Colorado Confluence

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There is a “liberals are hypocrites” post that is going viral among right-wing zealots on facebook, with thousands of shares and hundreds of comments on some of them, in which a news story about two African Americans who committed a violent crime against a white is, once again, proffered as proof that 1) George Zimmerman was right to pursue and shoot Trayvon Martin, 2) “Stand Your Ground” laws are good and necessary, 3) those who oppose them are trying to turn good, law-abiding (i.e., “white”) folks into unarmed innocent victims of bad, law-breaking (i.e., “black”) folks, and 4) Liberals are hypocrites because we aren’t concerned enough about black-on-white violence.

My following response, which is an expression of sheer disgust at continuing to see this ugly bigotry repeated over and over again, apparently resonating with far too many people, only addresses the first three of these issues. (The fourth can be summed up as follows: There is virtually no one defending black-on-white violence, and no laws bringing into question whether some incidents of it –or, more precisely, acts of violence by those you DON’T identify with against those you DO identify with– can be prosecuted or not. The reason the white-on-black violence of the Trayvon Martin shooting is a larger issue is because there are people defending it as a non-issue and advocating laws that make it more likely to occur more often.)

The news story (about an incident of black-on-white violence), used in this way, highlights the fundamental difference between almost all variations of right-wing ideology and almost all variations of left-wing ideology: The former is firmly rooted in fear and hatred, while the latter aspires to hope and humanity. Those on the right scoff that those on the left would be so naive, though, in reality, hope and humanity is not only a more positive orientation, but, when leavened with reason and information, is also more pragmatic, better serves one’s own self-interest, than the fear and hatred that informs those on the right. (See, for instance, Collective Action (and Time Horizon) Problems, for one reason why this is so.)

Those on the far-right are blithely indifferent to the death of an unarmed black teen at the hands of an armed white vigilante, because the armed white vigilante, in their mind, had every right to defend himself against any and all potential or perceived dangers, while the unarmed black teen lacked even the right to life, as long as it is one of them rather than the government that deprives him of it. One rationalization that is used is the presumption of guilt laid on the teen due to the possibility that he reacted violently to being pursued, something that these ideologues should respect rather than condemn, if we each have a right to protect ourselves against perceived threats! Ironically, however, they only defend the armed pursuer’s right to “defend” himself, and not the unarmed pursued’s right to do so!

If these right-wing ideologues had any integrity, any consistency, were anything other than implicitly racist hypocrits, they would not point to the possibility that Martin was beating Zimmerman before he (Martin) was shot as justification for the shooting, but rather with approval that Martin was defending himself against the armed individual pursuing him! Why aren’t they chanting that it’s a shame Martin didn’t kill Zimmerman before Zimmerman killed Martin, since it was Zimmerman who was the armed pursuer, and Martin who was the unarmed pursued?

But, of course, that’s not the way their little minds work, because it’s all about who they identify with, and who they identify as their implicit enemy. The armed vigilante is LIKE THEM, and that’s all that counts. The unarmed victim is THE OTHER that they fear and hate, and so his innocence, the fact that he had his life taken away unjustly, is just no big deal. They excuse the armed pursuer, because they identify with him (racially, and ideologically as an armed pursuer of someone he thought was a criminal); they implicitly condemn the unarmed teen to a death sentence without a trial because they don’t identify with him (racially, and as someone who someone like them was inclined to suspect of being up to no good). It’s the very nature of their way of thinking, and the reason why it should be odious to all rational people of goodwill.

What an amazingly convoluted ideology it is that does such contortions to be indignant that anyone would raise any objections to an armed pursuer shooting to death an unarmed teen apparently doing absolutely nothing illegal at the time the pursuit began, but spares no indignation whatsoever on behalf of the unarmed teen who was shot to death! The imagined threat to Zimmerman, who was both the pursuer and the wielder of deadly force in this instance, is more salient to them than the real danger to Martin, who was the pursued and unarmed victim of a shooting death!

What gets me most about this is what it indicates about how far we’ve sunk as a nation. This isn’t just a fringe ideology that a few grease-painted jack-asses adhere to. This has become a mainstream ideology, a cult of implicit violence and hatred justified by fear and generalized enmity.

It goes beyond the rationalization of offensive deadly violence by an armed pursuer against an unarmed victim, justified only by the pursuers “reasonable” fear of crime in general (!), essentially legalizing paranoid racist violence. It goes beyond conveniently targeting those “scary blacks” (as the news story used to stoke the right-wing indignation so poignantly illustrates) whose crimes justify Zimmerman acting as police, judge, jury, and executioner at the sight of a black kid in his neighborhood. It even goes beyond their assertion that there is no racism in America, that their now oft-invoked fear and hatred of those blacks who have not proven that they are not a threat isn’t racism at all, but rather merely the rational response to the “racism” of those who think that laws that facilitate killing unarmed black teens due to a generalized fear of crime are a bad idea.

It includes and goes beyond all of this. It extends to and is fed by the delusion that there is no social injustice in America, that people fare well or poorly primarily by virtue of their own merit,  a notion that is not only absurd on the face of it, but is also thoroughly disproved by statistical evidence (see The Presence of the Past). It combines a blithe indifference to the legacies of history that relegate people to sharply unequal opportunity structures at birth, with the equally blithe willingness to subtly loathe the entire categories of people who, born into such opportunity structures, are overrepresented among the poor. But irrational bigots are not swayed by such things as fact and reason and human decency.

The fact that such a belligerent, inhumane, and just generally dysfunctional ideology can survive as a major ideological strain in American culture is scary beyond belief. This cultural virus has always been with us, but never before in my memory so virulent and widespread as it is today. Anyone who has any desire for us to remain or become a rational and humane people needs to take stock of this, to repudiate it, and to oppose it, passionately and constantly, because it is truly ugly and destructive insanity.

(See the following related essays on different aspects of American racism and xenophobia: “Sharianity” and Godwin’s Law Notwithstanding.)

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As I have discussed in A Dialogue on Religion, Dogma, Imagination, and Conceptualization and Do Deities Defecate? (among other essays), what people conceptualize as “god” may well be as legitimate an object of conceptualization as “infinity,” “eternity,” and “love.” It may well be as legitimate an object of conceptualization as “consciousness,” which, indeed, it is closely related to.

As humans, we know that we subjectively experience the existence of human “consciousness.” We have minds, which, by and large, are the expression of the functioning of our physical brains, in interaction with one another and our environment. We normally conceptualize this consciousness to be an individual-level phenomenon, each of us having our own, the connection among them being tendrils of communication among separate nodes of consciousness.

But this individual-level conceptualization becomes suspect on closer examination. We think in languages, using concepts, drawing on stories and narratives and sciences and philosophies that we did not individually invent. We wield metaphors and analogies and a wealth of material that preceded our own individual consciousness, with only a very slight individuation of that cognitive material on the margins identifying our own consciousness as unique, as differentiated from the collective consciousness from which it was born and in which it is embedded. (See, for instance, The Fractal Geometry of Social Change, for a vivid description of this collective consciousness.)

So human consciousness, in a sense, is not so much individual as collective, a shared process in which our individual participation provides the robustness and creativity, but in which our collective participation defines the scope and substance. But it is still strictly “human,” right?

Few who have ever had a beloved pet would be in complete agreement with that assessment. Our family dog Buttercup is clearly somewhat “conscious,” aware of our love for her and of hers for us, communicating her desire to play, to go out, to be petted, with ease and determination. She is excited at the prospect of walking to school with my daughter, where she knows she will get to run in the park on the way, and receive affection from the other children upon arrival. She has both human and dog friends that she recognizes and greets and communicates with on a rudimentary level. She clearly possesses some degree of what humans call “consciousness.”

To explore that “lesser degree” of consciousness so clearly evident in large mammals, it’s useful to switch from the cultural (consciousness as a function of language and symbolic communication) to the biological (consciousness as an expression of genetic codes). The human mind, as an artifact of the human brain –which is an anatomical product of an evolutionary process of genetic reproduction, mutation, and competition for reproductive success– is clearly not absolutely unique. Like the individual in a society on the cognitive level, the human mind is the individuation of a biological and genetic theme. We see similarities to it among other large mammals, and even among very different animals, in some ways: when an insect scurries away from danger, the scurrying LOOKS a whole lot like fear, even if it isn’t. But maybe the resemblance isn’t completely irrelevant after all.

What distinguishes humans from all other creatures on Earth (with the possible exception of some large sea mammals) is cognitively complex symbolic communication (i.e., “language,” though the qualifier “cognitively complex” is necessary, due to the complex languages of many other creatures, such as bees, whose intricate dances indicate where the nectar is to be found). And, indeed, it is that cognitively complex language which has created the echo of genetic evolution particular to the anthrosphere: Human History (and the cultural/political/economic/cognitive evolution that defines it).

But that cognitively complex language is the product of a very slight genetic variation. We are genetically barely distinguishable from other large apes, more closely related to Chimpanzees than Chimpanzees are to Gorillas or Orangutans. So while language gives our biologically-based consciousness a particularly robust expression, it does not remove it in essence very far from our nearest biological relatives. They, too, have a nearly equal quantity of the individual-level stuff of consciousness, but merely lack the complex tendrils of communication that launch that consciousness into the societal level of development and expression.

What we see by looking at consciousness both through the lens of a cultural and human historical context, and the lens of a genetic and natural historical context, is that it is neither a particularly individual level phenomenon, nor an exclusively human phenomenon. It is, rather, something that is “out there” in the fabric of nature, finding different degrees and forms of expression in different contexts.

Neither is it any coincidence that these two lenses are both “evolutionary” lenses, one the lens of biological/genetic evolution and its products, and the other cultural/memetic evolution and its products. “Consciousness” as we know it, both in terms of the expression of the functioning of the human brain (a product of biological evolution), and in terms of the expression of the cognitive material accumulated and refined through communication among human brains (a product of cultural evolution), is an expression of evolutionary processes.

What is the exact nature of the connection between “evolution” and “consciousness”? Here’s one surprising suggestion: Both can be defined as the purposeful refinement of behavior and form in response to experience. Evolution is a process driven by the lathe of trial and error, in which the forms and behaviors (those genes in general) of living organisms are refined over time in response to relative reproductive success, preserving those that are most reproductively successful. Human consciousness is a process driven by the lathe of human experience and communication, in which those forms and behaviors (those cognitions in general) that are most copied by others are the ones that are preserved.

In fact, biologists routinely use the language and mathematics of economics to describe evolutionary and ecological phenomena. They refer to “strategies,” and employ the microeconomic tool of analysis known as “game theory” to analyze the evolution of competing biological strategies. Biologists are quick to emphasize that this is a metaphor, that there was no conscious intent behind the evolution of competing reproductive strategies, that they just “resemble” intentional human strategic action, that they just resemble “consciousness.”

But might this not be a bit anthrocentric of us? I am not disputing the recognition that biological evolution is not the intentional product of a centralized mind in the same way that human strategic behavior is (though, as I indicated above, even human strategic behavior, when involving any organization of human beings, has a decentralized element to it as well). But I am bringing into question the sharp conceptual differentiation between a process that we recognize as consciousness because we subjectively experience it, and the process that produced it that appears to be remarkably similar in form.

Might it not make more sense to conceptualize human consciousness, which is the product of evolutionary processes that envelope it and preceded it, as similar to those processes, rather than conceptualizing those preceding and enveloping processes as being similar to human consciousness? If it were not for the fact that we are human beings, subjectively aware of our own consciousness, wouldn’t it be more rational to give priority to the biological and historical progenitor of our consciousness than to its by-product (i.e., human consciousness)?

This conceptual journey began with the human individual, and panned out to identify consciousness as a function of the human collective, and then panned out futher to identify consciousness as a function of the evolutionary ecology of the planet Earth. Can we continue panning out, to see these all as nested levels of a coherent aspect of nature, that is woven into the fabric of the cosmos, and that finds different kinds of expression at different levels of manifestation?

Fritjov Capra, UC-Berkeley Physicist and author of The Tao of Physics, wrote more recently in The Web of Life, that a biological paradigm was replacing a physical one as the fundamental paradigm of Nature. The reason for this, posits Capra, is that the emerging science of complex dynamical systems (best known as “Chaos Theory”) is discovering that the kinds of processes most commonly associated with organic processes, with life, are far more widespread, far more fundamental, far more woven into the fabric of Nature, than we had previously realized. The universe and its subsystems are, in many ways, more like a vast living thing with living things nested within it, than like a dead mechanical device comprised of nested levels of mechanical components.

Even physics itself, moving toward String Theory, a mathematical model of “The Cosmic Symphony,” seems to be increasingly compatible with this view.

If it is more an organic than mechanical universe; if human consciousness can be recognized as a direct “echo” of preceding and enveloping natural processes; and if we step back in yet another way and recognize that the mere existence of human consciousness demonstrates that Nature is somehow inherently capable of producing such a phenomenon, that matter and energy can be arranged in such a way as to become “conscious,” and if we contemplate the mind-bogglingly subtle and complex coherence of the universe and its myriad subsystems, is it such a leap to conceptualize the universe itself as a conscious entity, the fabric of Nature being, in a sense, “consciousness”?

Isn’t it that primal wisdom, that neolithic recognition, that has found expression in the form of God and gods? The error is not in the conceptualization, in the use of the metaphor and the exploration of reality that it facilitates, but rather in our conceptualization of conceptualization itself. We can’t seem to make the move from recognizing that what we hold in our minds and what those thoughts refer to are never identical, that we are always reducing, simplifying reality into forms we can grasp and work with, that reality itself is always more subtle and complex than our conceptualizations of it.

We seem to have fallen into two distinct patterns of error: The religious one, in which the world and universe is conceptualized as intentionally ruled by an anthropomorphic God that thinks and acts suspiciously similar to how a human being thinks and acts; and the atheistic one, in which the world and universe is conceptualized as a dead machine in which random chance produced the otherwise unremarkable isolated phenomenon of human consciousness.

Perhaps it’s no coincidence that the ancient civilization that was most remarkable for the florescence of rational thought and subtle and insightful natural philosophies was also most remarkable for the incomparably robust and rich mythology that it produced. The ancient Greeks demonstrated that when we are most prolific and innovative in the generation of the products of the human imagination, we are most prolific and innovative in the generation of the products of human reason as well. The two are more intimately related than we sometimes realize.

So, while I believe that literary gods serve us better than literal ones, I also believe that investing in the processes of consciousness serves us better than entrenching ourselves in its ephemeral products (see, e.g., Scholarship v. Ideology, Ideology v. Methodology and An Argument for Reason and Humility). The error is not that our literal gods need to be replaced with an equally off-the-mark recognition of their literal absence, but rather that we need to refine our entire relationship to reality, understanding that our conceptualizations are just that: Conceptualizations. Our own consciousness best articulates with the consciousness of which we are a part when it does so most flexibly, most humbly, and most imaginatively. The gods beckon us to know them better by knowing less and contemplating more.

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Accessing Intensive Mental Health Services (AIMS) for Children Report:

The Co-Occurring Disorder Dilemma

Written by Steve Harvey, Esq., J.D., M.A.,

Funded by a University of Colorado Law School Judicial Fellowship

Executive Summary:

This paper addresses the widely reported but poorly documented problems in the coordination of Medicaid services for children and adolescents with co-occurring conditions with behavioral implications, including mental illnesses, developmental disabilities, autism spectrum disorder, traumatic brain injury, and fetal alcohol syndrome.

Even though the behavioral services and treatments appropriate for these conditions are often identical, the structure of Colorado’s Medicaid program is such that families must qualify for help from different providers, using different eligibility criteria, often based on an arbitrary assessment of which behavioral problems are attributable to which diagnoses. The consensus among professionals in the field is that there is no diagnostic or clinical basis for this distinction. It is an administrative artifact that leads to onerous difficulties for already overburdened families seeking services, and the potential denial of services to children who are both eligible for them and would benefit from them.

There appears to be widespread recognition of this problem among professionals and other stakeholders in the Colorado behavioral health and developmental disabilities communities. Families experiencing such obstacles most frequently report that they occur through informal denials, rather than a formal Notice of Action (NOA) that can be appealed or aggrieved.

It is the recommendation of this report that the state conduct a comprehensive study to determine the extent of the problem, what best practices should be implemented, and, if appropriate, what changes can be made to better coordinate and integrate related behavioral health services.

Table of Contents

Section One: Introduction……………………………3

Statement of the Problem…….……………………..3

Basic Overview of Colorado Medicaid and Behavioral Health Services…….4

Section Two: Statement of the Goals of the Project………………6

Section Three: Anecdotal Evidence……………………………………6

Case Study One…………………………………………………….7

Case Study Two…………………………………………………….9

Case Study Three………………………………………………..10

Anecdotal Evidence of Informal Denials (or “Non-Denial Denials”)…11

Section Four: BHO Formal Denials Data……………….12

Section Five: An Analysis of Relevant Issues…………14

Section Six: An Example of a Program That Works Well (Intercept Center)…..22

Section Seven: Possible Solutions and Recommendations………23

An Overview of Policy Goals……………………………23

A Survey of Specific Solutions………………………26

Conclusion…………………………………………………29

Methodology…………………………………………30

Section One: Introduction.

Statement of the Problem.

This report addresses a widely recognized but poorly documented gap in the provision of mental health services to children and adolescents1 on Medicaid who have co-occurring conditions with behavioral implications (which I will refer to throughout the report as the “Co-Occurring Disorder Dilemma”). Children who exhibit behavioral problems consistent with a covered mental health diagnosis, who also have such co-occurring conditions as developmental disabilities (DD), autism spectrum disorder (ASD), traumatic brain injuries (TBI), or fetal alcohol syndrome, are sometimes, perhaps frequently, formally or informally denied the mental health services to which they would otherwise be entitled.

My primary task, initially, was to determine the frequency and causes of the Co-Occurring Disorder Dilemma, and whether it required a system-wide solution. Some of the reports received by those who informed me of this problem indicated excessive administrative barriers. Some indicated poorly trained in-take personnel and misinformation given to applicants as a result. In the course of researching and compiling the report, some of the underlying dynamics of the problem became clearer, and some strategies for improving access to covered Medicaid mental health services for multiple diagnosis children and adolescents began to emerge. These strategies, as discussed in detail in Section Seven below, involve identifying the different kinds of obstacles to access involved, how they interact, and the different kinds of institutional reforms that can address them.

Cases coming to the attention of advocates and attorneys, and discussions with advocates, attorneys, providers and parents who have dealt with similar problems raised concerns that this might be a chronic, critical structural problem in the Colorado Medicaid program. In order to assess how prevalent this problem was, I simultaneously sought out quantitative data and anecdotal evidence. As discussed in the Methodology section at the end of this report, the research involved talking with stakeholders, reviewing documents, and requesting data, which was then sorted, distilled, assembled, and compiled to form this report.

The most critical conclusion that can be drawn from the evidence assembled is that some families, already burdened in extraordinary ways with children whose behavioral problems are onerous and overwhelming (often accepting this responsibility voluntarily by adopting children that others would not), are left without recourse, without assistance, and often with only desperation and frustration. They encounter a system that, to them, seems to be comprised of walls without doors. The evidence also demonstrates that this is not necessary. It is not dictated by limited resources but rather by limited imagination and resolve. Significantly superior outcomes are well within reach, outcomes more conducive to the individual and family welfare of those most directly impacted, and to our collective fiscal, economic, and social well-being.

This report examines one set of systemic problems in how we manage and provide mental health services to Medicaid-eligible children and adolescents. Nothing in this report is intended as an indictment of any individual or any particular organization, even when a critical eye is cast at the institution they represent or the incentives they are confronted with. The goal is to create systems that ensure optimal performance (including ensuring that the system most effectively selects and incentivizes the individuals within it), regardless of the particular individuals occupying particular positions at any particular time. The purpose of this report, then, is to help inform actions dedicated to realizing institutional reforms that reduce or eliminate the Co-Occurring Disorder Dilemma.

Basic Overview of Colorado Medicaid and Behavioral Health Services.

Medicaid is a federal program administered by the states that opt to participate in it (which all 50 states do), and funded jointly by federal and state governments. The Early Prevention, Screening, Diagnosis and Treatment (EPSDT) program is “Medicaid for children.” It eliminates the distinction between mandatory services (those that states must provide) and optional services (those that states may provide but don’t have to), obligating states to provide all medically necessary mandatory and optional services for all child and adolescent Medicaid clients. It also mandates a series of screening, diagnostic, and treatment protocols to ensure a higher lever of intervention and care for children on Medicaid.

Colorado Medicaid, in compliance with federal law, is overseen by a single agency, the Colorado Department of Health Care Policy and Financing (HCPF). This agency is completely separate from the Colorado Department of Human Services (CDHS), and the Colorado Division of Behavioral Health (CDBH) within CDHS.

HCPF contracts with five regional Behavioral Health Organizations (BHOs) to manage the provision of behavioral health (i.e., mental health and substance abuse) services covered by Medicaid. The BHOs are paid a “capitated” rate, determined by the number of people on Medicaid in their region, their eligibility category, and the historical trends concerning costs per person. The services themselves are provided by Community Mental Health Centers (CMHCs) and provider networks that contract with the BHOs. This managed behavioral health care system is often referred to as “Capitated Medicaid.”

The five BHOs, seventeen CMHCs, and five specialty clinics are members of an umbrella nonprofit organization called The Colorado Behavioral Healthcare Council (CBHC). CBHC represents the interests of these members.

The BHOs are contractually obligated to manage the provision of medically necessary covered services (as outlined in Exhibit E of the state’s contract with the BHOs), that carry one of the covered procedure codes listed in Exhibit F of the contract, for one of the covered mental health diagnoses listed in Exhibit D of the contract, by a provider credentialed to provide that procedure for that diagnosis (as outlined in Exhibit O of the contract).2

Diagnoses, services, and procedures not listed in Exhibits D, E, and F of the state’s contract with the BHOs, but otherwise covered by Medicaid, are considered “medical” services, and are administered separately through a system by which providers bill the state for each procedure or service according to a predetermined billing schedule. This is called “fee-for-service” Medicaid. The four major co-occurring diagnoses (DD, ASD, TBI, and Fetal Alcohol Syndrome), and most services commonly associated with them that are covered by Medicaid, are covered under the fee-for-service system.

Twenty geographically defined Community Centered Boards (CCBs) are responsible for meeting the needs of individuals with developmental disabilities and developmental delays. Various advocacy organizations, advisory councils and committees, comprised of various kinds of stakeholders (including service providers, government agency officials, managed care CEOs/EDs, advocates, and “consumers”), intersect with and overlap the formal structure described above.

Section Two: Statement of the Goals of the Project.

The original purpose of this project was to look beyond the anecdotal evidence to determine the scope, intensity, causes, costs, and possible solutions of The Co-Occurring Disorder Dilemma. But research quickly revealed that a fundamental aspect of the dilemma is the degree to which relevant data is either not collected or not aggregated and analyzed, leaving little information other than anecdotal evidence available for consideration.

Due to the relative lack of data, the project has evolved. Anecdotal evidence of the nature of the problem remained an integral component. But, rather than attempting to quantify it, emphasis shifted to an analysis of the underlying dynamics and issues involved. This analysis helps to frame consideration of the range of possible solutions, including programs currently in existence that do a better than average job of attending to the needs of multiple diagnosis children. Denials data generously provided by the Behavioral Health Organizations (BHOs) are also summarized and discussed.

This report does not address several related issues. Among them are deficiencies in funding, deficiencies in covered diagnoses and treatments, deficiencies in the availability of providers or facilities, or hospital denials of in-patient care to multiply diagnosed children in crisis. It does, however, touch upon the issue of the adequacy of training for providers and in-take personnel, since this is a crucial component of The Co-Occurring Disorder Dilemma.

Section Three: Anecdotal Evidence

Among the parents, advocates, program directors, and service providers that I interviewed, there is a widespread and deeply felt perception of a serious and pervasive problem that needs to be addressed. At a stakeholder meeting held by the Colorado Department of Human Services (CDHS), there was repeated discussion of what I am now calling the Co-Occurring Disorder Dilemma by various stakeholders and a murmur of acknowledgement by other attendees whenever it was mentioned. While popular perception of a phenomenon does not prove its existence, popular perception by professionals of a problem relating to their profession is at least suggestive and warrants due attention.

Other than such perceptions, the principal evidence for the existence of the Co-Occurring Disorder Dilemma is comprised of the personal stories of those parents of multiple diagnosis children who have encountered it. A few of those stories are recounted below.

Case Study One.

C (child) was placed in P’s (parent’s) home when C was 6, having suffered severe abuse in his birth home. His birth family, for instance, had tried to “cure” his Tourette Syndrome by pouring caustic chemicals down his throat.

C had a low IQ and was at times very violent, flying into uncontrollable rages. In one instance, he broke both the hands of his disabled adoptive father and cut his (the father’s) face with broken shards of glass. He also frequently tried to hurt himself. When not suffering such an episode, however, he had a completely different personality, and would be overcome with remorse. This was a heavy burden for P and her husband, who undertook this responsibility that few others are willing to.

Despite this pattern of behavior, and his mental health diagnoses of mood disorder, PTSD, and OCD, his BHO never authorized residential services for C, even after episodes of extreme violence. The BHO said he wouldn’t benefit from behavioral health services, that his behavioral problems were a result of his developmental disability rather than his mental illness, and that the behavioral issues were the responsibility of the Community Centered Boards (which address developmental delay issues) rather than of the BHOs.

On three occasions, once for six weeks, P managed to access the Neuro-psychiatric Special Care (NSC) in-patient and day treatment services at Children’s Hospital, an excellent but overburdened treatment program for children with dual (or multiple) mental health and developmental disability diagnoses. NSC bills as a psychiatric treatment center under capitated Medicaid (requiring a mental illness diagnosis, as C had, and a BHO determination that the behavioral problems for which treatment is being sought is a result of the mental illness, as P had to advocate for). C had received medical services related to a suicide attempt, and, due to the bifurcated billing discussed below, could not access mental health services at the same time. While in the NSC center, follow-up surgery was required, but to get it, P would have had to have C discharged from the NSC unit and readmitted on the medical side, causing C to lose his place in the NSC unit and be placed on a six month waiting list to get back in.

According to P, her BHO had told her that since C was adopted, C was social service’s responsibility, but this is only true in dependency and neglect cases. When C was 12, social services placed him in the category of “at-risk youth” or “child out of control of parents,” adding their interventions to the burdens that P was facing. Thus one of the perennial problems of bringing in social services arose: P faced a threatened dependency and neglect determination. Having adopted a child with developmental disability and mental illness diagnoses, seriously abused in infancy, showing signs of PTSD and Reactive Detachment Disorder, desperately seeking appropriate care for this child, P found herself under a cloud of presumed suspicion.

During the course of this years-long ordeal, P had to use the emergency room as an alternative to the residential care that C needed, as is frequently reported in such cases. On one occasion, she had to wait in the emergency room until a bed opened up for C, bringing her husband and plugging his ventilator into a wall socket in the emergency room, and not going to the bathroom (which would have been considered “abandonment” of the child). After all that, C was not admitted because the BHO was called and refused to cover the expense.

As numerous service providers, advocates, and family members have noted, only the most tenacious parents, who advocate relentlessly for their children, generally succeed in cutting through these kinds of obstacles. For instance, it was a threat by P to file an American with Disabilities Act (ADA) Section 504 complaint that first got the BHO to the table after continually refusing to provide mental health services.

As a result of P’s tenacity, some progress was made on the DD (fee-for-service) side. C was placed on the wait list for the children’s extensive support (CES) waiver. The CES waiver is for DD children who need 24 hour line-of-sight care, and provides about $30,000 of services, in-home behavioral support and respite care. P’s CCB used local money for people on the wait list and provided in-home behavioral support. Eventually, the Colorado Cross Disability Coalition (CCDC) got everyone at the table to kick in something for in-home care, and talked about creating a virtual residential treatment center in the home. (C passed away due to complications related to his pre-adoption abuse before this could be implemented.)

Case Study Two.

Q (parent) adopted D (child) when D was two weeks old. There were immediate neurological symptoms. D was originally diagnosed with attachment disorder. Therapy helped a little.

D was later diagnosed with Schizophrenia, “mood disorder with psychotic features,” and ASD, and received a year of day treatment. Q believes that the behavioral issues need to be treated regardless of the diagnostic labels attached to them, but relies on the mental illness diagnoses to access necessary and appropriate mental health treatments for D.

Despite the Schizophrenia diagnosis, Q’s BHO refused to provide behavioral treatments appropriate to D’s mental illness diagnosis, stating that the BHO doesn’t provide services for Autism. Subsequently, Q used D’s Schizophrenia diagnosis to obtain treatment, without disclosing that D also had ASD.

Q insists that the mere mention of the word “autism” provokes a negative response by BHOs and CMHCs. “You can almost hear the screeching of the brakes at the other end of the line.” But Q argues, as do many others (including clinicians), that Autism disrupts communication and social skills, resulting in behavioral symptoms that can be treated in the same way that behavioral symptoms associated with mental illnesses can be treated. However, Colorado Medicaid distinguishes between behavioral problems that are a result of Autism (or other developmental disabilities), and identical behavioral problems that are a result of a mental illness.

Q noted one of the most oft-cited disconnects resulting from this artificial distinction (discussed in more detail below): That Applied Behavioral Analysis (ABA) is an autism-specific treatment that has a behavioral health billing code. This means that ABA can only be accessed if the patient has a mental illness diagnosis, despite the fact that Autism (for which ABA is considered the standard of care) is categorized as a medical diagnosis. Q discussed (as did many other providers and advocates in my conversations with them) the need this imposes on parents and providers to rely on creative coding and labeling to navigate the system.

Q reiterated another frequently repeated observation: That it’s hard to imagine someone who isn’t a professional advocate, or otherwise thoroughly versed in the intricacies of the system, navigating the system. Q observed that there are three systems that have to deal with and pay for children’s maladaptive behaviors: Education, Health Care, and Juvenile Justice. Each wants to shift the burden to the others. And since Juvenile Justice is the only one that can’t deny services, too many children in need of behavioral health services end up in the Juvenile Justice system.

Case Study Three.

E (child), who is diagnosed with psychotic disorder, autism, and mood disorder, has long suffered from explosive tantrums, auditory and visual hallucinations (sometimes “advising” him to act violently), anger, obsessive behaviors, volatile mood swings, and other symptoms. E is a teen-age male, who, like C in Case Study One, poses a risk to self and others. At home, E is often aggressive and demanding, damaging property, having difficulty with personal hygiene, and in general lacking independent living skills. R (parent) was particularly concerned for the safety of a much younger sibling also living in the home.

Despite these symptoms, as in the case of C described in Case Study One, the parent and other adults who have had contact with E describe him as “a sweet kid.” They perceive the symptoms of his mental illness to be distinct from his essential character as a human being.

E was placed in a succession of out-of-classroom programs by the school district, from kindergarten onward. He has relied on outpatient therapy and medication nearly all his life. He was hospitalized several times due to his behaviors at home. The BHO refused to pay for his last hospitalization, claiming that it was not due to a covered diagnosis.

R (parent) originally sought day treatment for E, in which E could receive both mental health and educational services, which had previously proven very useful. The BHO denied day treatment for E, insisting that in-home treatment was more appropriate and less costly. E’s doctors were adamant that E needed day treatment, that it was a medical necessity. The BHO insisted that the behavioral issues were due to E’s developmental disability rather than a covered mental illness (despite the ample mental illness diagnoses), and that day treatment “wouldn’t do him any good,” despite the fact that it had done him good in the past, and that his doctors adamantly recommended it for him.

In the course of negotiations on this matter, the BHO tried to place responsibility for E’s mental health care on the school district, insisting that it was a problem for Special Education to deal with. Eventually litigation was threatened, and the BHO made some concessions to avoid it, reversing its decision regarding day treatment, but authorizing it for an insufficient length of time. R continued to struggle with the BHO over the provision of appropriate and necessary mental health services for E.

R agreed to try in-home therapy, but it has not been very successful. Due to the continuing threat to the safety of E himself and others in the household, E’s psychiatrist and his clinician both recommended residential care for E, stating that “out of home placement in a residential setting is strongly indicated . . . [T]his level of care has the potential to improve [E’s] psychiatric status and his functioning. [E] has responded best to a structured, supportive, therapeutic setting.”3 Despite these strong recommendations, the BHO refused residential care, stating that “[E’s] psychotic symptoms would not be expected to benefit from or require residential treatment level of care.”

R appealed the BHO’s decision, and received several independent evaluations confirming the need for residential care for E. In the light of this overwhelming evidence contradicting the BHO’s refusal of services, an Administrative Law Judge recently reversed the BHO’s decision to refuse residential services to E, ordering that the services be provided.

Anecdotal Evidence of Informal Denials (or “Non-Denial Denials”).

Almost all of the parents I interviewed reported similar experiences of receiving “informal denials,” either prior to, or in place of, formal ones (known as a “Notice of Action,” or NOA), which are necessary to initiate a grievance or appeal. In one particularly revealing incident, a CMHC had accidentally sent the parent the evaluating physician’s confirmation that the child had a covered mental health diagnosis and was eligible for services. But the CMHC then informally denied that child services, neglecting to send a letter of denial. Another parent reported that her CMHC refused mental health services to her child with a mental illness, who had suffered a brain injury sometime after receiving his mental illness diagnosis, because “we don’t treat medical conditions here” (implying that since a brain injury is a medical condition, all behavioral problems will be attributed to it, despite the fact that the bipolar diagnosis predated the brain injury). A BHO official confirmed this decision, showing this parent the contract, in which it is stated that the BHO is not responsible for medical problems. No Notice of Action was issued.

One parent spoke of the confusing forms, the inflexibility of in-take policies and procedures, how when laryngitis made it impossible for her to participate in a scheduled telephone call, she was kicked back to the beginning of the entire process of applying for access to services. She was not provided with information about respite care when she inquired into it. This parent, too, stated that she is not able to access services for her child if she mentions that the child has a developmental disability as well as a mental illness, without an NOA ever being issued.

Several parents, most advocates, and even many providers indicated that such informal denials occur with great frequency at various stages in the process, from intake to post-evaluation. Reports include clients being told by in-take personnel that violent behaviors by the child preclude eligibility for Medicaid covered mental health services, that such behaviors are a matter for the police and not for mental health care providers, or that network providers would have to be used but receiving outdated provider lists with disconnected numbers or otherwise inaccessible or non-existent providers. Clients (particularly adoptive parents) have also reported being inappropriately referred to social services for conditions that are Medicaid’s and not social services’ responsibility to address.

Section Four: BHO Formal Denials Data

According to the data provided to me by CBHC and the five BHOs, out of a total of 58,115 child and adolescent clients served (all children and adolescents served through the BHOs, according to Brian Turner of CBHC not just those on Medicaid or those with multiple diagnoses), there were 54 denials based on Co-Occurring Disorders (almost half by one BHO) issued by all five BHOs to no more than 49 individuals (not all BHOs indicated when multiple denials were issued to the same person) over an 18 month period. This data does not suggest a high rate of such formal denials, but three things should be born in mind: 1) We have not been provided with the relevant denominator, which is the total number of multiple-diagnosis Medicaid eligible children served, to determine what portion of those children are denied services due to their co-occurring conditions; 2) most of the personal stories related to me don’t involve the issuance of NOAs (and thus are not included in this data) but do result in denials of services, raising the question of the prevalence of “informal denials;” and 3) this is self-reported data by the BHOs that cannot be verified, and is not subject to any independent oversight.

To underscore these points, one BHO reports only 8 denials for 6 individuals during the 18 month period under consideration, though one of the CMHCs affiliated with it has a widespread and intensely felt reputation among the mental health advocates and providers I talked with for overzealous denials of services, particularly to multiple diagnosis children. (One professional, in no way affiliated with that CMHC, told me that the medical director of that CMHC has explicitly stated that he considers any behavioral problem that occurs in a child with a developmental disability to be by definition a neurological rather than a mental health problem, and thus never the result of a covered diagnosis, despite the protocol developed to ensure that such blanket denials of mental health services to children with developmental disabilities are not public policy.) Conversely, another BHO which includes a program with a stellar reputation for ensuring that multiple diagnosis children receive appropriate services, reports 11 denials of services, and gave by far the most complete and detailed information for each case of all five BHOs.

While the 54 formal denials of services to those children with co-occurring conditions, representing less than one thousandth of the total number of child and adolescent clients served, may not seem like an alarmingly high rate of occurrence, it is nevertheless a heavy burden for the families involved, and may represent a pattern of treatment toward a particular subclass of clients. Furthermore, this data gives us no insight into how many families were informally denied services, by being turned away before any official request for services was recorded.

Section Five: An Analysis of Relevant Issues

There are clearly numerous human, social, fiscal, and economic costs implicated in the failure to address this problem. The human costs borne by the individuals and families directly impacted are enormous, and well-represented by the anecdotal evidence reported above. The social costs include increased prevalence of socially maladaptive behaviors that can at times become violent or criminal in nature. The fiscal costs are typical of those borne by society when we are “penny wise and pound foolish,” failing to invest in proactive policies that reduce far larger and more cumbersome reactive costs. One simple and obvious example is the overreliance on expensive emergency room care for chronic conditions when less expensive and more effective appropriate preventative treatment is recommended. The economic costs include reduced productivity and an increased burden on our juvenile justice and criminal justice systems due to the failure to proactively address this and related problems.

In order to avoid these numerous and onerous costs, we need to meet the challenge of resolving The Co-Occurring Disorder Dilemma. The major interrelated structural problems that need to be addressed and rectified are:

1. The bifurcation of capitated Medicaid for mental health problems, and fee-for-service Medicaid for “medical” problems (which include co-occurring conditions such as developmental disabilities, ASD, TBI, and fetal alcohol syndrome), despite the fact that this distinction often segregates identical behavioral problems requiring identical treatments, distinguished only by the context in which they occur.

2. The distinction made between identical behavioral symptoms according to the presence or absence of diagnostically and clinically independent co-occurring conditions.

3. The need to align covered diagnoses (i.e., diagnoses that are covered under either fee-for-service “medical” Medicaid or capitated “behavioral” Medicaid) with covered treatments in the same silo (i.e., treatments that carry a billing code that falls into either fee-for-service or capitated Medicaid, matching the silo of the covered diagnosis). This is exacerbated by possibly overly-restrictive authorization of providers, even though clinical best practices require a more fluid matching of treatment, diagnosis, and provider according to particular confluences of circumstances.

4. The insufficient cross-training of mental health care providers in issues specific to people suffering from co-occurring conditions (particularly DD and ASD).

5. Insufficient integration of services and coordination of service providers.

6. Insufficient assistance to clients trying to navigate the confusing and convoluted behavioral health care system.

7. Insufficient tracking and oversight of formal denials of services by independent contractors paid a set fee to manage the provision of mental health care services under Medicaid.

8. Non-existent tracking and oversight of the apparently more pervasive informal denials, such as clients potentially eligible for services being told on the phone or at the front desk that they are not.

9. Insufficient training of in-take personnel, leading to an increased frequency in the occurrence of informal denials.

Structural problems 1-5, above, can be categorized as “siloing” problems. “Siloing” refers to a separation and lack of coordination among interrelated services, agencies, and procedures. Siloing is widely understood among those involved in publicly provided human services to be a fundamental structural problem, obstructing the efficient and effective delivery of services. Siloing clearly is a major factor contributing to the difficulties facing families of multiple diagnosis children and adolescents.

The first type of siloing listed above is the administrative lynchpin of the problem. Diagnostically and clinically identical maladaptive behaviors can fall into one of two administratively distinct categories: Fee-for-service “medical” Medicaid, or capitated “behavioral health” Medicaid. The latter include behaviors deemed to be caused by a diagnosed mental health disorder, and thus the responsibility of the BHOs and their provider networks to cover. The former include behaviors that are deemed to be caused by any of various co-occurring conditions (Autism Spectrum Disorder, Developmental Disability, Traumatic Brain Injury, Fetal Alcohol Syndrome), and thus the responsibility of fee-for-service Medicaid to cover.

The second, closely related, example of siloing implicated in the Co-Occurring Disorder Dilemma is the segregation of exhibited behavioral problems into those associated with a mental illness, and those associated with some other co-occurring condition. According to Dr. Judy Reaven, a child psychologist with JFK Partners at the University of Colorado School of Medicine, there is no diagnostic or clinical justification for this distinction. There is general agreement with this view among other clinicians I spoke with, such as Cory Robinson, Director of JFK Partners, and Dr. Marianne Wamboldt, Chair of the Department of Psychiatry and Behavioral Sciences at Children’s Hospital. All three agree that this is the prevailing view among clinicians.

Dr. Reaven emphasizes that there is no basis for distinguishing behavioral problems manifested by a child (or adult) with a developmental disability and behavioral problems that are symptomatic of a mental illness. Neither in terms of what we know about underlying causes, nor in terms of the efficacy of standard treatments, does such a distinction have any justification. Since there appears to be no medical basis for making such a distinction, it is an administrative artifact which serves as an obstacle to the implementation of clinical best practices, and facilitates the denial of mental health services to those who both need them and, by law, are entitled to them.

In Dr. Reaven’s words:

Related to the artificial distinction between “behavior” that is symptomatic of DD vs. a mental health condition, is that clinicians are asked to independently treat “mental illness,” and “autism or other DD” knowing full well that diagnostic complexity exists in most of the patients we see. It is nearly impossible to identify the specific symptoms that are only ASD vs. symptoms that are only mental illness. Finally – best practice would suggest that clinicians consider the whole child, as knowledge of the whole child must inform the specific treatment and modifications necessary for enhanced efficacy of the intervention. Not allowing clinicians to even acknowledge the complexity of patient’s presentation in many cases can lead to a superficiality of treatment.

Related to this is a phenomenon known as “diagnostic overshadowing” (coined by Steven Reiss in 1983), a tendency to disregard the diagnostic indicators if behaviors can be attributed to a developmental disability instead of to the mental illness diagnosis consistent with the behaviors, even though the presence or absence of the developmental disability is generally not diagnostically relevant. Again, in Dr. Reaven’s words:

Diagnostic overshadowing refers to the tendency to attribute behavioral challenges and mental health symptoms in an individual with DD or ASD, solely to the developmental disability or ASD, rather than assign an additional mental health diagnosis, even if the symptom presentation are all consistent with such a diagnosis; in other words, mental health symptoms are “overshadowed” by the DD/ASD and as a result are not appropriately identified or treated.

While co-occurring conditions can be clinically relevant, just as any number of other contextual factors can be, their presence does not generally imply that the use of standard mental health treatments and therapies will be ineffective, only that such treatments need to be adapted appropriately to the needs of the individual child, as is always the case. So, for instance, if a child has a developmental disability that affects his or her ability to communicate verbally, this is a factor that must be taken into account, not a factor which renders irrelevant the child’s mental health treatment needs.

According to the 2011 Ombudsman’s Report, BHOs do (and are contractually authorized, perhaps required, to do) precisely what Dr. Reaven described above as impossible and irrelevant to do: differentiate between similar behaviors as in some cases an artifact of a developmental disability and in other cases an artifact of a mental illness. According to the report, regardless of the diagnoses that exist, there is “a reluctance on the part of plans to approve treatment services for behaviors that may be caused by a medical diagnosis (autism or traumatic brain injury) which are then exacerbated by mental health conditions, or vice versa” (emphasis added). The key phrase above is “may be,” because, while the BHOs are contractually empowered to make such distinctions, they are rarely diagnostically or clinically justifiable.

Marceil Case of the Colorado Department of Health Care Policy and Financing (HCPF), the state agency which oversees Colorado Medicaid, stated at one point, in an interview with me, that if the BHOs determine that there is a mental illness diagnosis, then the BHOs are responsible for covering behaviors that are associated with that diagnosis, regardless of whether the client has a co-occurring developmental disability. The ambiguity of this statement sheds some hazy light on the nature of the problem, because the determination to provide or deny services hinges on whether the BHOs determine that the behavior meets the higher threshold of being caused by the diagnosis, rather than the more clinically meaningful threshold of being consistent with the diagnosis.

In fact, BHOs are authorized (perhaps required) to deny services for behaviors “associated with” a covered mental health diagnosis, if the BHO asserts that the behaviors are the result of a co-occurring condition rather than of the covered mental illness. Given that making such determinations reduces costs incurred by the BHOs, that such determinations can be and are at times made in opposition to clinical recommendations, and that such determinations are not automatically reviewed, it is economically axiomatic that such determinations are likely to be made excessively.

But even were the clinically more relevant criterion relied on, that any behavior requiring treatment that is “consistent with a covered mental health diagnosis” be covered, it still would leave open a large loophole through which services can be denied: It is left to the BHO’s discretion to determine whether such a mental health diagnosis actually pertains, a determination not bound even by what their own CMHCs or independent mental health providers may say. Therefore, the BHOs are free to claim that a behavioral problem exhibited by a child with a developmental disability is the result of the developmental disability rather than of a mental illness, even if that child has been clinically diagnosed with a mental illness, and even if they were obligated to provide services for anyone they deem to have a covered diagnosis (which is not currently the case). In practice, the BHO has complete discretionary power to determine whether the child has or does not have a covered mental health diagnosis. And, again, such determinations are not subject to automatic review.

In other words, the BHOs have complete discretionary authority to determine, independently of clinical recommendations, both whether a client exhibiting behaviors consistent with a covered mental health diagnosis actually has that diagnosis, and whether, if so, the exhibited behaviors are the result of that diagnosis. (The decisions can be appealed by the client, but the nature of the problem at hand is, in part, that there are so many obstacles strewn in the paths of clients. There is such a maze of bureaucratic hoops to jump through, that already overburdened parents and guardians seeking behavioral health services for their multiple-diagnosis children find themselves forced to become assertive self-advocates. As a result, they must either dedicate considerable time and effort that they can ill-afford, or fail to obtain services to which they are entitled.)

The third type of siloing listed above requires that only therapies that carry a billing code associated with one or the other of the two administrative silos (capitated or fee-for-service) are administered only for diagnoses that are covered under that same administrative silo. In other words, a therapy coded as a behavioral health treatment cannot be used for a diagnosis whose billing code is fee-for-service, even if that therapy is the standard of care for that diagnosis. This administrative requirement obstructs rather than facilitates clinical best practices: Appropriate and covered therapies should be provided for appropriate and covered diagnoses, by any qualified and competent service provider.

The consequences of failing to allow any covered therapy to be provided by any authorized and qualified behavioral health provider for any covered diagnosis is to effectively deny covered services for covered diagnoses to eligible recipients; to reduce the quality of care to many of those who do receive services; and to force frustrated providers to work around these arbitrary obstacles by making a mockery of the labels that impose them in the first place.

Brian Tallant, the program director at Intercept Center (a joint program between Aurora Mental Health Center and Aurora Public Schools discussed below), offers the following example of this problem:

Best practices for the treatment of Autism is a combination of Applied Behavioral Analysis (ABA), speech/language therapy and occupational therapy. ABA is considered a behavioral health service, and typically has a behavioral health CPT (Current Procedural Terminology) code that corresponds to that service. Speech/language therapy, as well as occupational therapy, are medical services and have corresponding medical CPT codes. Capitated (Behavioral Health) Medicaid has a list of covered psychiatric diagnoses, but excludes Autism as a neurological or medical condition, and therefore ABA interventions are not authorized based on the diagnosis of Autism. If a clinician provides ABA services under the diagnosis of Autism, and tries to bill medical fee-for-service Medicaid for ABA services, using behavioral health CPT codes, it is often rejected as being a “behavioral health” service, which should be covered by Capitated Medicaid. So you see how a child with Autism is caught between a system that excludes their behavioral treatment either by diagnosis (Capitated Medicaid), or by service code (medical fee-for-service Medicaid).

Brian Tallant describes how the provider is also caught up in the siloing of particular treatments for a particular diagnosis:

[T]he problem mostly rests with Applied Behavior Analysis (ABA), or other “behavioral” services, that are provided by a professional that has more of a behavioral health training and/or certification. These professionals can provide services that are best described by behavioral health service codes (ICD-9 codes), when they are authorized and approved for treatment of a covered diagnosis under capitated Medicaid. If a person has a medical diagnosis (excluded mental health diagnosis), such as autism or TBI, the behavioral therapist does not have medical ICD-9 codes that allow for billing under fee-for-service Medicaid. Behavioral services codes are rejected by fee-for-service Medicaid as being “behavioral health” services, even though they are qualified to provide those services, and they are treating a medical condition.

While this may be little more than a restatement of the problem of having to align covered diagnoses and covered treatments under a single silo, it draws attention to the fact that a provider fully qualified to provide the treatment that represents best practices for a given diagnosis may be prohibited from providing that treatment, simply as a result of how the treatment is coded.

The fourth and fifth types of siloing listed above involve the siloing of expertise, both by a lack of cross-training of service providers, and a lack of coordination among service providers. Due to a lack of cross-training, clinical assessments are made by service providers who may not understand the relationships between, for instance, developmental disabilities and mental illnesses, and thus make diagnostic and clinical judgments that are only partially informed. Due to the lack of coordination among service providers, clients seeking services in one silo may not be directed to services appropriate for them offered in another. This siloing of expertise exacerbates the interacting dysfunction of the first three administrative forms of siloing by reproducing and reinforcing it at the level of service provision.

The final four structural problems listed above are not siloing problems, but are rather problems in assistance to clients and oversight of managed care providers. They interact with the five siloing problems by leaving clients to fend for themselves in a system posing numerous obstacles to their ability to access appropriate services.

Many parents of multiple diagnosis children who are also knowledgeable advocates for the interests of multiple diagnosis children note that no one who is not a trained advocate could possibly hope to navigate this convoluted and obstruction-strewn system effectively. The anecdotal evidence is rife with stories of parents being misinformed, misdirected, and given a general run-around, while dealing with the other onerous burdens of raising developmentally disabled and mentally ill children. Clearly, this nightmarish maze that such parents must try to negotiate, against obstacles both intentional and unintentional, is a major part of the problem with how this system functions…, or fails to.

This bureaucratic labyrinth, which serves interests other than those of the clients who need to access the system, is left largely unchallenged due to a lack of administrative resolve and oversight. No state agency or advocacy organization is tracking formal denials of mental health services other than the independent (two nonprofit and three for-profit) contractors that have a financial incentive to deny them. No state agency or advocacy organization is extracting and analyzing information about the reasons given for denials in cases that are aggrieved or appealed. No state agency or advocacy organization is attempting to systematically track or assess the apparently far larger problem of informal denials, in which applicants are obstructed from accessing services to which they are entitled in ways that do not result in a formal Notice of Action (NOA). The first step to remedying the Co-Occurring Disorder Dilemma is to rectify this glaring lack of data collection and administrative oversight, and the enabling lack of sustained, focused advocacy insisting on such data collection and oversight.

Clearly, the imposition of new administrative burdens is not to be taken lightly. But the glaring deficiency in this case suggests that perhaps the current distribution of administrative burdens is not optimally targeted.

Section Six: An Example of a Program That Works Well

Intercept Center

Intercept Center is a joint program of Aurora Mental Health Center and Aurora Public schools, established in 1995, to accommodate the educational and behavioral health needs of Medicaid-eligible children from ages 5 to 21 with both a covered mental health diagnosis and a developmental disability. Aurora Public Schools provides the building, special education teachers, paraprofessionals, instructional materials, and itinerant special education staff and services, while Aurora Mental Health Center provides the mental health treatment services and personnel. Aurora Mental Health Center and Aurora Public Schools are currently putting together a Memorandum of Understanding to more fully formalize this joint venture.

Intercept Center operates as both a school and a day treatment center, with students receiving both their educational and behavioral health treatment needs in one location and under the auspices of one program. Intercept Center also functions as an intensive services outpatient clinic for multiply diagnosed children in the Aurora area. The relative success of Intercept Center in reducing or eliminating the gap in services encountered by many multiple diagnosis children on Medicaid is due, in large part, to the training of the mental health service providers there, and the assertive coordination with other facilities and programs to accommodate needs that fall beyond the parameters of the services that Intercept Center provides.

The success of such a program requires the willingness of the overarching Behavioral Health Organization (in this case, BHI), to permit a more rather than less inclusive determination of eligibility for services, and the stewardship of a program director (in this case, Brian Tallant) committed to ensuring that applicants receive any and all services to which they are entitled, whether under the auspices of this program, or through another service provider more appropriate to that particular child’s needs. Unfortunately, under our current overarching system, the satisfaction of these two necessary conditions is the exception rather than the rule.

While Intercept Center does not currently bill fee-for-service Medicaid to provide (“medical”) services that are not covered under capitation (“mental health services”), it does coordinate with providers who do. Aurora Mental Health Center is contemplating expanding the Intercept Center program to provide behavioral services that are covered under fee-for-service Medicaid, as well as the behavioral services that are covered under capitated Medicaid.

Intercept Center does not provide residential services, but has a close relationship with Smith Agency, which is a child placement agency for foster care, and the provider of Serenity Group Homes and Serenity Learning Center. Intercept identifies children who need residential treatment, informs parents of the procedures to go through and of the various options available to them. In one case, Intercept assisted foster parents in expanding their business into a group home, which they wouldn’t have been able to do without Intercept’s support and guidance. Intercept Center providers also go into Residential Child Care Facilities (RCCFs), which serve children with developmental disabilities, to provide certain mental health services on-site (particularly, capitated Medicaid-covered individual and group therapies), but children in RCCFs must come to Intercept Center for medication to be administered.

Intercept Center is evidence of the fact that it is possible to design and implement a relatively well-functioning model under the auspices of Colorado’s current Mental Health Medicaid system, but also, in its exceptionalness, of the fact that such models are not the inevitable by-product of that system. To the extent that we continue to operate within current parameters, one immediate goal is to ensure that the Intercept Center model is replicated as widely as possible. To the extent that we change those parameters, one intermediate goal is to ensure that the lessons of Intercept Center inform systemic and mandatory changes.

Section Seven: Possible Solutions and Recommendations

An Overview of Policy Goals

The principal recommendation of this report is that the relevant governmental agencies systematically research and remedy The Co-Occurring Disorder Dilemma, with persistent resolve and unflagging determination. Since this has not yet happened, and there is no evidence of it spontaneously occurring, the secondary recommendation is that all relevant advocacy groups place sustained, informed pressure on those governmental agencies and office holders to do so. The State of Colorado needs to commission a comprehensive study, incorporating data that either currently does not exist or cannot be accessed, and, based on that study, design and implement an affirmative plan to rectify the obstacles to access to mental health services faced by children and adolescents with co-occurring conditions.

The state has a number of options for addressing and rectifying the major interrelated structural problems listed in section five, above. We need to design and implement a set of policies which:

1. Eliminates the effect of bifurcation of Medicaid into capitated and fee-for-service enclaves, either by (ideally) eliminating the bifurcation itself or (more practically) perforating the wall between them sufficiently that it ceases to obstruct the diagnostically and clinically appropriate and necessary provision of services.

2. Eliminates the effect of administrative (diagnostically and clinically unjustifiable) segregation of identical behavioral problems according to whether they are administratively deemed to be the result of a mental health diagnosis or some co-occurring condition.

3. Eliminates the need to align providers, diagnoses, and treatments under one or the other of the two Medicaid silos described in numbers 1 and 2, above. This primarily involves eliminating the need to provide only behavioral therapies and treatments with a billing code that corresponds to the silo (either fee-for-service or capitated) that the behaviorally related diagnosis is covered under. A more flexible system is needed to ensure that any covered treatment for any covered diagnosis can be provided by any competent and qualified behavioral health service provider.

4. Ensures that behavioral health providers are appropriately cross-trained to know how to effectively diagnose and treat co-occurring developmental disabilities and mental illnesses.

5. Ensures the integration and coordination of services and service providers.

6. Ensures the shifting of the burden for navigating the complex and confusing behavioral health care system away from overwhelmed clients often poorly equipped to take on such a challenge, and onto designated and adequately trained personnel within the system itself.

7. Ensures comprehensive tracking and analysis of denials of services by responsible governmental agencies, and the exercise of adequate oversight of the BHOs contracted to manage the provision of covered services to those who are entitled to them. (The bureaucratic burden of doing so must be taken into account, and a careful cost-benefit analysis pursued, but it is clear that we currently have a sub-optimal level of such tracking and analysis in place, essentially “leaving the fox in charge of the henhouse.”)

8. Ensures a dedicated investigation and rectification of informal procedures by which services may be denied without any formal request for services ever being recorded, and thus no formal denial ever being issued.

9. Ensures that in-take personnel and other gate-keepers are adequately trained to record and follow up on all requests for services, to turn no one away on the basis of any peremptory assumption that clients seeking services are not entitled to services.

The structural factors and associated policy goals listed above fall into three categories: Gateway Problems (6-9), Service Provision Problems (4-5), and Underlying Structural Problems (1-3). The Gateway Problems are problems at the point of interface between clients and the mental health care system. They involve insufficient oversight of the formal and informal ways in which clients are refused services (7 and 8, respectively), and insufficient guidance and inaccurate information provided to clients seeking services (6 and 9, respectively). The Service Provision Problems are problems that affect access to services by dispersing rather than consolidating service provider expertise. They involve insufficient expertise regarding multiple diagnosis issues within individual service providers (4), and insufficient coordination of expertise among service providers (5). The Underlying Structural Problems are problems embedded in the administrative structure of Colorado Medicaid. They involve, collectively, an incongruence between the administrative structure for the delivery of mental health services, and the clinical reality of the delivery of mental health services.

Specific strategies for addressing the Co-Occurring Disorder Dilemma involve addressing specific combinations of the above policy goals for specific purposes. For instance, as Intercept Center’s success illustrates, by addressing the Service Provision Problems and one Gateway Problem -numbers 4, 5, and 9- local programs can dramatically reduce the Co-Occurring Disorder Dilemma on their own initiative (and with the support of their BHO). By concentrating and coordinating expertise in both mental illness and developmental disabilities, and ensuring that there is an open gateway to that consolidated expertise, a local program can distinguish itself even in the context of the other six unresolved structural problems.

Numbers 4, 5, and 9 can be addressed proactively, by any BHO or CMHC that chooses to take the initiative. Thus, significant local improvement in the provision of services to multiply diagnosed children can be accomplished even in the absence of statewide public policy changes. However, a sustainable and reliable statewide paradigm shift will almost certainly require overarching public policy refinements. And even such relatively successful local programs as Intercept are limited in the degree to which they can effectively address the Co-Occurring Disorder Dilemma by a lack of facilitating statewide policies.

The remaining Gateway Problems and related policy goals, 6-8, suggest a second strategic avenue comprised of direct advocacy for immediate and easily implemented administrative reforms. These do not require any major structural changes, simply superficial changes in policy that, for instance, provide clients seeking services with personnel competent to guide and inform them, and implement more diligent administrative oversight of the mental health managed care system.

Finally, the far-reaching statewide administrative structural changes conducive to eliminating or reducing the Co-Occurring Disorder Dilemma are summarized in numbers 1, 2, and 3, above. These would require significant legislative and administrative action, and are thus higher hurdles to clear. Progress on Underlying Structural Problems neither requires nor is a requirement of progress on either Gateway or Service Provision Problems. Long-term structural strategic goals and short-term immediately ameliorative strategic goals can be pursued independently and simultaneously.

A recommended comprehensive strategy for those who choose to act on this report, therefore, is to seek immediate widespread, either centrally directed or CMHC by CMHC, implementation of 4, 5, and 9, while simultaneously working toward both the superficial administrative policy changes suggested in numbers 6, 7, and 8, and the eventual implementation of long-term policy goals 1, 2, and 3.

A Survey of Specific Solutions

This section briefly examines examples of three different kinds of approaches to addressing The Co-Occurring Disorder Dilemma: 1) a broadly applicable and assertive social institutional approach (Medical-Legal Partnership), 2) a managed care-level administrative approach (Expanded BHO Contract), and 3) a flexible and accommodating provider-level administrative approach (The Medical Home Model). These three approaches are not mutually exclusive; they can be combined in part or in whole to form a comprehensive strategy for addressing The Co-Occurring Disorder Dilemma.

Medical-Legal Partnership: Medical-Legal Partnerships (MLPs) involve integrating lawyers into the health care team available to clients, to address the non-medical factors affecting their health. As The National Center for Medical-Legal Partnership (NCMLP) puts it:

Medical-legal partnership (MLP) is a new patient care model that aims to improve the health and well-being of vulnerable individuals, children and families by integrating legal assistance into the medical setting. MLPs address social determinants of health and seek to eliminate barriers to healthcare in order to help vulnerable populations meet their basic needs and stay healthy.4

One form of MLP is the inclusion of lawyers on a health care provider team to address exacerbating conditions that health care providers are neither qualified nor empowered to address, such as mold-infested housing aggravating the condition of an asthmatic child, or lack of food and heat creating health risks that cannot be resolved through medical treatments alone. In a sense, this is another reduction of “siloing,” such that the various kinds of circumstances that combine to create or exacerbate medical problems can be addressed in tandem with the medical treatment itself.

More generally, a Medical-Legal Partnership is the combination of advocacy and medical treatment, so that patients’ rights are protected in service to the provision of adequate health care that is not divorced from the broader social institutional context in which it occurs. As the above quote from the NCMLP website illustrates, such legal advocacy integrated into the “medical setting” could serve a vital role in placing sustained pressure on Colorado Medicaid’s administrative apparatus to address and resolve the structural defects that result in The Co-Occurring Disorder Dilemma. More broadly, the establishment of Medical-Legal Partnerships throughout Colorado’s health care system would provide institutionally integrated patient advocacy to address all such problems as they arise.

In the present context, a Medical-Legal Partnership would involve an alliance of behavioral health care providers and legal advocates working together to ensure that their clients receive the full range of behavioral health care services to which they are legally entitled, and to ensure that the services received are accessible, coordinated, and appropriate.

Expanded BHO Contract: One possible solution to the difficulties faced by families of multiple diagnosis children, favored by the Colorado Behavioral Healthcare Council (CBHC, the umbrella organization for the BHOs), would be to expand the state’s contract with the BHOs to include in their mandate responsibility and compensation for providing all covered services for all covered behaviorally related diagnoses, whether currently categorized as mental illness or in some other way (such as a by-product of a developmental disability). Another, similar solution would involve authorizing and equipping BHOs and CMHCs to provide all behavioral services, some covered by capitated Medicaid, and some charged to fee-for-service Medicaid, according to their billing codes. These solutions would address some of the factors contributing to the current systemic deficiency, but would leave many of the other contributing factors intact. As such, they are, at best, partial solutions.

Some advocates are concerned that these solutions would merely perpetuate the problem in a new guise, since the BHOs, intended as cost reducing intermediaries, are incentivized to deny services whenever possible. This may be a legitimate concern, but, when coupled with the Medical-Legal Partnership approach described above, the added vigilance thus provided might help to mitigate and counterbalance any overzealousness to deny services on the BHOs’ and CMHCs’ part. This combination might be a robust way to institutionalize, as a permanent feature of the Medicaid behavioral health landscape, a vehicle for negotiating the inherent tension between efficiency (i.e., cost-cutting) and protection of patients’ rights.

Medical Home Model: The Medical Home Model (sometimes called “patient-centered medical home,” or PCMH) involves a centrally coordinated, continuous and comprehensive system of care led by a primary care physician. Intercept Center (described above) incorporates some elements of the Medical Home Model, in which the program director coordinates with other service providers to deliver coordinated and comprehensive care (and educational services) to children in the program. As discussed above, using Intercept Center as an example, the Medical Home Model is most adept at addressing issues 4, 5, and 9 (cross-training of service providers, coordination and integration of services, and better assistance to clients in navigating the system). The Medical Home Model is often considered the best way to keep children with mental illnesses, developmental disabilities, and Autism Spectrum Disorder in the least restrictive environment, and provided with the most comprehensive and appropriate treatment plan.

In the context of reducing the effects of siloing in Colorado Medicaid’s delivery of behavioral health services, the Medical Home is a potentially essential partner to higher level solutions. If, for example, the BHOs’ contract were to be broadened to include management of care for all behaviorally related conditions, the Medical Home would be the ideal vehicle for coordinating and integrating that care. Thus, in one possible integration of these three approaches, the Medical-Legal Partnership could hold the BHOs accountable, while the Medical Home could implement their comprehensive mandate on the ground.

Conclusion

A combination of inherent financial incentives, excessive discretionary power by independent contractors, inadequate oversight, inadequately trained personnel, and inadequate availability of mandatory services helps to produce the gap in services experienced by children and adolescents with multiple mental health and developmental disability (or other “medical”) diagnoses. An administrative structure comprised of siloing in multiple, interacting ways (in terms of diagnoses, treatments, providers, and billing) obstructs rather than facilitates the coordination of services. And a lack of resolve among responsible agencies has left this problem largely unaddressed.

Previous attempts to close this and related gaps have proven insufficient. Protocols for clients with co-occurring DD and MI diagnoses, and co-occurring TBI and MI diagnoses, have done little to solve the problem. The Child Mental Health Treatment Act (CMHTA, or “HB 1116”), designed to provide access to residential treatment services without recourse to Social Services (which generally requires a Dependency and Neglect action, exposing parents to the risk of losing custody of their children in order to access vital services), has too often simply been disregarded or misunderstood. General awareness of the Co-Occurring Disorder Dilemma is widespread among advocates, affected clients, and individual service providers, but sustained pressure to resolve it has not yet been applied.

This difficulty in accessing necessary services, sometimes essential to the safety of the affected child and others in the child’s household, imposes an onerous burden on families already overburdened with the challenges of caring for children with multiple mental health and developmental problems. Solutions exist and can be implemented, ranging from the local and partial to the systemic and far-reaching. It is incumbent on all stakeholders to do their part to ensure that these solutions are implemented.

Methodology

The research for this report consists primarily of meetings and conversations with 1) parents who have had difficulties accessing mental health services for their multiple diagnosis children; 2) professional advocates for those with mental illnesses and developmental disabilities (frequently also parents of mentally ill or developmentally disabled children); 3) the executive director of an advocacy organization for adoptive families (adoptive families being disproportionately impacted by this problem); 4) Mental Health program directors and service providers; and 5) governmental agency officials and contractors.

Among the governmental agency officials, nonprofit executive directors, advocates and service providers I interviewed, met with, or corresponded with in the course of researching this issue are Marceil Case (HCPF Mental Health Specialist), George DelGrosso (Executive Director of CMHC), Brian Turner (CMHC), Janine Vincent (Ombudsman for Colorado Medicaid Managed Care), Julie Reiskin (Executive Director of Colorado Cross-Disabilities Coalition), Mary Ann Harvey (Executive Director of The Legal Center), Pat Doyle (Rights Advocate at The Legal Center), Deborah Cave (Executive Director of Colorado Coalition of Adoptive Families), KimNichelle Rivera (Outreach/Research Coordinator for Empower Colorado), Judy Reaven (Clinical Psychologist and Director of the Autism and Developmental Disabilities Clinic at JFK Partners, an interdepartmental program of Pediatrics and Psychiatry at University of Colorado School of Medicine), Cordelia Robinson (Director of JFK Partners), Betty Lehman (then Executive Director, Autism Society of Colorado), Marianne Wamboldt (Chair of the Department of Psychiatry and Behavioral Sciences at Children’s Hospital), Brian Tallant (Program Director, Intercept Center, Aurora Mental Health Center), and Sarah McNamee (Early Intervention Service Provider, LCSW).

Among the documents I reviewed while preparing this report are the BHO Contract with the State of Colorado; the Ombudsman’s reports for 2009-2011; the written criteria for BHOs to follow in the treatment of co-occurring mental health diagnoses and traumatic brain injuries; the written criteria for BHOs to follow in the treatment of co-occurring mental health diagnoses and developmental disabilities; a 2009 Primer on the mental health safety net published by the Colorado Health Institute; a 2011 updated report by The Mental Health Funders Collaborative on “The Status of Mental Health Care in Colorado;” a 2004 Urban Institute report on “Access to Children’s Mental Health Services under Medicaid and SCHIP;” a 2008 Department of Health and Human Services Inspector General “Review of Colorado Medicaid Mental Health Capitation and Managed Care Program;” a 2009 DBH and WICHE Mental Health Program “Population in Need” study; a 2008 report commissioned by HCPF on “Colorado’s Medicaid Mental Health Services Program: Issues & Future Direction;” “The Maze,” a 2009 report by Colorado Covering Kids and Families on barriers to access to Medicaid and CHP+ faced by eligible children and families, with a recommendation for streamlined access; some working papers on the clinical issues involved; and various provider and advocacy group newsletters.

Requests for both qualitative and quantitative data regarding the Co-Occurring Disorder Dilemma were made to the Colorado Department of Health Care Policy and Financing (HCPF, the single agency which oversees the Colorado Medicaid program), the Colorado Ombudsman for Medicaid Managed Care, various advocacy groups, and the five Behavioral Health Organizations.

With the exception of the five Behavioral Health Organizations (BHOs) themselves, no one was able to provide any hard data on the prevalence of The Co-Occurring Disorder Dilemma. The various advocacy groups contacted were unable to provide any relevant data other than the shared impression that The Co-Occurring Disorder Dilemma is a pervasive problem. HCPF, in response to a CORA request, provided raw grievance and appeals reports which contained no information relevant to the issue at hand. The Ombudsman did not follow up on an offer to send me relevant data.

With the assistance of George DelGrosso and Brian Turner of the Colorado Behavioral Healthcare Council (CBHC), four of the five BHOs contracted by the state as managed care providers for Colorado Medicaid supplied me with data summarizing the reasons for all of their formal denials, resulting in a Notice of Action (NOA), over the last fiscal year and the first half of the current fiscal year, to child and adolescent Medicaid clients with multiple diagnoses. (Access Behavioral Care, the fifth, provided only the raw number of denials -25- for the 18 month period reported on, and no other information. I was assured that this was due to technical difficulties and not a desire to withhold the information. The CEO of ABC, Rob Bremer, conveyed his willingness, through Brian Turner of CBHC, to work with me one-on-one to fill in that information if I so desired.)

1 For the remainder of the paper, “child” and “children” includes infants through adolescents, until age 21.

2 For the BHO contract and exhibits, see http://www.colorado.gov/cs/Satellite?c=Page&childpagename=HCPF%2FHCPFLayout&cid=1251568046976&pagename=HCPFWrapper.

3 Quotes are taken from the ALJ decision reversing the BHO’s denial of residential services.

4 http://www.medical-legalpartnership.org/

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I have posted before on The Signal-To-Noise Ratio, discussing the amount of noise in the blogosphere. But what I’ve increasingly become aware of is that the problem goes beyond this. There is, from many quarters and by many dynamics, a very virulent reaction to signal, in which noise is aggressively generated to interfere with signal as it emerges.

I encounter this with particular force on right-wing facebook pages, and, among them, libertarian/tea party facebook pages most of all. Most recently, on Colorado Republican State Senator Shawn Mitchell’s page, he and his friends very transparently demonstrated a commitment to burying posts that were inconveniently factual and rational under pure noise.

Within a day, as I was simultaneously responding to a global warming denier on one of Mitchell’s threads by listing the actual empirical evidence, and to someone oblivious to the history and nature of property rights on another thread, who insisted that taxation to mitigate anyone else’s poverty is theft, by linking to and expanding on The Paradox of Property, and as the signal-disrupting noise machine was revving up again, Mitchell blocked me from his page.

It’s always telling when a group of people implicitly admit that the only way they can win a debate is by locking out the opposition and holding the debate in their absence. It’s telling when they respond to invitations to all strive to be reasonable people of goodwill, aware that none of us has all the answers, by hurling pejoratives. It’s telling when they respond to “you may be right about everything and I may be wrong about everything” with no similar or reciprocal admission that there is any chance that they might not be completely correct on every single belief that they hold.

And this is exactly what defines that ideological faction. It’s not the substance of their beliefs, which I strongly believe are laden with irrational and counterfactual conclusions, but rather the simultaneous insulation of those beliefs from any intrusion of reason or evidence and promotion of them to the status of absolute truth, that is truly culturally and politically pathological.

As I explain in Scholarship v. Ideology, there is a continuum of modalities of thought ranging from ever-more irrational and blindly ideological in (often self-defeating) service to compassionless selfishness, to an ever-increasing commitment to the application of reason to reliable evidence in service to humanity (as well as enlightened self-interest). Approaching the pole of pure irrationality and dysfunctional belligerence, there is a two-step process employed by which completely unsupported beliefs are first insulated from reason and evidence and then assumed to be unassailable truth on no rational basis whatsoever (also described in Scholarship v. Ideology).

The first step is an appeal to a relativistic argument that all opinions are equal, and that therefore any counterargument to the ideological position that mobilizes reason and evidence can in no way claim to be privileged over the arbitrary opinion itself, even simply by being a more compelling argument. In this relativistic step, “reason” is always defined as completely subjective, formal logic dismissed as “your reason, but not mine,” and evidence whose reliability is better ensured by the methodologies designed to do so replaced with a combination of selective and manufactured factoids assembled solely to “prove” the desired conclusion.

The second step, ironically enough, is a dismissal of any other claim to the same relativism of the first step, insisting that to harbor any uncertainty regarding the arbitrary opinion that was insulated from reason and evidence in the first step would be to make the error of relativism, and that therefore the arbitrary opinion is indisputably the absolute truth. The most obvious example of the product of this two-step process is religious fanaticism, in which Faith, by definition, is insulated from reason and evidence, and then promoted to the status of absolute truth.

(I have posited, by the way, that there may be such a thing as “pure faith,” that has no reductionist object of belief but rather a deep sensation of belonging to a sublime reality, that might be conducive rather than an obstacle to the ever-fuller realization of human consciousness. See, for instance, “Is Religion A Force For Good?” and A Dialogue on Religion, Dogma, Imagination, and Conceptualization.)

But there are many quasi-religious, fanatically cult-like, ideologies that make no explicit reference to the divine. They utilize the same modality of thought, the same tactic of insulation from reason and evidence followed by promotion to indisputable absolute truth, and they are toxic to civil society and civil discourse. They not only are sources of adamantly-propagated noise drowning out the signal of disciplined thought that serves us far better, but they are actually targeted waves of such noise, determined not merely to compete with the signal by the rules of reason and evidence (which, on some level, adherents recognize is a losing strategy), but to jam the signal by any and all means available.

The currently most virulent and troubling secularized cult of irrational dogma is the libertarian/tea party movement, which is comprised of a combination of smaller “pure” factions (those who are not social conservatives or theocrats), and larger “hybrid” factions (those who combine libertarianism, social conservatism, theocratic tendencies, and a commitment to the preservation of inequitable distributions of wealth and opportunity into a “worst of all worlds,” internally inconsistent, ideological blend)

It is, as I have often said, a movement of organized ignorance, not merely insisting on its arbitrary false certainties, but zealously committed to imposing them on the world, regardless of the real costs to real people. The iconic moment was the choice to blackmail the nation with a threatened self-inflicted default of our financial obligations as a nation by refusing to raise the debt ceiling –a formality that has always been automatic, and in most nations IS literally automatic– because of the complete dysfunctionality of failing to do so, in service to an economic policy that even conservative economists opposed (the extension of the Bush tax cuts to the wealthiest Americans, in the midst of a recession). Predictably, it resulted in a downgrading of our national credit rating, which only served to further deteriorate our fiscal and economic health.

I am adamantly committed to the marketplace of ideas, to the belief that all views should be aired, should compete, and, hopefully, the most reasonable and well-evidenced and humane will be the ones to survive that process. But when some factions, some cults, try to drown out other voices, even if only within their own echo-chambers, those factions are stifling rather than facilitating that process of the competition of ideas, ensuring that, for themselves at least, their ideas never have to compete against any others.

To be sure, this goes on to some extent in other kinds of echo chambers, including echo chambers on the left, and it is just as wrong and dysfunctional when it does. But this cultish, dogged irrationality is not what defines any other ideology currently in vogue anywhere to the same extent as it defines contemporary conservatives. Indeed, it is their anti-intellectualism which sometimes leaps out most vividly, their rejection of scholarship as a liberal conspiracy, their rejection of journalism as a liberal conspiracy, their rejection of reason applied to evidence in any context or any manner as a liberal conspiracy.

If that’s a liberal conspiracy, then it’s one to which we all should belong.

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The difference between a scholar and an ideologue is that a scholar seeks out the truth while an ideologue is certain he is already in possession of it.

(This relationship is sometimes inverted, when there is overwhelming scientific evidence for something that ideologues want to dismiss. Under those circumstances, scholars are relatively certain while ideologues are conveniently uncertain; however, the latter is not an honest quest for knowledge, but rather a disingenuous obstruction of it. In both cases, one modality focuses on reason applied to evidence, and the other on the insulation of dogmatic belief from reason applied to evidence.)

It is true that everyone has biases, and that biases influence everyone’s perceptions and conclusions. It is untrue that there is no distinction in the degree to which this occurs and holds sway among competing modalities of thought. To put it simply, if scholarship were indistinguishable from other modalities, the accelerating production of subtle insights into the nature of reality that has characterized science could never have occurred.

The reason for this distinction is that scholarship involves an explicit commitment to apply reason to evidence, and to subject all ideas to the scrutiny of others who are doing the same. This can take the form of replicable scientific experiments, or, to explore phenomena whose variables are too difficult to isolate, variations of this procedure adapted to different conditions. The individual practitioners are more or less adept at it, and more or less committed to the systematic reduction of bias that is one of the principal reasons for this methodology, but to off-set that they must always convince a succession of committees of their peers, and then the general readership of their peers, that their conclusions are valid. This begins to resemble legal procedure, with arguments made for competing cases, judged by a jury of peers, though in scholarship it is a jury of peers with similar expertise.

More casual modalities of opinion formation more liberally incorporate bias into their perceptions and conclusions, sometimes developing precisely in a manner to do so as robustly as possible, systematically insulating irrational and counterfactual beliefs from the lathe of reason and evidence. One such modality currently in vogue is particularly fascinating. It involves a clever combination of relativism and absolutism, first to insulate arbitrary opinions from any intrusion of fact and reason, and then to claim that that opinion must be the absolute truth.

Step one in this anti-scholarship modality is to insist that no modality or opinion is any better than any other, and that the products of expertise or systematic investigation merit no more deference or consideration than any opinion held by any lay person. This is the relativism portion of this modality of thought: All opinions are equal, and none can be privileged over any other. This step insulates arbitrary opinions from any threat from reason or evidence, since any application of reason and evidence can only produce another opinion of equal value to the arbitrarily derived one.

Step two involves rejecting any suggestion that the arbitrary opinion must be considered a tentative conclusion rather than the absolute truth, on the basis that to do so would be to commit the error of relativism: There is one absolute truth, and to claim that one must be uncertain about reality is, according to this modality, a failure to accept the fact that there is one absolute truth. Therefore, the holder of the arbitrary opinion feels justified in being absolutely certain that their arbitrary opinion is the one unassailable Truth.

So, in this modality, first irrationality and counterfactuality is insulated from reason and evidence by means of a relativistic argument, and then it is promoted to unassailable absolute truth by recourse to an absolutist argument. Ironically, the very relativism that is used to insulate the arbitrary opinion in the first place is denied to all others on the basis that relativism is a fallacy! By doing so, the arbitrary opinion is promoted to the status of an irrefutable “truth,” since it can’t be challenged first due to the equality of all opinions, and second due to the fact that since only one of those supposedly equally valid opinions can actually be true, it must be the one that has “proven” impervious to all challenges (by fiat)! I’ve seen this two-step dance of insulated irrationality occur over and over again in “debates” with fanatical (generally right-wing) ideologues, usually accompanied by intense belligerence and a flood of ad hominems directed at anyone “pretentious” and “priggish” enough to challenge that modality.

In some ways, these two modalities, scholarship and what I am calling anti-scholarship (the two-step insulation and promotion of irrationality) define the extremes of a continuum, with various modalities falling along the spectrum between them. Obviously, I’d like to promote a shared commitment, by each and all, to do our best to move along that continuum in the direction of the more disciplined and bias-reducing modality of scholarship.

(See also The Elusive Truth, The Hydra’s Heads, The Signal-To-Noise Ratio, Un-Jamming the Signal, Un-Jamming the Signal, Ideology v. Methodology, The Voice Beyond Extremes, The Real Political & Cultural Dichotomy, Sacred Truths, The “New” Reductionism, The Tyranny of Blind Ideology, An Argument for Reason and Humility.)

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The shared human enterprise is multidimensional. Its various dimensions don’t exist in mutual isolation. Each dimension implicates all others. Human efforts and developments within the various dimensions need to articulate with human efforts and developments in all others. Politics can’t be considered without considering economics, and economics can’t be considered without considering technological developments. None can be considered without considering the production and dissemination of ideas and values and understandings and techniques (and the emotional reactions to them), in short, of human cognitions (including emotions).

The evolution of our social institutional and technological landscape is the overarching theme of human history. Wealth is produced and distributed, ideas created and disseminated, wars sparked and fought, buildings designed and built, political forms and processes developed, all due to and through and as an expression and producer of our ever changing social institutional and technological context.

Technological developments pose both opportunities and challenges. They provide new ways, new tools with which, to produce wealth and address problems. But they also create new problems of their own.

The Economist magazine recently provided a glimpse into the immediate future, by exploring some cutting-edge technologies of the present (see http://www.economist.com/node/21552901). Perhaps the most striking aspect of the package of new technologies changing the face of manufacturing is the 3-D printer:

3-D printing is one aspect of the larger phenomenon of “digital manufacturing,” which in turn is one aspect of the larger phenomenon of what can be called an “information technological revolution.” We all are aware of it, but we don’t always incorporate that awareness into our more generalized understandings and strategies. The fact is that the rapid developments in information technologies (i.e., the set of technological innovations that includes computers, the internet, and mobile communications devices that now are hand-held communications and information processing instruments) is transforming our world, and will continue to do so, in dazzlingly dramatic ways.

The impact of this IT Revolution isn’t just that everyone has or soon will have an i-phone, hooked into a global network of thought and information access. It is also that the more generalized processes of conceptualization, communication, creation, development, production and distribution of cognitive material and all of its products is undergoing a major paradigm shift that has deep structural implications that will ripple and reverberate throughout the social institutional and technological landscape in acceleratingly transformative ways.

We’ve seen the first salvos of the political implications in “The Arab Spring” and other geopolitical events and transformations in recent years, with autocratic governmental control of information flows (and thus of populations in general) being eroded by the IT Revolution. We’ve seen it in our own political system, with political organizing and fund-raising and networking enhanced by new tools which favor those who most rapidly become most adept at their utilization (see, e.g., A Major Historical Threshold or A Tragically Missed Opportunity?). We’ve seen it in science and scholarship, starting with the development of “Chaos Theory” in the early days of modern computers, and growing from there into an accelerating transformation of our understanding of the nature of the world of which we are a part (including the evolutionary ecology of the social institutional and technological landscape itself; see the essays linked to in the first box at Catalogue of Selected Posts).

Now we are seeing it in how we create, produce, and distribute the material manifestations of human existence, the machines and commodities and, in general, the “stuff” of our lives.

What does this all mean for those of us who are most consciously engaged in the human enterprise, who are committed to working with others similarly committed to do the best we can in service to humanity? It means we need to start thinking in new ways, ready to utilize new tools. We need to develop new paradigms that incorporate all of this massive information, these massive changes in the processes that comprise our shared existence, this threshold through which we are passing, and address the future not just as an economic challenge narrowly conceived (as some do), and not just as a technological challenge narrowly conceived (as others do), and not just as a political challenge narrowly conceived (as still others do), and not just as a scientific or scholarly challenge narrowly conceived (as still others more do), but as an integrated challenge incorporating all of these together.

One of the lagging components of the paradigm shift we are undergoing (perhaps always the lagging component in all historical paradigm shifts) is the intentional or organic integration of its various parts for maximum human benefit (see, for instance, American Universities: Two Dimensions on which to Improve, for a discussion of the need to better integrate and articulate the products of our scholarship across disciplines). This is where the crucial challenge lies: How do we gather together these various threads of thought and innovation, and synthesize and channel them most effectively for human benefit?

One of the common threads emerging from the IT Revolution is coherent decentralization. Our ability to publish, network, and organize (social media and the blogosphere), to be vigilant (see Counterterrorism: A Model of Centralized Decentralization), to raise funds (see Tuesday Briefs: The Anti-Empathy Movement & “Crowdfunding”), and political and economic collaboration in general (see Wikinomics: The Genius of the Many Unleashed). But it’s not just augmented multi-lateral communications in play, but simultaneously augmented information processing (e.g., the data analysis function of computer technology), and now, the direct translation of information into its physical manifestations (i.e., production and construction). 3-D printers enable anyone anywhere to manipulate the design of an object digitally, integrating mass production and custom design into a single technology, and to manufacture that object remotely, for anyone else anywhere else, on demand.

One of the central implications of our current technological trajectory is that the demand for human labor will be increasingly a demand for highly trained, technically proficient, information-intensive labor. Humans will be more and more relegated to doing the tasks for which humans have –and will long have– a unique comparative advantage over any devices we can invent, and that is in our highest levels of cognitive functioning, in our imaginations and creativity, in our unique human consciousness. Increasingly, developing that consciousness as something more than a set of mechanical skills that can be sold on the labor market will not only be what feeds our souls, but also what imbues us with what will increasingly be the only asset for which there will be a future demand on that same labor market: Brilliant, imaginative, inventive, creative minds.

There will never be a shortage of opportunities for minds thus developed, but there will increasingly be a shortage of opportunities for everyone else. In a society and world where we haven’t yet met the challenge of educating our children sufficiently to meet the needs of the past century, meeting the challenge of educating our children sufficiently to meet the needs of this imminent and in many ways already present future poses an urgent, imperative challenge to us as a society.

This is nothing less than a revolution in the speed and agility of our technologically augmented collective consciousness, and in the speed and agility of our ability to translate that consciousness into action and objects, into wealth and welfare, into opportunity and the accelerating realization of human potential. But it also poses daunting challenges, challenges in how we prepare people to contribute to and participate in this production of wealth, and how we cope with the inequities and inhumanities that will result to the extent of our failure to do so.

There is so much dazzling new cognitive material currently flourishing in our shared cognitive landscape, a garden of possibilities bearing rich new fruits to be picked. But it is through their constant cross-fertilization, through the interweaving of their various vines, that the richest and most abundant fruits will be produced. The future is hanging low on the boughs of human consciousness, of imagination and innovation. We need to stop waiting for its fruits to fall on us of their own accord, and reach up and grap them with conscious intent and design, because, by doing so, we increase their value and quantity. When it comes to human consciousness and all of its products, it is through the act and intentionality of harvesting it that we most effectively cultivate it.

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(The following is a response to an extreme Libertarian who posted the New Hampshire Constitution’s endorsement of a right to revolution as a justification and encouragement to his ideological fellow travelers.)

The only problem is that you are “rebelling” against a government that is both Constitutional and, within those constraints, democratic. You resent the will of the majority, which differs from yours, and misname the will of the majority, with Constitutional restraints to protect minorities, “tyranny.” By your definition, any use of government of which YOU disapprove is automatically tyranny. Rather, you would wish to overrule the will of the majority, and discard the Constitution, in order to impose your radical, economically illiterate, ahistorical, impractical, inegalitarian, and nationally self-destructive ideology on the rest of us. You can utter all of the magical rhetorical incantations you want, but it remains what it is: A cultish, glassy-eyed fanaticism rearing its ugly head in our own country and our own time, as it has reared its ugly head in so many other times and places.

The government you are rebelling against is Constitutional because your main objection, to the taxing and spending of Congress, is a Constitutionally granted power. Article I, Section 8, Clause i of the United States Constitution grants Congress the unlimited power to tax and spend in the general welfare. You can argue about what constitutes the general welfare, and, in perhaps some extreme instances, can find a Supreme Court that would hold that some use of that power was too clearly NOT in the general welfare to pass Constitutional muster (e.g., Congress taxed and spent in a manner which was unambiguously and incontrovertibly only on the welfare of the members of Congress), but none of the programs that are in controversy fall into that range. The Constitutional limitation on Congress’s power to tax and spend in the general welfare is the electoral system, by which we can fire those members of Congress whom we feel have abused that power, or have not executed it as faithful agents of our will and interests.

The government you are rebelling against is democratic, because the people making the decisions with which you disagree were elected according to our electoral process, administered with a relatively high degree of legitimacy and precaution against fraud and abuse. You oppose the will of the majority, appropriately constrained by Constitutional protections of minorities, and wrap that anti-Constitutional, anti-democratic inclination to impose your own factional will on all others, in defiance of both our Constitution and our electoral process, in a faux-nobility and patriotism, though it is, in fact, exactly the opposite.

The government you are rebelling against is the one that has been honed by the lathe of history, in part through a Civil War and Civil Rights Movement which institutionalized the recognition of the fact that minorities and individuals don’t just need to be protected against the tyranny of the federal government, but also against the tyranny of state and local governments, and, in some instances, the tyranny of private corporations or individuals (e.g., against racist employment discrimination).

And, ironically, the consequences of your efforts, to the extent that they are successful (whether through legal or extralegal means), is the increase of real tyranny, not only by rolling back such protections, not only by reducing our national commitment to equality of opportunity, but also by transferring de facto political power from those public institutions which are (imperfectly) Constitutionally and democratically constrained, to those powerful private institutions that are not.

This is a subtle and complex world we live in, in which the lathe of history works on the raw material produced by our Constitution and by our basic values as a nation. The development of our political economy, of our administrative state, of our need to rein in not just governmental power but also private corporate power which in many instances has grown to the size of medium-sized nations, are not developments to be tossed away because a group of blind ideological fanatics believe that there is some single platitude which overrules all other knowledge and historical experience. You counsel for a kind of imposed mass stupidity, a quasi-religious fanaticism which rejects all knowledge in deference to generally misinterpreted sacred documents and ancient prophets. You may succeed; there’s enough lunacy in this country for that to be a real possibility. But to the extent that you do, it will be an immeasurable tragedy for those hundreds of millions who must suffer the consequences.

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…but everything is politics.

On the one hand, the almost exclusive focus of highly engaged, intentionally political activity is electoral politics and governmental decision making proper. On the other hand, the implicit recognition of the paramount importance of public opinion pervades that same narrowly conceived arena. The hot-button issues of campaign finance reform and corporate power, for instance, are firmly rooted in that implicit recognition, for, in the final analysis, campaign finance and corporate political power is entirely a function of the ability to influence public opinion. (“Follow the money” if you doubt that conclusion.)

Human history is a story of the dynamical tapestry of human cognitions and emotions (see e.g., The Politics of Consciousness , Adaptation & Social Systemic Fluidity, The Evolutionary Ecology of Social Institutions, The Fractal Geometry of Social Change, The Evolutionary Ecology of Human Technology, The Fractal Geometry of Law (and Government), Emotional Contagion, Bellerophon’s Ascent: The Mutating Memes (and “Emes”) of Human History). Politics is one slice of that dynamo, the slice which involves everything from forceful subjugation to sophisticated mass persuasion. The more democratic a society is, the more salient is the latter modality. Despite the flaws in our own American democracy, it is sound enough that mass persuasion is at the root of all political decision-making.

But we tend to address that paramount challenge of swaying public opinion on too superficial a level, issue by issue, candidate by candidate, fighting against impenetrable fortresses of confirmation biases, with drawbridges raised at first sight of the party or issue-position already opposed. We tug back and forth between ideological and partisan camps, while deeper forces are constantly shifting the ground beneath us.

Those deeper forces are in a largely unconscious struggle of their own, between, on the one hand, reason and goodwill, and, on the other, irrationality and belligerence. One of the principal challenges facing reasonable people of goodwill is to turn that unconscious struggle into a conscious one, to engage in it not just candidate by candidate and issue by issue, but on a more fundamental level. When, for instance, Martin Luther King Jr. spoke before the Lincoln Memorial, what made it so momentous, what made it so effective, was that it wasn’t an appeal just to pass a piece of legislation or elect a particular candidate, but rather an appeal to rise to the heights of our better natures. And that is a very powerful appeal indeed. (See The Power of “Walking the Walk” and The Foundational Progressive Agenda )

I’ve written about Meta-messaging with Frames and Narratives, using stories and narratives, without reference to specific policy issues or specific candidates or specific political ideologies, to disseminate and inculcate a framework invoking shared underlying values conducive to the forces of reason and goodwill. My archetypal example of a meta-message has always been Charles Dickens’ A Christmas Carol (which I adapted as such in A Political Christmas Carol), but I did not know until recently that that was exactly how Dickens had intended it.

In Grand Pursuit: The Story of Economic Genius, by Sylvia Nasar (author of A Beautiful Mind), the author describes how Dickens had written A Christmas Carol as an intentional response to Thomas Malthus’s An Essay On The Principle of Population, which had been the intellectual basis in opposition to England’s public welfare system and a move in the direction of greater cruelty and callousness exemplified by work houses and other memorable relics of Victorian England. Dickens believed, and history has borne out, that we are capable of reaching for and achieving greater heights of humanity than the callous indifference that characterized so many in his time and place, and, shockingly, so many in our own as well.

And who would deny that, while it may be impossible to attribute any specific political achievement to the immense success of his wonderful little tale, it has almost certainly played a role in those gradual, invisible shifts of the ground beneath our feet, keeping them at times from moving as far as they might have in the direction of greater callousness, and perhaps even nudging them at times in the direction of greater kindness.

We can’t all write such wonderful stories, but we can reiterate and amplify on them (as I did in A Political Christmas Carol), disseminate them, facilitate their reverberation through our collective consciousness. Politics, at its most fundamental level, isn’t as much about candidates and elections, or public debates about specific issues and the governmental processes which determine what public policy will be regarding them, as it is about what people think and believe, what people feel, what forms the substance of human consciousness.

So for those who live as though politics is everything –eating, drinking, and breathing what we narrowly conceive of as political engagement– please remember that there is much more beyond those explicitly political endeavors of ultimately deeper and broader significance to how our futures are formed and down what channels the currents of history flow. While some throw all of their weight and all of their passion into the tug-o-war between competing ideologies regarding competing candidates and policy positions, the real struggle, and the more momentous movement of humanity possible within it, lies largely unattended by any conscious and organized effort. Imagine the untapped potential of devoting just some small fraction of our passion and energy to that deeper challenge, tunneling under the ideological fortifications that deny entry to reason and humanity, collapsing those walls with subtler and more strategic assaults upon them.

(See A Proposal: The Politics of Reason and Goodwill for a complete discussion of how to go about this.)

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I’ve frequently encountered the argument that any reference to the legacy of history, to continuing evidence of a racially differentiated distribution of wealth and opportunity, is irrelevant because: 1) “I’ve never owned any slaves;” 2) everyone has the opportunity to succeed in America today, and it’s entirely the fault of those who don’t succeed if they fail to take advantage of that opportunity; and 3) the statistical trends are a result of sub-cultural problems that are the fault of the people who are suffering from them. All three of these rationalizations contain errors that are easily demonstrated.

One commenter insisted that the past is remote and irrelevant, that it is full of discredited ideas and so why should we turn to it to understand anything about the present or future? My answer was that disredited past ideas and well-evidenced past realities are two distinct things, that I am not arguing that we should be bound by past beliefs —far from it— but rather that we should be informed, in part, by past realities.

I do not oppose developing state-of-the-art new ideas and insights. Indeed, that’s what I live for. I’m a student of the ever-evolving explosion of human consciousness and its products. But those are all part of a historical process. They do not just exist in the present; they emanate from the past.

Even aside from the persistence of racist attitudes, of actual prejudice and discrimination (which are far more prevalent than some are willing to admit), there are other mechanisms by which past prejudice and discrimination continue to have present consequences. Children inherit from their parents a variety of legacies which are differentiated by history, passed down through the generations, legacies which include material wealth, social and institutional connections and privileges, and habits of thought and action adapted to and conducive to the social and material context of previous generations. Those who inherit more material wealth, richer social and institutional connections and privileges (such as ivy school “legacies,” in which the children of alumni receive preferential treatment in admissions considerations), and are socialized into the patterns of thought and action incubated in and conducive to socio-economic success, are clearly advantaged over those who inherit less material wealth, poorer social and institutional connections and privileges, and are socialized into patterns of thought and action adapted to and reproductive of relative poverty.

Paradigms persist even when we are no longer invested in their persistence. It is not enough to eradicate racist laws, or even racists attitudes, to eradicate the effects of racism. It requires a social investment, based on a recognition of a social responsibility.

There is an economic concept called “path dependence,” which refers to the tendency to remain in sub-optimal paradigms due to the up-front costs of paradigm shifts. For example, if there is new physical plant that produces something far more efficiently than what had heretofore been used, any calculation of the benefits of replacing the old with the new includes the huge up-front costs involved, and, even if there are huge long-term benefits to be gained, if the up-front costs are onerous enough, those benefits might never be pursued.

This can take many forms, from changing physical plant, to changing forms of government or economic systems, to changing understandings of reality. All of these confront various kinds of path-dependent resistance.

Here’s a very simple (and trivial) example: The “QWERTY” computer keyboard arrangement (named for the first five letters, from upper left, on the computer keyboard). If, for some purpose, someone needed to know why computer keyboards, in the present, are arranged that way, they would not be able to discover the answer by limiting themselves to consideration of present reasons why it might be so. The reason, rather, lies in the past: It minimized the jamming of mechanical typewriter hammers. It is a present reality, determined by past circumstances.

There are limitless other examples, in limitless arenas: The human spine has its shape because we evolved from walking hunched over (from four-legged, going further back), to standing upright. The spine wasn’t designed from scratch, but rather took its form from successive developments that built on previous conditions. And it is a sub-optimal design, leading to a lower back that is weaker than structurally necessary. The past is present in the present.

The notion that meeting current and future challenges requires thinking in the present and in no way benefits from understanding the past relies on a false dichotomy: Acting in the present and understanding the past are not incompatible, and, in fact, to do the former well, you have to include the latter in your approach.

Those “vague events of the past that really have no bearing” (as one commenter put it) are not so vague, and not so irrelevant. Such assertions conveniently ignore the statistical fact that the two most historically oppressed racial groups in American history, African Americans and Native Americans, are far more represented among our impoverished than random chance would allow. Why? Surely those who deny the relevance of this fact aren’t explicitly arguing that those racial minorities just happen to have an excessive amount of non-meritorious people among them, that they are “inferior” races. But it’s hard to see how their argument can be based on anything other than an implicit assumption to that effect.

The argument that members of those races have individually failed to take advantage of the opportunities available to them doesn’t address the statistical reality that so many more individuals from those races have failed in this way than individuals in the race that historically oppressed them. What a coincidence that the descendants of those who were enslaved and conquered are, on average, so much “less meritorious” than the descendants of those who enslaved and conquered them. Just highly improbable random chance, no doubt, and in no way involving those vague and irrelevant facts of history.

And the argument that it is a subcultural phenomenon begs the question: Why these subcultures and not others? Will those arguing this position really stand by the claim that it’s just a coincidence that the subcultures burdened with these problems just happen to encompass the populations we massacred, enslaved, and oppressed for centuries? Or will they admit that, to the extent that a mediating cause of social problems borne by these populations is subcultural in nature, the development of such subcultural dysfunction has as a first cause the centuries of oppression in which it was incubated?

The argument that some once disadvantaged ethnic groups have prospered, so why don’t these, doesn’t cut it either: There are many variables in play, and they lead to a wide variety of outcomes. Two major factors come into play: 1) No other disadvantaged population was ever quite so extremely and enduringly disadvantaged as the two I’ve named, and 2) the fact that there are circumstances in which countervailing factors overcome the liabilities of prejudice and discrimination doesn’t negate the existence and salience of prejudice and discrimination. In the case of generally new waves of exploited and impoverished immigrant groups who then prosper later, combinations of economic factors, less entrenched discrimination, and cultural characteristics particularly conducive to success can all come into play.

Just as some formerly underprivileged groups prosper, so do some individuals from underprivileged backgrounds, not because all is well and everyone has an equal chance, but because other factors intervene to counterbalance the injustices that really do exist. An individual might have gotten lucky by having exceptional talents, or exceptional mentors, or other bits and pieces of countervailing good luck.

But these bits of greater good fortune overwhelming an unjust situation don’t excuse the perpetuation of the unjust situation. There were slaves that escaped and prospered as well; that doesn’t mean that slavery was just fine, because, after all, some born into it prospered. The injustice isn’t erased by some fraction of those who escape it. And the fact that our current distribution of wealth and opportunity is unjust is conclusively proven by statistically significant differences in average outcomes for large populations on the basis of race, ethnicity, or gender.

The purpose of understanding the past isn’t to change the past, or to apportion blame, or to cultivate a sense of guilt and a sense of victimhood, or to suggest that descendants of victims of injustices necessarily deserve reparations beyond a commitment to erasing the legacy of those injustices, or to suggest that any inequality itself is unacceptable. The ultimate goal isn’t to recognize the role of history in forming the present, but rather to mobilize that knowledge in service to humanity today and tomorrow.

Who cares why the keyboard is as it is, or the human spine is as it is, or the inequitable distribution of opportunity in America is as it is, unless there is some present use for that knowledge? In the former two, there really isn’t, because we are willing (or have no choice but to) accept the current state, and so how it became so is of little practical relevance. But, if there were a question of fundamental justice involved, of human rights and human dignity, then it would be relevant, as it is in the last mentioned case.

Letters on a keyboard aren’t conscious and don’t care where they’re located. Human beings are, and do. The “QWERTY” of the distribution of wealth and opportunity has a relevance that the “QWERTY” of the location of keys on a keyboard doesn’t. And the relevance of the history that created that distribution of wealth and opportunity is that it exists, that the injustices of history have not been erased by time, that they are still embedded in the chances of birth. A commitment to our most basic values compels us to face that fact and deal with it responsibly, rather than deny it and pretend that each person fares only according to his or her own merit and effort, despite the overwhelming evidence that that just isn’t so.

It is not merely, or even primarily, to demonstrate the relevance of past racial discrimination to current inequitable distributions of wealth and opportunity that we should be informed by this presence of history, but rather to demonstrate the existence of social and economic injustice itself. I might be inclined to argue that those who are impoverished in America, or struggling in circumstances characterized by poorer than average opportunities to thrive, regardless of their race, are by-and-large victims of ill-fortunes that were not their own making, and did not enjoy a true equality of opportunity such as we, as a people, should be striving to realize. I might be inclined to argue that our policies for addressing these injustices shouldn’t be racially targeted, or race-conscious, but rather address the problems themselves that are disproportionately borne by members of some formerly oppressed races, and by doing so address the injustices at their root, as they occur, rather than superficially by the categories in which they most prevalently occur.

But the people who deny that the injustices of the past have any relevance to the injustices of the present are doing so to argue that there are no injustices in the present, or at least no injustices of a kind that incur any social responsibility borne by us collectively as a people and a nation. They argue that those who are poor are poor because they lack merit, lack resolve, lack something that those others who are not poor have, in complete defiance of the evidence.

The number one predictor of future wealth is the wealth into which one is born: If you are born into a wealthy family, you are likely to become a wealthy adult; if you are born into a poor family, you are likely to become a poor adult. There is far less social mobility than our mythology pretends (indeed, less even than in the more liberal countries of Western Europe). When one’s fate is largely determined by the socioeconomic class into which they are born, there is less difference, in terms of social justice, between our current political economy, and the more unabashedly inequitable systems of the past. Obviously, the ideal of equality of opportunity is far from being a reality in this country.

One of the fundamental challenges facing us as a people is to recognize this, and continue to strive to remedy it. In America, too many people hide behind a political philosophy that allows them to “have their cake and eat it too,” to enjoy the benefits of living in a society without undertaking any of the moral responsibilities that that incurs (see The Catastrophic Marriage of Extreme Individualism and Ultra-Nationalism  for a discussion of a different aspect of this overly-convenient and pernicious blend of individualism and nationalism). It is time we once again heeded John Donne’s famous admonition that

No man is an island entire of itself; every man is a piece of the continent, a part of the main; if a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as a manor of thy friends or of thine own were; any man’s death diminishes me, because I am involved in mankind. And therefore never send to know for whom the bell tolls; it tolls for thee.

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On this 100th aniversary of the tragic sinking of the Titanic, it seems fitting to write a tribute to that historic event, but one which takes what lessons it may offer and applies them to our own ship of state today.

A story on the PBS Newshour yesterday (Friday, 4/13/12; http://www.pbs.org/newshour/bb/media/jan-june12/titanic_04-13.html) about an interesting New Yorker article (“Unsinkable: Why We Can’t Let Go of the Titanic,” by Daniel Mendelsohn; http://www.newyorker.com/reporting/2012/04/16/120416fa_fact_mendelsohn) got me to thinking about the parallels between that ill-fated vessel, and our perhaps equally tragic nation. The parallels Mendelsohn drew were to Greek tragedy, to the themes of hubris, of Man v. Nature, of something glorious and admired and full of a sense of its own exceptionalism going down in flames, or icy waters, as the case may be. It is about too much smugness and too little pragmatism.

As Mendelsohn aptly put it: It’s too perfect, too much like a story, the “unsinkable” ship sinking on its maiden voyage. Like Oedipus, the flawless hero, swept up and sucked down by forces that grab hold of all those who eschew humility, the great Titanic was doomed by its own sense of perfection, or the sense of those who had invested their identities into it. It was about the limits of technology, about class and injustice, about the bracing, icy reality confronting the dreamed up ideal. It was, of course, the ideal of unsinkability rather than the reality of unpredictability which sank.

The United States is, in many ways, “the Titanic Nation,” this great ship of state launched by the culmination of European development, by the Enlightenment and the Industrial Revolution, full of a sense of its own exceptionalism, bigger than life, “unsinkable.” We are still on our maiden voyage, for the first couple of centuries in the history of a nation is still its infancy. And we are careening toward the icebergs of our hubris, of our uncompromising belief in our own exceptionalism, in our scoffing at the demands of pragmatic reality in deference to the oversimplified ideal we believe will always trump it.

Despite what many say, despite what many cling to, despite the satisfaction it may give to entertain the notion, in the final analysis, America is not an ideal; it is a nation, a product of history, a living, breathing, thriving and striving and faltering and self-correcting society, a work in progress, an on-going challenge to be met with a modicum of humility and a heavy dose of pragmatism. And it is the increasing rather than decreasing loss of this awareness that sends us hurtling toward unseen icebergs, destined, perhaps, to collide with them and rip ourselves to shreds in the process.

But we have not collided yet. We have not sunk yet, and do not have to. We can regain our humanity, our recognition of being nothing more or less than a nation struggling with the challenges of thriving in a complex and subtle world, a nation guided by wonderful values and founding principals, but a nation that is not invulnerable because of them, or beyond improvement in deference to them. Sometimes, we need to correct our course, to re-chart our trajectory, to avoid the obstacles that those who designed and launched us could not possibly have anticipated. Their design, and the course they charted for us, remain our foundation, but they do not remain the limits of who and what we are.

There are those in America today, too many, too loud, too smug, too full of hubris and folly, too natonally self-destructive, who insist that we must not evolve, that we must not develop our political economy to confront the challenges of today, that we must not adapt and grow and steer our course through the ever-dangerous waters of history. There are those who offend the spirit and character of the brilliant but historical and fallible men who drafted our Constitution by reducing it to a shallow sacred document, stripping it of its meaning, stripping it of its intent, and seeing in it only a mirror of their own blind ideology, whether its specific clauses actually mirror that ideology or not. (See. e.g., Right-Wing New-Speak.)

There are those who insist that a century-old non-empirical Austrian economic philosopher got everything right, and the entire empirical and analytical discipline of economics as it has developed ever since has gotten everything wrong, and who claim that theirs is the only reasonable position imaginable, all others being error. There are those who are as lost in their own blind ideologies, as insulated from reason and evidence, as any Medieval Inquisitor ever was, and who insist that that is what America is, that that is what America was meant to be. And they are steering us straight toward those icebergs of human folly, of ignorance, of hubris, of believing that an act of admirable engineering, whether technological or social institutional, whether a historically unprecedented giant ocean liner or a historically unprecedented national Constitution, once accomplished, need no longer be piloted in response to the realities as they are encountered, and can not possibly fail if only left to barrel ahead blindly.

As the economist and dynamical systems analyst Brian Arthur noted in his wonderful book, The Nature of Technology, these feats of engineering, of historical innovation, are not faits accompli, but are rather always works in progress, always tested and honed and refined by the reality of life and the challenges that it poses. The brilliance of our nation is not that we got it right once and for all, and only must adhere to that perfect, unsinkable design, but rather that we accomplished something admirable on which we can build, which we can continue to steer, which will take us farther than we ever imagined if only we continue the work rather then rest on ancient laurels.

We are, indeed, a Titanic Nation. But ours is one Greek Tragedy whose ending hasn’t yet been written. We are the ones who will write it. We are the ones who will determine whether it is written by our hubris and folly, or by our wisdom and humility. We are the ones who will either steer it into the icebergs that lay before us, or will continue to navigate our way among them, refining our institutions and developing our humanity to confront a reality that was not part of or foreseen by our original design, but rather is a part of what continues to make us . . . or break us.

As I like to say, let’s write our story well.