patients and their ideas on how to help them in their treatment.

Sometimes my head spins from the ideas circulated around the table; hopefully, now it will be clearer to practitioners what treatment fit means in the context of supporting people in their healing with functional impairments. Mania can seem like the best high in the world and must be undersold as an affective state impairment in functioning. Mania is all intoxicating. Mania can make you believe and buy into fantasies of all shapes, sizes and forms. During a manic episode, you can transcend historical points of reference and religious symbolism/iconography prescribed by your belief system and find yourself incorporated into it despite anachronistic markers, which should signal a problem with your perception. In this case, mania will, in fact, create a new reality, if only for the moment, and shift your guidance system into a space that will seem like anything is plausible when something is very wrong with your affective regulation. I have experienced firsthand manic episodes in which I have been awake for weeks at a time without sleeping or need for rest. I have witnessed other people so dysregulated from mania that they would do somersaults across the floors of the psychiatric ward floors just to find out their bodies would later feel the shock of these poorly planned acrobatic theatrics. With certain diagnoses, manic symptoms become more difficult to identify. People carrying diagnoses that include psychotic symptoms should pay even closer attention to their moods because psychosis can worsen with extreme elevations of mood, which then further complicates a person’s insight into and judgment of their symptoms. For most generic mood disorders, extreme euphoria, decreased need for sleep, hyper-sexual arousal, and religious ideation are the usual suspects when manic symptoms present. Should these symptoms activate in a subclinical or mostly unproblematic manner in your life, you may be working with hypomania.

In terms of self-management and self-regulation, several options are available for reducing the harmfulness of a manic episode on your interpersonal life and your capacity to execute activities of daily living without incident. These strategies are dependent on the manner in which mania was activated and how severe your symptoms are. Stimulant and drug-induced mania is just as dangerous as organically driven manic episodes. Considering substance abuse treatment for cases like this will be an important step in managing your symptoms for the long haul. Like most people, even minor stimulant use from caffeine can trigger an episode. Living a chemical free lifestyle is not for everyone, but it can provide a baseline, at least temporarily, with which to gauge further consumption of foods and beverages that might trigger an episode. For nonchemically induced episodes, internal and external barometers are essential for knowing your affective state baseline. Listen to your friends and colleagues. Maybe recent complaints have been made about your behavior. Or maybe you feel like it’s hard to maintain a balanced mood. Begin to create markers in your living environment and for your internal g. At times, you may have to live with unresolved symptoms. However, creating a plan for friends and family will greatly reduce the risk of potential harm from an episode. This means making friends and family aware of your symptoms and triggers so they can help you avoid the ups and downs of mood dysregulation and even help you make decisions if your judgment and insight are too impaired for rational decision making. I send emails to friends and family when I feel like my moods may be impaired or have impaired my decisions or, in the future, might harm others. Preparedness and attention to details are always essential when managing an illness. Surround yourself with supportive people and allies in your recovery. You should never feel embarrassed by your behavior, but you always need to accept responsibility for it. That’s how recovery works: acknowledging that change is necessary and moving forward in the process of adapting our behavior until it serves our purposes

Personality disorders, interpersonal distress and identity issues

Previous research suggests that the gathering and interplay of symptoms between “grandiosity and defensiveness” in people typically carrying a diagnosis of Narcissistic Personality Disorder (NPD) rarely benefit from traditional psychotherapy. In the state hospital center, these diagnoses were talked about in the previous statistical manual, the DSM-4, and termed “Axis-II” due to their secondary status to “Axis-i” diagnoses which were considered treatable and the priority to address first in and out of the hospital. No doubt, these so-called “untreatable” personality disorders were labeled as such because the state hospital center is the last place real work can be done by the consumer to find remission and relief from symptoms .I am now suggesting a new approach that gets underneath the psychology of these so-called symptom as, namely, for Narcissistic Personality Disorder (NPD) and similarly other related disorders which showcase “center-staging” behaviors as strengths. Instead of signaling to consumers all their symptoms are just inconveniences which interfere with their interpersonal health, therapists can teach consumers to capitalize upon positive manifestations of their symptoms and put their so-called deviant behaviors into good use socializing and engaging in other prosocial interactions. Firstly, it must be said that, by and large, people do not come in through the therapy office door requesting treatment for their NPD. NPD by-in-large can contribute to other diagnoses becoming too overwhelming and become even more problematic when these comorbid illnesses begin to accumulate. Certainly, as psychological problems begin to mount for patients with comorbid personality disorders managing in the community without treatment is a giant risk to take for patients requiring urgent mental health requiring urgent mental health treatment without being concerned about landing in a state psychiatric center due to being connected with the wrong treatment fit .

The primary focus of psychotherapy should not be on treating the NPD symptom but, instead, on its manifestation in other psychiatric and psychological problems, such as depression, anxiety, and other affective state regulators which become corrupted when the NPD symptom becomes active. Thus, instead of reinventing the wheel in psychotherapy, practitioners can focus on treating the real problem with the same sophistication as any other disorder that fits the treatment approach. This can be done in group therapy, which has proven to be helpful for clients to gain the reflective lens necessary to cultivate personal insight into their interpersonal landscapes. With the exception of “lacking empathy”, most, if not all, of the so-called indicators for NPD can be mobilized into strengths for consumers of NPD treatment. I will use the example of grandiosity and requiring excessive admiration from others to illustrate how this “deficit” can be flipped into a strength, even an asset, to the person carrying this label.

When treating comorbid personality disorders it is in the interest of people carrying a diagnosis to mobilize all of their resources and support to meet their day-to-day challenges and reduce the likelihood of their opportunities coming up short of their expectations and hopes. Simply put, no reason exists not to be fully prepared for the day’s endeavors and to be ready for anything. In a world where the unlikely is possible and nothing is definite, I can fully understand why people carrying this diagnosis are labelled as grandiose, when it is really about being mindful and articulate about your needs as a consumer and what it will take for you to be successful in life. Ultimately, it is not the therapist’s role to teach empathy to the consumer unless that is the stuck point in the work that is keeping someone from realizing a missed opportunity for insight-building. Teaching empathy can instead be repositioned and posited as a skill or technique for people to learn in psychotherapy to barter for their own goals without walking over the needs of others in his or her life. Through bartering, people carrying this diagnosis will be less inclined to feel envy, or excessive self-admiration because they are participating in a system that leaves room for greater currency of emotions and a greater exchange of ideas, reducing the overall volume of self-referential thinking which can interfere with a consumer’s functioning. Instead of placing emphasis on excessive limitations and teaching hyper-restraint in therapy, people with this diagnosis are taught to reach for the upper limits of their personal and interpersonal success.


Let us be completely honest about healing after discharge from the state hospital center Depending on the functional impairment or limitation in completing self-directed tasks to maintain a standard of living and quality of life after discharge, treatment plans to address interfering symptoms is only the very beginning when it comes to complete recovery and healing. I am suggesting that depending on the goals of the individual, the interfering symptoms should not be the focus of treatment in people carrying a diagnosis; instead, we need to be focusing on strengthening the weak points in functioning, regardless of the particular symptoms blocking the person’s ability to maintain their desired quality of living. Interfering or unresolved symptoms can be treated, but they certainly should not be the focus of treatment. Some people never experience relief from their symptoms due to extreme chronicity and untreatable impairments. Not every symptom is rooted in a diagnosis. Sometimes, flaws in our personalities govern the expression of our limitations. We need to refocus treatment to target and identify the weak points in a person’s functioning, whatever the symptoms are that block abilities and create impairments. I have seen first-hand clinicians and peers dwelling on unresolved and chronic symptoms as if strengthening a person’s weaknesses in functioning would n0t help them move forward in their healing.

At the root of it, community-based practitioners can address impairments, but sometimes the wounds do not close and the scars do n0t fade. They need daily, ongoing care. Like the emphysema patient on oxygen, sometimes daily maintenance and care is the only way to keep moving on in the path to healing and recovery. Being honest with yourself about your mental and physical status will go much further than waiting for the miracle cure or, even worse, ignoring the problem because it’s unmanageable. Well, if good health means healing, then feeling better will require us to have better self-management skills, moving forward. It is not the problem that is the important thing to always focus on resolving, it’s the solution. Accepting the solution for what it’s worth will require you to always sharpen your self-management skills to live the quality of life you want and choose for yourself. Sometimes a situation calls upon people to “right the ship” and be more authoritative and directive in their approach to public policy, mental health, and personal issues interfering with patients self-managing their lives and particular situations. I suggest starting here to locate your internal barometer. This is a little more involved then tuning into your gut and doing what feels right. During a looming personal crisis, tuning in to your feelings is only the beginning. If a situation needs fixing, it should capture more than just your feelings on the subject. Some ethical or, at the very least, problem of energy flow should be interfering with the mechanics involved to complete the task before it is jeopardized. My point is, your “feeling” world and your “rationality” world need to be interlinked and counterbalanced to be successful in tuning into the moment for deciphering, filtering-out, and choosing a better way ahead. In the United States, and anywhere outmoded treatment such as state-level psychiatric center still exist and go unchallenged as a viable treatment pathway, the better way ahead rests in the resolution of system issues highlighted in this presentation to bring treatment at the local level to the forefront of government and health services initiatives around the globe. Citizens must be involved with these issues requiring our urgent attention and focus to reform without further national incidents from ineffective mental health practices. Ultimately, we need to be prepared to look at the entire situation of mental health affairs today in the United States when instituting this new plan.


La, E. M., Lich, K. H., Wells, R., Ellis, A. R., Swartz, M. S., Zhu, R., & Morrissey, J. P. (2015). Increasing access to state psychiatric hospital beds: Exploring supply-side solutions. Psychiatric Services, 67, 523–528. Retrieved from http:// ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201400570

Parks & Radke. The vital role of state psychiatric hospitals

Sisti, D. A., Segal, A. G., & Emanuel, E. J. (2015, January 20). Improving long-term psychiatric care: Bring back the asylum. Journal of the American Medical Association, 313(3), 243–244.

Quinterno, J., & Rash, M. (2012). Serving mental health patients in crisis: A review of the state’s program to buy beds and build capacity. North Carolina Insight, 23, 54–113.

Guttman, Maxwell. (2017). Intramuscular injection and its impact on perspectives in mental health medication, psychotherapy, ethics, peer process, and recovery.

Guttman, Maxwell. (2018). Mental health diagnosis: Axioms, continuum, and future directions.

Wells, S. M., NASMHPD, & CSG. (2010). Responding to a High-Profile Tragic Incident Involving a Person with a Serious Mental Illness. Alexandria.

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