We bought a house in 2012. About five weeks after moving in, the seven lilac trees on the eastern border of the property bloomed and filled the afternoon and evening air with their powerful fragrance.  It was both presently wonderful and jarringly nostalgic.

I instantly remembered the last time I had noticed lilacs. There were three huge lilac trees on my grandmother’s property that sat about 15 feet in front of the back door (there may have been more, but three stick out). The three lilacs formed an imposing wall, behind which reigned several large apple and pear trees. There was a four and half foot hole that was between two of the lilacs – it was about five feet deep and it made a perfect pathway for children to the greater lawn and our favorite apple tree. The second photo shown here is from when I was five or six years old. It was taken in front of the base of one of the lilac trees (I regret the Princeton shirt, but my parents didn’t know any Rutgers alumni in 1982).

I was raised to revere Lincoln (my parents didn’t have to push hard). I discovered Walt Whitman in a high school poetry class my junior year, and though “O Captain My Captain” is my preferred Whitman eulogy for our 16th President, I very much like “When Lilacs Last in the Dooryard Bloom’d” (it also reminds me of my father, who mentions it from time to time).

When I was in college, I took an art history class (renaissance art to the present). It was all new and the tests were difficult. The professor encouraged us to take individual trips to the MET to look at various pieces. I fell hard for Claude Monet (there is a room in the Impressionist section that I have a sense of ownership for). Last spring, I traveled to Paris and spent a great deal of time in museums, particularly hunting down the works of Monet and Rodin.

I saw this painting at the Musee D’Orsay (the fifth floor holds the distinction of being my world favorite, so far). Monet painted it in his garden at Argenteuil in 1872. It is titled “Lilacs, Grey Weather” (there is also “Lilacs in the Sun” and it is housed in the Pushkin Museum in Moscow). I stared at it for a long time, both close up and at a distance of over 20 feet. When I returned to NJ, I bought a print of it and hung it in my kitchen so I could see it every day.

When I taught high school English in Elizabeth, I discussed about 75 poems fairly in-depth. One of the poets that received repeat business was Pablo Neruda. His poem “I’m Explaining A Few Things” begins with the line “You are going to ask: and where are the lilacs?” It is devastating. Neruda is known for musing on love and nature. This poem is about the horrors of the Spanish Civil War, the destruction of Madrid and all the slaughtered children he saw. He mourns that markets of fruit & fish and the boxes of flowers that hung in Spanish windows. He cannot smell the lilacs due to the stench of gunpowder and the dead. It is a universal poem, and can be applied to current war torn regions around the world.

I returned from military duty yesterday evening to find my lilacs in full bloom. I can think of nothing better to come home to in the Spring from Army duty, where I had to take a gas mask off in a gas chamber. The scent of lilacs versus the stinging of chemical warfare training adroitly sums up the dichotomy of my life. “Where are the lilacs?” indeed.

Here are my lilacs.

There is a PDF form of this on my website as well. You can access it here.

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Policy Brief Regarding the Improvement of Services for Veterans with Substance Misuse Disorders or Veterans in Recovery on College Campuses

March 16, 2017

The Substance Abuse and Mental Health Services Administration (SAMHSA) held a two day conference in Washington, D.C. on March 13-14, 2017, that brought national college leaders together to discuss how to increase the population and improve outcomes of diverse and underserviced populations. I was brought in to facilitate the conversation regarding veterans with substance misuse disorders (as well as veterans in recovery) on college campuses. In addition to veterans, this brief also applies to military service members who attend college while in the National Guard or Reserves.

Challenges:

• Veterans often only want to associate with other veterans.
• Veterans that report having positive military experiences are far more likely to access services than veterans who report having negative military experiences. Those that report negative military experiences usually have greater need of services.
• Veterans and service members often use their military experiences as a cudgel to resist therapy and other forms of assistance by uttering lines such as “you weren’t in (or there) so you wouldn’t understand” or “unless you lived it, you can’t help me.”
• Veterans are more likely to be older and have families than traditional students. There is a lack of services for their spouses and children.
• Because they are often older, veterans and service members sometimes report feeling “behind in life.”
• A lack of coordination between veteran services and other departments on college campuses.
• Lack of housing for veterans.
• Lack of ability to identify and treat PTSD on campus.
• Military and veteran culture usually encourages and normalizes heavy alcohol consumption.
• Tuition remission, VA payments, and GI Bill moneys are frequently delayed, causing financial hardships which result in late payments to college which results in deregistering from classes
• Campus professionals have a lack of knowledge of outside services available to service members and veterans.

Solutions:

• Collaborate with veterans center or services on campus. Set up in person meetings between professional staff at least once a semester. You will need to go to them.
• Approach veterans and service members as if they are in precontemplation on the stages of change model. Provide outreach and educational training on stress and how service members often use negative ways to cope (eating, shopping, gambling, substance misuse, fighting, sex).
• Currently, 42 college and universities have Peer Advisors for Veterans Education (PAVE) on campus (paveonecampus.org). Start a chapter on your campus.
• Work with veterans services or center on campus to develop a program that supports families. Using peer support for veterans’ families is cost effective and efficient. Syracuse University has a robust program called the Institute for Veterans and Military Families (IVMF).
• Use the experiences of veterans and service members to your advantage. Encourage them to engage in your community by putting them in leadership positions, and/or asking them to be of service to other students: they can lead activities such as hikes or captain intramural athletic teams; they can help students with physical fitness; they can tutor others; they can lead service events to soup kitchens and organize clothing drives; and those in recovery can take other people to meetings.
• Offer yoga (and other services) in your wellness or recovery centers that veterans and service members can attend without signing in. Getting them into your building anonymously will expose them to your building and professionals and may lead to rapport and trust.
• Having a veteran in your college recovery community will open the doors for more veterans and service members, much like other under-represented populations in CRCs.
• Work with admissions to identify service members and veterans. Reach out multiple times throughout the school year.
• Do not allow veterans and service members with substance misuse disorders (and/or mental health disorders) to use their military experience to push away therapists and professionals. This is enabling them. One does not need to have military experience to break through their resistance, but one should get some basic training on military and veteran structure, culture, and issues. Let’s call it Military Cultural Competency.
• Have a list of on campus and off campus housing options (including for families) handy for those that need it.
• Talk to the professionals at the veterans service program (if there is one on campus) about not providing alcohol nor normalizing its use.
• Ensure the counseling and medical professionals on campus are trained in adequate substance misuse disorder and PTSD screening. Ensure that new hires are trained in these areas. Be aware of local services that screen and treat Traumatic Brain Injuries (TBI).
• Work with financial aid and the registrar’s office to smooth over financial problems that are related to delayed paperwork from military units, VA payments and late GI Bill checks. This is the most common problem that veterans and service members in college and universities complain about.
• Be aware of local and national services and organizations that can assist veterans and service members. I have compiled a list of vetted services at https://greenagel.com/for-soldiers-and-veterans/

Frank L. Greenagel II

MPAP, MSW, LCSW, LCADC, CASAC, ACSW, ICADC, CJC, CCS

Adjunct Professor – Rutgers School of Social Work

Instructor – Center of Alcohol Studies

NJ Governor’s Council on Alcoholism & Drug Abuse

1^st LT – PA Army National Guard

[email protected]

[email protected]

The Newark Star Ledger released a blistering editorial on Gov. Christie this morning. They argue that while Gov. Christie dedicated 66% of his recent State of the State address to addiction, has appeared in numerous commercials about drug treatment, and has tried to set himself up as a national figure on addiction, he has stayed silent on Trumpcare and the Medicaid rollback. Drug policy experts and the Congressional Budget Office (CBO) have stated that 1.3 million Americans were able to access drug treatment only after the Medicaid expansion that was part of the Affordable Care Act (ACA).

Gov. Christie was among a handful of Republican Governors (including John Kasich, R-OH) who decided to take the Medicaid Expansion. Last August, Gov. Christie said that “the naysayers were wrong” and that over 500,000 NJ residents became insured under the ACA, most of them from the Medicaid Expansion. When he ran for President in 2015-2016, he touted his record on drug treatment and his willingness to split from the standard Republican position of total rejection of the ACA.

President Trump, Secretary Price and Speaker Ryan recently introduced the American Health Care Act (AHCA). Mr. Trump has said, “We have come up with a solution that’s really, really I think very good,” but both moderate Republicans and Democrats have cited independent and partisan studies that state that over twenty million people will lose coverage in the next 10 years and that this will have a potentially disastrous effect on the heroin and opioid epidemic. Republican Governors such as Mr. Kasich (Ohio), Bruce Rauner (Illinois), and Brian Sandoval (Nevada) have come out strongly against the AHCA. Despite Mr. Christie’s previous praising of the ACA and Medicaid expansion and the examples set by the other Governors, he has not uttered a word about the AHCA.

Here’s the rub: it makes sense for Gov. Christie to remain quiet. He has less than a year left in office, and his best (and last?) hope for a future political position is in the Trump Administration. While there are examples in American history of a President appointing someone who blasted them, it is rare. The passage or defeat of the AHCA will not be impacted at all by Christie’s opinions. While a critique of the AHCA and the Medicaid Rollback would momentarily please newspaper editors and drug policy experts, it makes absolutely no political sense.

I value loyalty. Very highly. I have worked for a couple of excellent bosses/supervisors. We have usually marched in tune together, but there have been rare occasions in which we disagreed on some issue or policy. I never broke with them publicly (those reading this may think about all of my criticisms leveled at Gov. Christie and other politicians that I have worked with, but I have never directly worked for them). On the same vein, I have always wanted subordinates to question and even challenge me, but only behind closed doors. I very much doubt that I would hire someone who publicly challenged or attacked me on a position or issue. Nor would almost anyone else. There is much to hit Governor Christie on, but his failure to criticize President Trump is not one of them.

This article was written by Andrew Walsh. He is a grad student of mine at the Rutgers School of Social Work. This is the first of three articles that he is writing under my guidance this year.

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In response to the increased demand for substance abuse treatment, several facilities have created addiction hotlines as a means of steering clients to their facilities. Over the last two years, there has been a dramatic increase in both print and radio advertisement regarding those hotlines. These advertisements assure the viewers and the listeners that help is a phone call away. This increased focus on advertisement is a response to legislation being drafted in New Jersey that will make substance abuse treatment more accessible and provide longer stays. With the passage of this legislation, substance abuse treatment will become an even bigger business in the state of New Jersey (but to be clear, the abuses by the for-profit treatment industries’ addiction hotlines is a national problem).

To gain an inside perspectives of how these hotlines operate and the services they provide, I decided to call a few, posing as a twenty-seven-year-old individual looking for substance abuse treatment.  Every intake specialist followed a similar script:

• Seeks to befriend
• Asks about insurance
• Asks about substance use
• Diagnoses as dual diagnosis
• Asks about family psychiatric history
• Pressures to get into treatment immediately

The first hotline I came across was from a simple google search for “addiction hotline.” I was brought to a website that provided a twenty-four-hour hotline which promised free help. I browsed the website but was unable to determine which facility it was associated with. Having exhausted my search of the website, I picked up the phone. I was not prepared for what followed. As the phone rang I assumed the mindset of an individual who was struggling with alcohol addiction; scared and lost. I was greeted by an individual who identified himself as Jay. He started by asking how he could help me and why I decided to call in. I described how I was struggling with dealing with the pressures of full-time work and full-time graduate school and how my alcohol consumption had increased dramatically in recent months. Within the first two minutes of our conversation Jay was inquiring about whether I had insurance or would pay for treatment out of pocket. Upon verifying my insurance, he informed me that my drinking was not my problem, but rather that alcohol, “was not a bottle in my hand but rather Tylenol.” Jay detailed how I needed a dual diagnosis facility because I was suffering from a substance use disorder and a psychiatric disorder. Jay made this diagnosis after talking to me for less than five minutes. In the next few minutes, Jay went through questions ranging from my history of substance use to my family history of psychiatric disorders. Ten minutes after our conversation started, he was detailing the facilities that they had in New Jersey, California, Florida, Nevada, Louisiana, and Missouri. I expressed a desire to stay in New Jersey, and Jay readily assured me that this was possible. He was thrilled to hear that I was seeking treatment immediately and took my information so he could contact me after speaking with the facility in New Jersey. As our conversation ended, I asked Jay if I would be able to get in the next few days. He assured me that I would, stating, “If it was me I would start doing laundry”. Fifteen minutes after I picked up the phone, I was diagnosed as needing an in-patient stay in a dual diagnosis facility by an individual who I had never spoken to in my life before.

The next company I investigated specializes in recovery villages. Within two minutes of getting onto the website I received a live chat message from an employee. There was a message on top that stated, “Don’t wait another day. Help is a phone call away.” The message provided the hotline number to call. As I dialed the number I again assumed the mindset of an individual struggling with drug addiction. My phone call was answered by Trevor, an intake specialist. As I explained that I was calling because I was struggling with alcohol abuse, he congratulated me for having the courage to pick up the phone. Trevor quickly asked about my insurance and I provided him with the details. He then described the various locations they had facilities: Colorado, Florida, and Washington. Trevor also asked me a list of questions ranging from history of substance use to my family history. He assured me that he was only there to provide options to individuals seeking treatment and that the average length of stay was 30 to 45 days. Trevor believed that the facility in Colorado was a good fit for me and inquired if I would purchase my own airline ticket or whether I would need the facility to purchase my ticket and bill me later for it. He told me that the cost of an airline ticket would not prevent me from receiving treatment at their facilities. Trevor detailed how the staff in Colorado all had master’s degrees and were in recovery themselves. He went as far as to offer to speak to my mother to inform her of how I was struggling and needed an in-patient stay for substance abuse. Our call ended with Trevor telling me how he was proud of me for reaching out for help.

For the final program, I was on the facility website when I received a live chat message from an employee named Chris. As I was browsing the available locations, I decided to engage with Chris and inquired if they have any facilities in New Jersey. He responded that they have facilities all over the country with placement determined by the medical staff. When I told Chris that I was seeking services for myself he stated, “I am so proud of you for reaching out!” I told him that I could not talk on the phone currently but wanted to continue our conversation via live chat. After a delay, he responded that he was happy to continue. At this juncture, our conversation took a negative turn. Chris apparently forgot that I was inquiring about treatment for myself and instead continued to reference the individual looking for treatment as “he.” Chris’s focus moving forward in our conversation was solely based on my insurance coverage. He did not inquire about my substance use, about any psychiatric issues I was struggling with, or any personal information about me. Every message he sent me was about my insurance coverage. I asked Chris explicitly a second time if they had any facilities in New Jersey and he replied, “Remember, we are all over the country. Let’s leave this up to our doctor to determine the kind of care that is needed.” He then wrote, “Trust me, you are in very good hands.” I found this to be both frustrating and alarming since he would not answer my direct question, especially since I had researched the company before our conversation started and knew with certainty that his company did not have any facilities in New Jersey. Chris instructed me to call him later and our conversation ended.

From my conversations, I identified several areas of concerns:

1. Each intake specialist acted as a friend, quite often exhibiting unprofessional behavior
2. On every phone call I was relentlessly asked about my insurance coverage
3. All the intake specialists were quick to diagnosis me after only speaking to me for a few minutes (this brings up another issue: are they qualified to diagnose?)
4. During the subsequent days following my conversations I received dozens of phone calls, voicemails, and text messages regarding treatment options
5. Not only were these calls from intake specialists that I spoke with, but also from people and facilities I never spoke with

These trends underscore the take away from this exercise. Every single intake specialist I spoke with and their respective facilities viewed me as a source of revenue instead of as a person.

This exercise helped illustrate the behavior of intake specialists working for hotlines. These intake specialists are not acting illegally. Their actions and processes are an industry wide practice. Intake specialists are diagnosing over the phone after a five minute assessment without clear credentials. Interaction with the intake specialists at these hotlines is reminiscent of dealing with a used car salesperson; the client feels that they have been worked over. One last step I took was calling all the hotlines again, this time posing as a twenty-six-year-old with no insurance or money seeking substance abuse treatment. The longest phone call lasted three minutes. I was provided a referral to the SAMHSA hotline. Unsurprisingly, I have yet to receive a voicemail or a text message from any of the intake specialists looking to check in on their “buddy” now that I do not have insurance.

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Andrew Walsh, MHRM, MSW Intern, is currently pursuing his MSW and LADC at Rutgers University. Prior to returning to Rutgers, he worked in the Gulf of Mexico oilfield as an internal business consultant. Andrew is a lover of books, cuisine, and theater.

On January 10, 2017, Governor Chris Christie uttered his seventh and final state of the state address at the statehouse in Trenton. In the early years of his administration when the Governor was popular and strutted across the national stage, seats at these speeches were extremely difficult to come by. On January 6^th, Christie’s staff was still sending out email invitations in order to fill up the room (I declined)

The Governor’s approval ratings hover in the teens, and politics clearly mirrors life in this simple fact: people don’t show up to unpopular peoples’ parties (unless the food is really good).

Mr. Christie is a historically unpopular politician who is serving out his last year in office. NJ is facing a cascade of economic problems: slower job recovery than the rest of the region, declining home sales, high property taxes, crumbling infrastructure, companies moving out of state, and one of the worst cases in the country of underfunded pension obligations. Despite statements to the contrary, the Governor has been unable (or unwilling) to address those aforementioned issues (he has also overseen a record number of state credit downgrades), and they will be passed on to the next person who takes over in January of 2018.

These difficult economic issues and his resounding unpopularity may have influenced the focus of this year’s state of the state address. The Governor fell back upon a topic that he has forcefully and eloquently talked about for years: drug addiction. He spent over 2/3 of his speech discussing policies and programs around addiction and recovery (this was not historic – the Governor of Vermont devoted his entire State of the State to addiction in 2014). This is a subject that has bi-partisan support and one that can still get him positive media coverage. The day after his speech, a member of his staff sent out a self-congratulating email with links to glowing coverage from the area papers as well as the Governor’s appearance on “Fox and Friends” that morning.

To the average citizen with a cursory understanding of addiction and recovery, it appeared that Mr. Christie is a visionary with several incredible and well-meaning policy proposals. Advocates, those deeply ensconced in substance misuse policy, and other politicians know the real story, and we’ve been sharing it with various media outlets over the last three weeks.

Some of my friends and colleagues have asked me why I have been so critical of the Governor when he is finally focusing more attention on this issue. Two analogies: (1) You work very hard at a job. You put in long hours. It’s clear that you are vital to the organization. Other people of less skill and work get raises. After seven years, you finally get a 3% raise. While you are happy for the money, you think, “Why did it take so long and why so little?” (2) You do a majority of the housework in your home (more than your spouse/kid/parent/sibling). After three years, your spouse/sibling takes out the garbage and cleans the kitchen sink. Once. How much praise do you give them?

During his speech, Governor Christie announced or asked for the following:

• That he wants a bill from the legislature that mandates insurance coverage of inpatient treatment for six months. Senator Joe Vitale introduced a bill that would cover three months last September. Six months is unlikely to pass and even if it does, would be subject to a massive pushback on the state and national level by insurance companies. The Governor did not address whether or not this would apply to people on Medicaid or those without private insurance. If it did apply, it is something that the state could not currently afford.
• He announced a one-stop number for people to call about treatment – 1-844-REACH-NJ. This is redundant. On July 1, 2015, the state created and funded the NJ Addiction Hotline. That number is 1-844-276-2777. Either Governor Christie is creating a redundant program or is changing the number in order to get some press for a program that has been around for 18 months.
• He ordered the creation of a curriculum on opioids and other prescription drugs for school children of all ages. The NJ Heroin and Opiate Task Force suggested this in its report back in 2014, and the NJ legislature has tried to pass legislation regarding this for the last few sessions.
• He talked about Narcan saves, but he did not say that he would ensure that first responders received the additional funding required in order to have Narcan. Gov. Christie was slow to support Narcan, and its presence, use and expansion in this state is largely due to the front line work of advocates like Patty DiRenzo and Paul Ressler, both of whom last their sons to this epidemic.
• Christie said he would instruct his Attorney General to limit initial opiate prescriptions to 5 days. Seven day limits have passed in NY and Massachusetts in the last couple of years. This is a sound policy and a major departure from the Governor’s lack of motivation of regulating doctors (he refused to mandate the Prescription Drug Monitoring Program, require medical providers to be trained on addiction, or require doctors to warn parents of those under 18 about the dangers of opiate painkillers when prescribing them).
• The Governor did not discuss needle exchange programs, the NJ Recovery High School in Union, the importance of medication assisted therapies (and much needed regulation that would require them to be accompanied by urine screens and counseling), or the various programs that police are trying to utilize to address what happens after an overdosed person is revived.
• A few days later, Governor Christie announced the creation of yet another Task Force to study the problem. He largely ignored the report of the first Task Force (which I chaired in 2012). The co-chairs of the second Task Force were at the statehouse for his speech. Advocates, policy advisors and politicians have made the issues very clear. There are many other states that have implemented good programs and strong regulations. It is hard to fathom why we need a third Task Force.
• Perhaps most significantly, he has not commented at all on President Trump’s plan to repeal the Affordable Care Act and gut the Medicaid expansion. Thousands of New Jersey citizens were able to get access to treatment with that expansion, and many in the future will be cut off. Despite his big talk about wanting to address this issue in a bi-partisan way, the Governor has shown himself loathe to criticize the President. That isn’t leadership. Breaking with Trump and stating the very obvious fact that Medicaid expansion helped treat thousands of people (and saved a lot more money in the criminal justice system and health care) would be leadership.

Within the first year of taking office, Governor Christie supported expanding drug courts as an alternative to incarceration (which is costly and largely ineffective in addressing addiction). I was excited to hear him talk, and I believed that a Republican Governor who had been a US Attorney had a much more real shot at meaningful criminal justice reform and overhauling the treatment industry than a Democrat (who would be accused of being soft on crime, wasting tax dollars, and suffering from a bleeding heart). Despite talking about expanding drug courts, he didn’t significantly increase their funding. This is a pattern he has oft-repeated over the last 7 years. Mr. Christie is quick to talk about new laws, effective programs, tougher regulations and increased funding, but when it comes time to sign the dotted line, he hems, haws, delays and under-delivers. But by that time he has already basked in the sunlight of media attention and public adoration, and the citizens of NJ are either too busy or too apathetic to notice that he has accomplished very little.

At at little after 2 pm yesterday afternoon, Gov. Chris Christie gave his seventh and final state of the state address. After a brief review of other policies, the Governor used most of his time to address drug addiction. He appeared on the front page of papers around the state today, and received a lot of fawning coverage. Jeremy Rosen, a member of his staff, sent out an email to members of the state and national media this morning about all the positive press and highlighted Mr. Christie’s appearance on Fox and Friends this morning.

Ken Serrano of the Asbury Park Press called me immediately after the speech and asked for my opinion. His write-up can be read here. Michael Hill of NJTV news interviewed me in my home this afternoon (click here to see it). With my media appearances concluded, I wanted to write out a blow-by-blow response to Mr. Christie’s speech.

The Good

1) Mr. Christie stated that drug addiction affects kids, schools, health care, law enforcement, jobs and even your family. Agreed.

2) He said we can’t “arrest, jail, or pray” ourselves out of this problem. Agreed.

3) The Governor talked about the prison program that will open in the spring. He talked about it at last year’s address. I have heard from people setting it up that the plans are moving smoothly. I hope high hopes for this and expect that this will be his greatest legacy.

4) Mr. Christie railed against legalized marijuana and mentioned that if you legalize it, more people will use. He said that one of the biggest predictors of someone becoming an addict was starting to use substances at a young age. I am against legalized marijuana. Mr. Christie’s point about age of first use is correct. But while the Governor wants to continue criminalizing marijuana and locking people up for using it, I want to see it decriminalized.

5) He said that insurance companies must pay for up to six month of inpatient treatment and eliminate pre-authorizations and early medical reviews. New York passed a similar bill last summer. Senator Vitale recently introduced a bill covering these very issues but it only required up to three months of inpatient treatment. Gov. Christie took it further. This was the highlight of his speech. If this happens, I will stand up and clap for him and praise him on this achievement.

Taking Credit For Work Others Already Did

6) Mr. Christie announced a one-stop website and phone number for people to call to get information and find treatment. The number is 1-844-REACH-NJ. NJ already has a one-stop phone number. The NJ Addiction Services Hotline is 1-844-276-2777 and began to take calls on July 1, 2015. It has 22 full time staff members and is run by Rutgers Behavioral Health Care. Over 85% of the phone calls they have received are from people with no insurance or on medicaid. This new number is a redundancy – a true waste of tax payers’ money. When I called it today, the automated menu put me on hold. After a long wait, I told the person on the phone that I had a friend with no insurance. They referred me to the NJ Addictions Services Hotline.

7) The Governor said that 18 and 19 year olds would be considered youth when it came to mental health and addiction treatment, allowing them to get more funding and better services. Commissioner Alison Blake has been advocating and working on this plan for the last three years. It is a good idea that should have been implemented years ago. More lives could have been saved.

8) Mr. Christie said that we needed a new curriculum on opioids and other drugs for kids of all ages – different programs for kindergartners, middle school kids, and high school students. Great idea, but it was suggested years ago. The NJ Heroin and Opiate Task Force suggested this back in 2012 and included it in its paper in 2014. Last fall, Senator Joe Vitale introduced legislation covering this very thing.

9) He talked about all the saves from Narcan and how law enforcement officers around the state are administering it. This is wonderful. Governor Christie delayed the wide scale use of Narcan back in 2012. When the bill allowing for it finally passed in 2013, he did not provide funding for police departments. Grass roots activists like Patty DiRenzo and Paul Ressler pushed this issue to the forefront of municipalities and police departments and helped raise public money to train civilians and first responders on it. More lives would have been saved had Christie not delayed the release and engaged in a massive push of funding for police officers from the beginning.

10) The Governor talked about counselors helping those that have overdosed. They are not counselors, but rather Recovery Specialists. They have a little training and a small scope of practice – they meet with individuals who have overdosed and through sharing their personal stories and reducing stigma, have better outcomes at getting addicts to go to treatment. This program was created by the Ocean County Prosecutor several years ago.

11) Mr. Christie talked about the role of recovery dorms on college campuses. He said he would increase the funding for these vital programs fourfold. Senator Vitale sponsored a law that passed in the fall of 2015. It mandated that all colleges with over 5000 students living on campus must have recovery housing in the next four years. Christie signed the bill into law but did not provide funding for it. A fourfold increase does not even support the current existing programs, much less help the other schools establish this new required housing. Usually Mr. Christie likes to talk about specific numbers, but he didn’t do so in this case because the numbers are so small.

12) People without a deep knowledge of this issue were impressed by the time he gave to addiction and praised him for being out in front on this issue. Gov. Pete Shumlin of Vermont devoted his entire 2014 state of the state address to addiction and then followed through on his plans. Advocates around NJ had been begging Christie to do the same thing. It would have been more effective had he done it a couple of years into his reign when he had a 54% approval rating. He has done it much too late – his number hover around 12% and he has only a year left in office.

13) He instructed the Attorney General to issue a special rule that limits initial opiate prescriptions to 5 days. NY and Massachusetts have laws with a seven day limit on the books. We have tried to get this passed in NJ, but Democrat Herb Conway kept killing it in the Assembly Health Committee. If this actually happens in NJ, it’s great news. We asked for it ages ago. Until this happens though, I am skeptical. Big Pharma donates a lot of money to NJ politicians. 

The Horrifying

14) The Governor said that we need more sober living and recovery houses, and that he would push to deregulate them. Sober living and recovery houses are not regulated in NJ. This is a huge problem. I have fought to have these houses regulated. They need to have (a) 24/7 staffing; (b) urine tests two times a week; (c) a curfew; and (d) reasonable access to 12-step meetings and treatment. There are no requirements like this right now. There have been a number of deaths in NJ sober living houses because of a lack of oversight. The lack of regulation of sober living is such a problem that Florida has created a Task Force to shut down programs. There is nothing to deregulate in NJ. This is particularly upsetting because it is well known and has been well reported that Mr. Christie has rich friends who have made a lot of money from running half way houses for people coming out of the criminal justice system. And they have run them very poorly. I am afraid that Mr. Christie is looking to give his friends another financial windfall at the expense of the suffering.

15) Mr. Christie spoke movingly about AJ Solomon, a young man who worked in his office and had a drug problem. While I am happy for Mr. Solomon that he has found recovery, I am deeply concerned that he is opening a private treatment program next month in Camden. He is 26 years old and less than three years sober. These are the exact kind of experiences and qualifications that individuals often have when they open up the kind of for-profit facilities with problems that I mentioned in point 14. Being in recovery does not mean one has an understanding of treatment or recovery support services.

The Unmentioned

16) Needle exchange programs reduce the rate of new Hep C and HIV infections. This saves lives and money. NJ has only a few small exchanges that have survived on private funding. Gov. Christie approved $200,000 for those programs last summer. But they need to be both continually funded and expanded.

17) The Governor said he would crack down on doctors who profit off of pills and the industry that supplies them. He did not say how he would do it. He did not say he would take away medical licenses, push for fines or throw doctors or pharmaceutical executives in prison.

18) He still has not mandated the NJ Prescription Drug Monitoring Program.

19) Mr. Christie did not talk about the NJ Recovery High School. Nor has he helped raise funds for it, nor provided for it in his budget. The school has been supported by Senator Ray Lesniak, a Democrat of out of Union who has had a long-term antagonistic relationship with the Governor. That is probably why Mr. Christie has neither visited it nor supported it. He has let petty politics get in the way of helping addicted children.

 In Summation

Many of Mr. Christie’s announced policy plans are positive. But most of them have come much later than they should have – the number of overdose deaths have increased significantly under his watch, and he was advised on these issues years ago. I am concerned about whether or not these laws will be passed or if the programs will be funded (and if they are funded, will it be a one-off or will they be continually provided for). The timing is problematic. The Governor is deeply unpopular. He has no political capital and the treasury is not only bare, but horrifically in debt. Mr. Christie has a year left in office. He was quick to tout the reception of his speech on go on Fox to talk about it. It seems that he has once again fallen back on this public health issue to address his dreadful poll numbers and try to engage in a comeback. Despite my distrust of the man and his history of disappointing me, I hope that some of these policies and programs will come to fruition. But I fear that we will all be fooled again.

“Meet the new boss. Same as the old boss.” – The Who, 1971.

Yesterday afternoon I found out that a  young man that I knew quite well had died. Bobby (not his real name) had been an individual patient of mine, off and on, from 2010 through most of 2016. I’ve spent much of the last 24 hours thinking on him.

Bobby was referred to me by another therapist. That therapist started treating him when he was 17 and saw him for several years. Bobby was a very bright kid from a good family. He used substances a little bit, had a penchant for minor crimes, and often used his wit to lessen his consequences. In his early 20s, he discovered crack cocaine and his life spiraled downward. Within two years, the drugs had severely impacted the functionality of his brain. Bobby’s sharp mind had been permanently dulled. His therapist thought he should see a drug expert, but also found it brutally difficult to see Bobby in his newly diminished capacity.

I met with Bobby and his parents  during our first session. It was clear that they were kind and loving and desperate for their son. They were frustrated too. Bobby would put together a month or two of living substance free, and then would spectacularly relapse and sell his things (he went through several laptops). Bobby had been seeing a psychiatrist and was on a heavy regimen of a variety of medications. He had also begun to experience a bit of religious psychosis. Despite all of this, Bobby was able to get and maintain good part time jobs that paid well. We worked out a plan.

Bobby and I met weekly. Because of his mental state, he no longer had any friends that he hung out with. I tried to get him to reach out and engage with others, but he had little desire to and perhaps not much ability. Every session, he would ask me a very painful question: “When will my brain heal?” Despite doing significant damage to his cognitive functions, he was aware of the fact that he was changed. I refused to lie to him. I told him that he may have done permanent damage to his brain, but that we wouldn’t know for sure until he had a few years clean from drugs and allowed it to heal if it could. This would register, but he always asked me the same question the next week. It was heartbreaking.

Bobby had a kind heart. We would talk about the needs of other people. He had vast empathy for not only his family, but strangers. He eventually put together 11 months clean. He was saving money, occasionally attending 12-step meetings, and was slowly repairing his relationship with his parents. Then he disappeared for a few days. His Mom tracked him down in a dumpy motel. He expressed remorse and got clean again. He was 30 credits or so shy of a degree, so he went back to school part time (and worked part time too). He relapsed after a little more than a year. His parents cut him off and after a few months of a vagabond lifestyle, he checked himself into one of the indigent treatment centers in NJ. He got out after six months and called me up. He said he had no money but wanted to see me. I had folded up my private individual practice in order to focus on all of my other work, but I felt a deep obligation to Bobby. He offered to pay a small fee once he got a job and I agreed.

We met off and on over the next two years. We worked on a plan for meetings, exercise, family communication, work, school and in a few other areas. He would often cancel for one reason or another, and eventually I figured the best way to get him to keep his appointments was to meet him outside of his apartment. Occasionally he still cancelled. The last time I saw him was in the summer.

When I found out he died, I was not surprised but it still jolted me. My first thought was “I should have done more.” That was also my first thought when my friend Frazer overdosed and died in 2002. Then I thought about his Mom. And his Dad. And his other family members. I called his Mom an hour after I found out. I hadn’t spoken with her in three years. She told me that he had been home for the holidays and died in his sleep. She said he went peacefully. And then she started to cry. Heavily. I told her that there are no adequate words of comfort. I told her I mourned with her. I also said that I knew hundreds of parents that had lost their children, and that I would like to put her in touch with them, if and when she was ready. She thanked me and told me how much Bobby liked me. Even in this moment of ultimate despair, she was trying to soften the blow for someone else.

I’ve worked with a lot of people that have since died. Some were students, but most were clients that were in some kind of rehab or outpatient group. A man who was very dear to me died from complications around his relapse and liver cancer four years ago. That was awful (I still carry around the prayer card from his funeral). I’ve trained and supervised many therapists who have lost a patient. They always grieve the loss, and they often beat themselves up for missing something or not doing it differently. I tell them that working in mental health and addiction is brutal, and that death is horribly common aspect of our work. I tell them that it is a reminder of how limited our powers are.

When a patient was sent to prison in 2004, my first real supervisor told me that I couldn’t wear the successes and failures of my clients, because I was (a) not that powerful or responsible and (b) that I would burn out. He told me I had to focus on the process. It was my duty to listen, to educate, to inform them about resources, to model healthy communication and behavior, and to provide honest and forthright feedback. I have shared that story with every counseling student and supervisee since then. I did all of those things for Bobby. And he still died. I spent hundreds of hours with Bobby talking about the most intimate aspects of his life and mind. I liked him. I hoped and rooted for him. And now I mourn him.

I avoided the gym today because I wanted to avoid the resolution tourists that plague it on National Gym Sign Up Day. Most of the newly signed (gym general managers call them rubes but count on them to turn a profit) are long gone by the Super Bowl, but the monthly deductions from their bank accounts may last the rest of the year.

New Year’s Resolutions are not new. There is evidence that Babylonians, Romans, and millennia of Jews and Christians vowed to make changes at the start of a new year (the wikipedia article is quite interesting). If there is such a long history of resolutions and people really mean it when they make them, why do so many fail?

1) Too vague – I’m going to lose weight. I’m going to start working out. I’m going to drink less. I’m going to save money. None of these are specific. I’m going to lose 15 pounds by May. I’m going to work out three times a week for at least a half hour each time. I’m going to have five drinks or less a week. I’m going to save $500 more a month. These are much more specific. They are also measurable.

2) Too ambitious – I’m going to lose 50 pounds by March. I’m going to work out every day for at least 90 minutes. I’ll never drink, smoke, or gamble again, and I’m also going to give up sugar and caffeine. I’m going to save 40% of my gross income. Failure is not only almost certain, but probably immediate. Set reasonable, specific, and measurable goals.

3) No plan – Plans are specific and set up a course of action. If you want to quit smoking, you should talk to other people who have quit. You should investigate different medications, gums, patches, and cessation groups. You probably should avoid other smokers (when they are smoking…this is really important for anything you are quitting). You may need to carry gum (I suggest Wrigley’s) or toothpicks or a squeezey ball (to squeeze when people irritate you and you feel like smoking).

4) People don’t track/measure them – You are far more likely to succeed with exercise, weight control, saving money, planning a trip, or quitting smoking if you measure the progress of your plan. Daily. That means writing things down. In the same place (not on scraps of papers, napkins or on your phone).

5) An utter lack of support – Alcoholics Anonymous works because people are trying to make a major change with the support of other people who are either (a) just making that change themselves or (b) made the change a long time ago and offer wisdom and support. This is the major key to Weight Watchers. It is also why most people do better with a workout partner (at least early on). There will be a day (in week 2 or week 5 or month 9) where you want to give up. Or cheat a little. Having another person or group you are accountable to helps you stay on your new path.

If you do all five, you still aren’t guaranteed success. But, it will be much more likely. And here is where it gets really cool. Once you’ve changed,other people will eventually see it (in the long run) and then you can help them change too.

I am on a number of email lists and newsletters. This came to my attention this morning. I have worked in a number of fields for many years on both the micro and macro levels, and I'm often aghast at the treatment that is offered and the governmental policies that fail to direct or regulate or (at times) pay for those services. Dr. Lieberman wrote the following piece for other healthcare professionals. It was so nice to read the words of someone else so that I know that I am not alone in my frustration. I received his permission this afternoon to repost this, and I'm thrilled to pass it on to the readers of this site.
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Jeffrey A. Lieberman, MD
November 23, 2016

Hello. This is Dr Jeffrey Lieberman of Columbia University in New York City, speaking to you today for Medscape. Lately I have been feeling as though I am becoming more of a curmudgeon. I have been irritable and intolerant, and things get me more upset than they used to. But maybe it is for good reason.

I owe my current distress to several events that underscore the continued neglect, inattention to, and prioritization of issues of clear need and benefit to the American people that we have not acted upon. When I say "we," I am referring to our government, the media, the healthcare system, and even the population at large, which should demand its rightful due in the way of services, policy, legislation,
and funding.

I am specifically talking about mental health care and mental illness. Mental illness has always been neglected and given short shrift. Psychiatry and mental health care are what I call the Rodney Dangerfield of medicine—they do not get the respect they deserve. As we become more and more aware of the deleterious consequences of this, one would think corrective actions would be taken, but they
are not or they are happening much too slowly. Several recent occurrences dramatically highlighted this and, frankly, ticked me off.

Missed Legislative Opportunity

This summer, a piece of legislation that could be transformative for mental health care in the United States was finally passed by the House of Representatives. I have talked about this in previous blogs. The Helping Families in Mental Health Crisis Act, HR 2646, was initiated by Congressman Tim Murphy and Congresswoman Eddie Bernice Johnson in the aftermath of the massacre of children by Adam Lanza in Sandy Hook, Connecticut. It was meant to bring about sweeping changes in the way that mental health services are coordinated and financed by the federal government.

This bill slogged its way through the political process for 3 years; in July it was finally approved by a nearly unanimous vote of 533 to 2. The Senate version, the Mental Health Reform Act, S 2680 (formerly S 1945), is a far cry from the House bill, and if passed, it would need to be reconciled with the House bill. Unless some measures of the House bill are incorporated into the reconciled bill, the whole
exercise will not be nearly as effective as it could be.

The opportunity to pass this meaningful legislation is running out of time, and the political challenges are particularly concerning to me, not least because Congress adjourned for the election and will return afterwards only for a lame duck session. If nothing is done before the end of this Congress, then the process has to start all over again the next year. This is a missed opportunity—big time.

Agenda for Mental Health Care Ignored

On August 29, 2016, in the midst of the presidential campaign, Secretary Clinton released an agenda for mental health care. When was the last time a presidential candidate—not a president but a presidential candidate—ever released a thoughtful, potentially comprehensive position statement on mental health care? I cannot think
of any. There have been presidential commissions, but not a position statement by a candidate in advance of an election. That is noteworthy. 

The Clinton campaign released this agenda on a Monday, the beginning of the week, clearly hoping for continuing media attention during the rest of the week (in contrast to releasing something at the end of the day on a Friday before a holiday weekend, which would be buried). But what really got my dander up is that it got no attention. An August 31, 2016, editorial[1]in the Washington Post took note, saying
essentially that the Clinton agenda was released and no one was talking about it. It got next to no play in the media, which tells you how much interest the media believes the public has in this topic. Shameful.

Psychiatrists Overlooked After Hinckley Released

Ten days later, on September 10, news came that John Hinckley Jr, the would-be assassin of President Ronald Reagan, was being released from St Elizabeth's Hospital in Washington, DC. After he tried to murder President Reagan, a court found him not guilty by reason of insanity and he was remanded to St Elizabeth's, and presumably has been getting better for 35 years. He does seem fit to be released back into
society, meaning that he is better and out of danger, and whatever punitive action was intended by his mandated residence at St Elizabeth's has been accomplished.

The real issue is whether he really is better and is not a danger. I have no opinion about that because I do not know his mental status, his diagnosis, the treatment, and aftercare. In the wake of that announcement with all of the media coverage that attended it, there was commentary by lawyers, police, and criminal justice experts.
No commentary by psychiatrists was included among those opinions. Psychiatrists presumably would be an integral, if not essential part, of any consideration of how such a case should be handled given the primary question: Is he better? Does he possibly continue to be a danger? How do we ensure that he is not a danger by providing the necessary treatment? No commentary by psychiatrists. What does that
say about the way the media views this and the credibility of input from psychiatrists? Not much.

The Displaced With Mental Illness

A week later, on September 18, the New York Times published a very interesting article,[2] written by a journalist who had been stationed in Asia for the past 25 years. He and his family had finally returned to the United States and he was assigned to cover a beat in northern California. The article was about returning to
his home country and his impressions after having been away for more than a quarter of a century.

Among a number of very interesting reactions, the author's dominant impression was of walking through the middle of San Francisco and seeing the homeless on the street, including large numbers who were displaced persons with mental illnesses. He commented that, despite the poverty and the much lower level of development in the many Southeast Asian countries he covered, he had not seen the kind of human detritus strewn through those communities that he saw in San Francisco, one of the richest metropolitan areas in the world. How could this happen in a country with the resources and the level of development of the United States?

Awareness Is Growing but Policies Remain Shortsighted

In the aggregate, these four developments, occurring within a relatively short period of time, point to a social problem that has existed historically yet has not been accorded the importance and the attention it deserves. This is how our society cares for people with mental illness, provides for them in terms of mental health care, and finances the social policies that govern how mental health care is
provided and made accessible to people. Although awareness of the scope of the problem is growing in terms of the statistics, costs, epidemiology, and awareness of the consequences, particularly the burden of illness, our government does not act. This burden includes the monetary costs to society and the egregious social pathologies that crystallize in our society as a result of this neglect—homelessness, prisons crowded with persons with mental illness, rising rates of addiction, increasing demographic groups with suicidal behavior, and the mass violent incidents, some of which are perpetrated by individuals with untreated mental illness.

It is infuriating. I hate to believe that I am becoming less tolerant and that my emotional response is disproportionate to the perceived problem. I do not believe that is so in this case. I simply have an acute awareness that appreciates how self-defeating and shortsighted our policies are. Rather than be discouraged and walk away from this, throwing up our hands, becoming angry and having a tantrum, I
encourage you, as myself, to stay the course, redouble our efforts, and continue to try to make people appreciate the scientific, clinical, and social reality of mental illness. We must underscore our ability to provide evidence-based care that is effective and will reduce the burden of illness and the consequences and costs to
our society. And we must press for change.

Change will come. We will be using our ability full force to provide mental health care. The rate-limiting factor will be how quickly legislation, financing, and social policies will change. That will happen; the question is, when?

Thank you for listening.

Dr, Jeffrey Lieberman of Columbia University,

References

1.      Editorial Board. Clinton just made a very important announcement — and
hardly anyone is talking about it. The Washington Post. August 31, 2016.
https://www.washingtonpost.com/opinions/clinton-just-made-a-very-important-announcement--and-hardly-anyone-is-talking-about-it/2016/08/31/5379ddfe-6ef5-11e6-9705-23e51a2f424d_story.htmlAccessed
November 10, 2016.

2.      Fuller T. What San Francisco says about America. The New York Times.
September 18, 2016.
http://www.nytimes.com/2016/09/18/opinion/sunday/what-san-francisco-says-about-america.html?_r=0
Accessed November 10, 2016.

After a mind numbingly long 18 month election season, many of us hoped to return to a regular routine that involved less reading, discussing, and arguing about politics. Three days after the election, people are still debating the election, protesting, gloating, and generally extending what has already been an overly long process. Whether it was your candidate that won or lost, you might be more than a bit irritated with family members, friends, co-workers or facebook friends that voted for the other candidate. I have fielded a number of texts, messages, emails and calls from people that say something to the effect that “I don’t know if I can be friends with XXXX anymore.”

Very simply: you can and you should still be friends with that person (or people) in your life who voted for the other candidate. Here is a quick guide to help you get through this:

1) Spend less time on Facebook and other social media.

2) If there are people who voted for the other candidate that are gloating, arguing, complaining, protesting, attacking, or just posting a shit ton of political articles, you can unfollow them for a while. In a few weeks or months, you can refollow them as facebook returns to normal and they post annoying holiday photos of their children, write about how cold it is, share memes that aren’t funny,  promote some event that no one wants to go to, and perhaps, just perhaps, share a heartwarming story or glorious photograph.

3) Take a few minutes and recognize why you are associated with the individual in question in the first place. Don’t cast them off just yet if they meet any one of the following criteria: if you have common blood; have broken bread together; suffered through war, incarceration, early recovery, freshmen year or a terrible boss together; one of you attended the funeral of the other’s loved one; you’ve gone on vacation together; there is a picture of the two of you smiling. If they are someone that you have no connection to other than you like to collect facebook friends, then by all means, purge them from your life.

4) Focus on those above mentioned commonalities rather than your profound irritation with their horrible political choices.Throwing that relationship away as you choose to surround yourself with people who only share your worldview is the move of a small and close minded individual. The ability to listen to those that you disagree with is a good one, and will help you deal in your professional and personal relationships (particularly in romance).

5) Before you blow off point #4 with “But they are so fucking stupid and annoying,” ask yourselves what other differences in people you have accepted. For example, I really disagree with the following lifestyle choices:

(a) eating vegetables

(b) those that think Eli Manning is even close to a Hall of Fame quarterback

(c) people who give me shit for smoking cigars

(d) people who thought Titanic was a good movie

(e) anyone who follows the Kardashians

(f) tattoos

(g) dogs – they are like babies that never get better

(h) skateboarders

(i) not showering

(j) people who talk on their phone in public

(k) people who walk while looking at their phone

My curmudgeon list can get really long. I think I have a friend or a family member that believes or engages in every one of those ridiculous choices. And I still like them (and in a few cases, love them). My point is that almost all of us have accepted differing beliefs from people in our lives.

6) I have an uncle who has not talked to me for eight years because he disagrees with my politics. That was his choice, not mine. Of his four niblings (that term covers nieces and nephews), I was the one who sent him gifts most often and made a point to visit him when I was in California or he came to the East Coast. I accept the fact that he chose to end our relationship based on differing political beliefs, but I would not do that to someone else. Here is the tragedy of that relationship: other than politics, we got along really well. We like a lot of the same foods, books, movies and sports. He made me laugh and was really good to me when I was a teenager. The whole situation is sad.

(7) Over the next few weeks do some (or all) of the following:

(1) exercise more

(2) spend time with friends and laugh and don’t discuss politics

(3) go for hike in the woods

(4) plant bulbs for the spring

(5) binge watch whatever horrific shit of a tv show you like

(6) attend some kind of community event or service (religious, AA, bowling league, PTA fundraiser, etc…)

(7) Read that book you bought two years ago but never got around to reading

(8) organize your closet

(8) And if you really care about politics, then stop thinking that posting or liking articles on facebook or engaging in hashtag activism makes a difference. It doesn’t. It creates an echo chamber where you turn off those that disagree with you and are supported by those that already agree with you. Go get involved. Contact your local Republican, Democratic, Green, Socialist, Libertarian, Pirate, or Sith party and start doing real work. Pick an issue you really care about and become an expert in it. Advocate for it on the local or state level. Shit, run for office. All sides of the political map need good people.

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* This does not apply to the netherworld of Twitter. Those are horrible people.