Behavioral and Psychological Symptoms of Dementia or Behavior and Psychological Changes Due to Dementia

I have continued to refine my thoughts, as precipitated by friend and colleague Kate Swaffer, on 1) Caregiving Teams, 2) Use of labels, 3) SYMPTOMS due to Dementia/Alzheimer's vs CHANGES due to the disease, 3) Use of drugs for symptoms and changes, and 4) Attending to and respecting the human rights of people diagnosed with Dementia/Alzheimer's.

It is a very complex conversation and I am sure it will continue.

• • • • •

September 10, 2018 

Kate,

I have given much thought to your recent posts on BPSD (Behavioral and Psychological Symptoms of Dementia) and the abolition of such. I have attempted to share comments several times, did a little on one of your posts, but for the most part was overwhelmed by the implications you present and therefore I went into “hyper-thought” to try to make some sense of the situation (at least for myself!)

While I agree with you strongly, and join you in your fight for “Human Rights” for people diagnosed with Dementia/Alzheimer’s, I also feel that I need to clarify in my mind what it is that WE (or at least I) am/are actually dealing with here.

First issue—Good vs Bad People and Caregiving Partners:

There are Good People and Bad People. There are good intentioned people who make bad choices and ill intentioned people who think they are making good choices. And there are people on the continuum between the extremes. 

How caregivers provide care is also on a continuum of good to bad, informed to uninformed, appropriate to inappropriate, etc. These continuums affect how people diagnosed with Dementia/Alzheimer’s are treated and how the care they receive is given.

There is a difference in care given by family and friends vs paid caregivers. There is a difference in care given when the person diagnosed with Dementia/Alzheimer’s lives at home or lives in a memory care facility. How a person receives care differers greatly when they live alone, have no family or have been ignored by family. 

I know that based on the experience of many relatives, the care given in many memory care facilities, is unconscionable and with little respect for Human Rights and more for the facilities convenience, but that does not condemn all such facilities!

Finally, the nature of those diagnosed with Dementia/ Alzheimer’s and the nature of their family caregivers, will determine the reactions and changes and response to being part of the caregiving team. Caregiving teams which are used to RESPECT will most likely continue to operate with respect. Those teams which were ARGUMENTATIVE, DEMANDING, and or INCONSIDERATE will most likely continue to operate in that way.

Second Issue—Good vs Bad Labels:

While labels can be harmful, I believe that they are also useful and necessary. Some say that we should not have to categorize or label and that the labeling itself is part of the problem. I believe that labeling and categorizing can be part of the problem but it is also part of the way in which the human mind comprehends, deals with, and makes decisions with regard to the every day complexity of life!

I believe that labeling must remain flexible, open, nonjudgemental, and subject to careful, continuing scrutiny and the willingness to change.  STEREOTYPING, NO, but understanding our life through categorizing and labeling is how we all make sense out of complicated issues as well as helping us to make every day decisions.

Third Issue—BPSD A Good Label or Bad Label?: 

Using the term BPSD (Behavioral and Psychological SYMPTOMS of Dementia) does MIS-REPRESENT many of the NORMAL HUMAN REACTIONS that people diagnosed with Dementia/Alzheimer’s experience and present. There are changes in behavior which take place, which most likely reflect the confusion and frustration, memory loss, and especially with the loss of language which comes with the disease. I believe that early in the disease, many behaviors incorrectly considered symptoms really are “human nature.” 

But I also believe that at times Dementia/Alzheimer’s DOES have symptoms, especially as the illness progresses, as cognition and language are compromised, as the brain is not able to function as normal. Examples of SYMPTOMS of Dementia are loss of language, forgetting, verbal repetition, hallucination, confusion of past and present, eye/hand coordination, difficulties walking, etc. Getting frustrated and angry because of the inability to explain ones needs is a HUMAN REACTION, messing ones pants is a DEMENTIA SYMPTOM. 

Perhaps there needs to be two sets of labels to differentiate? BPSD (Behavioral and Psychological Symptoms) and BPCD (Behavioral and Psychological Changes?)

Fourth Issue— Human Rights and Use of Drugs:

Use of drugs to support people diagnosed with Dementia/Alzheimer’s is NOT ALWAYS BAD! Sometimes the use of drugs is necessary. It can be beneficial when used after all other options are exhausted, when used in the person’s best interests, when using the lowest possible dosage, and when being monitored carefully.

The first line of inquiry must be finding out the source of desire, need, confusion, frustration, discomfort, or pain. This is especially difficult and time consuming, but absolutely necessary, especially when the person no longer has use of language. Not excusing it but rather stating the reality of it.

Fifth Issue—Human Rights vs Loss of Rights:

I am not living with the diagnosis of Dementia/Alzheimer’s, and while I can empathize, I know that I can never really know what it must be like to slowly loose my cognitive and language abilities, among others. So I can only look at them through the lens of my own “normality” not the lens of one diagnosed with the disease! I can imagine but will never really know!

Through my lens, when the person diagnosed with Dementia/Alzheimer’s can no longer use language to express their needs/desires, when their cognition no longer functions in what we know and experience as “normal,” when issues of safety and maintaining health are at stake, then decisions must be made on their behalf, always of course with their best interests in mind. This arbitrarily means a loss of rights for the person to decide for themselves. 

Sixth Issue—Time and Place:

Each of the previous issues and how they are dealt with depends on the stage of the disease, the behaviors presented, and the care location (home or memory care facility.) In a perfect world we would know when and where and how to work with each with every behavior presented. We would have time and energy to understand the needs even when the person diagnosed can no longer express themselves. However, this is not a perfect world. We can only WORK TOWARDS PERFECTION when it comes to helping human beings live the best life possible.

Seventh Issue—Human Nature/Existence—The Same Only Different!

Due my need to clarify, through GRAY and not BLACK & WHITE, how I look at life and the trials it brings to us and those we love, everything I have talked about above, has to do with doing one’s best to live a loving, active, productive, compassionate, respectful (among other descriptors) life.

When any catastrophic illness or experience strikes, whether Dementia/Alzheimer’s, Cancer, suicide, accidental or sudden death, etc; the true colors of the people involved in the caregiving team and in the drama of life raise to the top. Depending on how the team entered the experience, they most likely will exhibit the same ways of dealing with the situation. Sometimes they are able to raise above their usual. Hopefully, everyone will come through the experience (or at times ending up on the other side of life) in a way that respects and supports all players as deserving human beings.

Maybe the solution, based on the thinking that has helped me put this essay together, is to say: 

"Labeling and medicalizing behavioral and psychological symptoms due to dementia, can be harmful and wrong. Many are not really SYMPTOMS but rather HUMAN BEHAVIORAL RESPONSES which are complicated and at times exaggerated due to the nature of Dementia/Alzheimer’s as it progresses.

Perhaps two labels would suffice: 1) BPSD (Behavioral and Psychological SYMPTOMS of Dementia) and 2) BPCD (Behavioral and Psychological CHANGES with Dementia.) 

Also, we must strive to make sure that if solutions are not obvious and at times not available, if the presenting difficulties are not amenable to usual solutions, then: 1) utmost care must be taken to keep the individual’s human rights in mind when making decisions that affect those rights, 2) such decisions must be in the person’s best interests and not those of other individuals or institutions, 3) such decisions must be loving, respectful, and compassionate and reflect best practices and 4) be the least invasive possible.

We should work on looking for better solutions, provide more support to caregivers and staff, increase staffing so time is available to listen and to look for solutions, and provide more time to training caregivers and staff. 

Know that we can only do the best we can do in caring for people who are at advanced stages of Dementia/ Alzheimer’s and we must always be mindful that no matter what stage, they are human beings who deserve the best care possible!!! We must remember to treat them as we would want to be treated!

The Term Behavioral and Psychological Symptoms of Dementia (BPSD) Can Do More Harm Than Good

My friend and colleague in the area of Dementia/ Alzheimer's Care, Kate Swaffer, who also has been diagnosed with Dementia in her middle 40's, wrote the following in a recent blog post:

"To say I honestly believe, with every cell in my body, that the notion of BPSD (the Behavioural and Psychological Symptoms of Dementia) as a helpful term, and the labels within it being due to the pathology of dementia, is harmful, is an understatement. I’m sure the term itself is doing harm, to the point it should be removed completely from all dementia policies, programs, and care plans."

Basically, she is talking about the human rights of people diagnosed with the disease and how they are cared for and how their rights are so often violated.

CLICK HERE to open Kate's Post in a separate window. 

I AGREE, I AGREE ... but ... I feel that we need to go further. We need to qualify and/or to suggest alternatives. I also believe that perhaps we must also acknowledge the changing need to use BPSD language based on the advanced stages of Dementia/ Alzheimer's. I do not know what these alternatives might be but feel that minimally the "qualification" must be acknowledged.

At a certain stage, perhaps it is not a question of a person's rights but rather more their comfort, safety, and the safety of others! These decisions must always be made with the person's best interests in mind and based on "best practices" and available research (often times the interpretation of available research being more complicated in itself.) 

I know that the rationale of comfort and safety are often used as the excuses, but I would prefer to place the blame on the availability of staff time, on staff training, greedy "bottom line" profit facilities, on available research, and on those of us who look for answers to better care not looking far enough!

At times these decisions are not easy ones to make on behalf of another, emotionally or intellectually! But as someone who loved and lived with a person who lived with Dementia/ Alzheimer's, I experienced the need to make these decisions.

In the many presentations I have made on Gregory's and my journey, I too red flag the "medicalization" of the disease in favor of redefining and reestablishing the sense of home, family, and relationship. Towards the end of Gregory's journey, these changes to normalize our situation, reflecting the changes in Gregory's needs, sometimes took place on a daily or hourly basis. Discussing the "medical condition" did not help much.

When Gregory moved to a Memory Care Facility, however, I was faced with many of the concerns which Kate expresses. I negotiated his care, advocated for him, and was involved in all decisions made on his behalf. I was, however, also willing to listen to suggestions, best case scenarios, and to accept the limitations of what the facility was able to do.

I was fortunate that I was able to hire a daycare person to be with Gregory seven days a week from 11:00 to 7:00 pm to provide the social/emotional and additional physical needs which the facility could not provide.

Even though the facility scheduled a head nurse for the unit, two floor nurses, a secretary, custodians, food service people, and more CNAs (certified nurses assistants) than required by the state, there was never enough time to met the real needs of all residents!

They were able to meet the minimal needs but that certainly should not be enough! I also fought for changes within the facility and often helped make change!

While I avoided "medicalizing" our situation, I did need to begin taking the medical into consideration as Gregory's situation worsened, variously including changes and the deminishing of abilities  in the area of cognitive issues as well as physical, mental, physiological, psychological, social, emotional, medical, etc ... and which was complicated by the many ways in which his needs expressed themselves.

I have gone through Kate's list and responded (sometimes offhandedly with no disrespect meant) to her beliefs based on condemning the practices without offering solutions. I know that first, awareness comes, then solutions. But I am always uncomfortable stating something as a truth when under certain conditions it is not a truth. I personally need to at least clarify the possibility both!

Also, I in NO WAY want to diminish Kate's concerns and her noble work to make life as good as possible for those diagnosed. I have great respect and love for this woman. 

Having known her via the internet for the last five years, I had the opportunity to meet her in person (she lives in Austrailia) at the 33rd annual Alzheiemr's Disease Conference, here in Chicago last July, at which we both made presentations. I have come to respect her work even more if that is possbile! 

I need, however, to state my discomfort in "talking problems" without "talking solutions."

Perhaps instead of BPSD, one should talk about changes in BPSD that may or may not come about at the various stages of Dementia/ Alzheimer's!

The following then, in italics, is taken from Kate's BLOG.

IN CAPITALS are my comments. 

Some of Kate's comments should be easy to solve, others are not. I have tried to address both.

• Labeling and medicalizing normal human responses to dementia is harmful and wrong.
• AGREED BUT AT VARIOUS STAGES OF DEMENTIA/ ALZHEIMER'S THE ALTERNATIVES ARE NOT OBVIOUS.
• 
  
• Labeling and medicalizing normal human responses to being segregated are wrong; this is also a breach of our most basic human right under the CRPD.
• IS IT NOT POSSIBLE THAT THE "SEGREGATION;" WHICH ITSELF CAN BE INTEGRATED WITH PEOPLE OF VARIOUS SEXES, RACES, RELIGIONS, AGES, ETC; BE A GOOD THING AND HELP CREATE A NEW SENSE OF COMMUNITY WHICH BY ITS NATURE IS MORE COMFORTABLE, PREDICTABLE, AND EASIER WITH WHICH TO COPE?
• 
  
• ARE THESE RESPONSES, OFTEN CAUSED BY DYSFUNCTION OR MALFUNCTIONING OF THE BRAIN STILL CONSIDERED BASIC HUMAN RIGHTS? 
• 
  
• Labeling and medicalizing normal human responses to being physically restrained is wrong; even people without dementia do not want to be locked up, and this is also a breach of our most basic human right under the CRPD.
• AGREED THAT PHYSICAL RESTRAINT IS WRONG UNDER ANY CONDITION BUT ARE "LOCKED FACILITIES" WRONG WHEN COMPARED TO A PERSON'S GETTING LOST, HIT BY A CAR, FROZEN TO DEATH IN THE WINTER, THE FEAR OF BEING LOST WHEN REALIZING THEY DO NOT KNOW WHERE THEY ARE (POSSIBLY OUTSIDE IN A NIGHTGOWN OR NUDE?) 
• 
  
• IS THE DISCOMFORT AND PAIN IN BREAKING A LEG OR ARM WORTH NOT PROTECTING THE PERSON FROM FALLING DOWN A FLIGHT OF STAIRS OR NEEDING A CHAIR ALARM? 

• Labeling and medicalizing normal human responses to chemical forms of restraint is wrong.
• WHAT SHOULD HAPPEN WHEN A PERSON'S QUALITY OF LIFE IS SO PAINFUL DUE TO DEPRESSION? CONFUSION? FRUSTRATION? VIOLENT BEHAVIOR (NOT THAT THE PERSON IS VIOLENT BUT THE EXPRESSION OF THEIR DISCONTENT RESULTS IN HARM TO SELF OR OTHERS?)
• 
  
• IN REAL LIFE PEOPLE TAKE TRANQUILIZERS, ANTIDEPRESSANTS, AND ANTIPSYCHOTIC DRUGS WHEN NECESSARY WITH CAREFUL, CAREFUL MINIMAL DOSAGES AND MONITORING. SHOULD THAT NOT BE A RIGHT FOR PEOPLE DIAGNOSED WITH DEMENTIA?
• 
  
• Labeling and medicalizing normal human responses to feeling lonely and wanting someone to take notice of you as ‘attention seeking” or ‘a screamer” is wrong.
• NO ONE SHOULD FEEL LONELY OR NEGLECTED BUT OFTEN TIMES THIS IS THE RESULT OF NEGLECTFUL FAMILIES. 
• 
  
• A PERSON SCREAMS FOR A REASON. CARE FACILITY STAFF DEFINITELY SHOULD PAY ATTENTION TO SOMEONE SEEKING ATTENTION, ESPECIALLY WHEN THE PERSON CAN NO LONGER FIND LANGUAGE. THE FAULT IS STAFF NOT HAVING ENOUGH TIME OR ADEQUATE TRAINING NOT NECESSARILY THAT THEY DO NOT WANT TO LISTEN.

• Labeling and medicalizing normal human response to the need to walk as wandering is wrong; everyone needs and wants to walk!
• YES EVERYONE HAS THE NEED TO WALK BUT WHAT DO YOU DO WHEN THEY DO NOT RECOGNIZE DANGEROUS SITUATIONS? WHAT WOULD HAPPEN IN THE FACILITY WAS NOT LOCKED?
• 
  
• Labeling and medicalizing normal human responses to being ignored is wrong.
• NO ONE SHOULD BE IGNORED OR HAVE THEIR NEEDS IGNORED BUT WHAT HAPPENS WHEN THE PERSON CANNOT EXPRESS THEIR NEEDS. YES, THERE ARE OFTEN NON-VERBAL SIGNS THAT WILL TELL OF THE PERSON'S NEED. SOMETIMES MEDICAL TESTING CAN REVEAL WHAT IS CAUSING THE DISCOMFORT. BUT OFTEN THERE IS NO OBVIOUS CLUES TO THE UNDERSTANDING OF THE NEEDS. 

• Labeling and medicalizing normal human responses when someone is unable to communicate their needs or wants is wrong.
• THIS IS PROBABLY ONE OF THE MOST DIFFICULT SITUATIONS TO OVERCOME AS MENTIONED IN SEVERAL POINTS ABOVE.
• 
  
• Labeling and medicalizing normal human responses to untreated pain is wrong.
• AGAIN YES, YES, YES. I PLACE THE FAULT WITH THERE NOT BEING ENOUGH TIME FOR OR TRAINING OF STAFF TO LEARN HOW TO LISTEN. 
• 
  
• Labeling and medicalizing normal human responses to being forced to live in an institution is wrong; we know institutional care ensures poor care, and out of choice, almost no one wants to live in one.
• AGREED! BUT OFTEN LIVING AT HOME IS NOT AN ALTERNATIVE. MOST OFTEN AT CERTAIN TIMES, LIVING ALONE IS NOT AN ALTERNATIVE. WHAT DOES ONE DO? FAMILY IS NOT ALWAYS AVAILABLE.
• 
  
• Labeling and medicalizing normal human responses to being forced to eat with a group of strangers is wrong; when I go to a restaurant, I sit with my family or friends!
• BEING OFFERED A CHOICE IN SEATING, CHANGING SEATING WHEN NECESSARY, ALLOWING A PERSON TO TAKE THEIR MEAL IN THEIR ROOM, AND ENCOURAGING FAMILY AND FRIENDS TO JOIN MEALS MIGHT HELP WHEN A PERSON IS IN A MEDICAL CARE FACILITY. BUT IS IT BETTER TO PROMOTE ISOLATION THAN IT IS TO FORCE AT TIMES INTEGRATION WITH OTHERS?

• Labeling and medicalizing normal human responses to being forced to do an activity you don’t like, or don’t want to do, is wrong.
• NO ONE LIKES TO BE INVOLVED IN SOMETHING THEY DO NOT WANT TO DO. BUT IS IT BETTER TO HAVE NOTHING TO DO? OF COURSE, GIVEN ENOUGH PARAMETERS PERHAPS THE STAFF COULD FIND SOMETHING THE PERSON WOULD WANT TO DO BUT AGAIN THERE IS THE TIME AND TRAINING CONUNDRUM!
• 
  
• Labeling and medicalizing normal human responses to being forced to eat food that is spiritually or culturally inappropriate for a person is harmful.
• AGREED! ALTERNATIVES SHOULD ALWAYS BE AVAILABLE.
• 
  
• Labeling and medicalizing normal human responses to not liking the food you are served is also wrong.
• AGREED BUT MORE DIFFICULT THAN ABOVE. ALTERNATIVES SHOULD BE OFFERED FOR ALL MEALS.

• • • • •

Maybe the solution and one that would sit better with me is to say, 

"Labeling and medicalizing (as BPSD) normal human responses to dementia, can be harmful and wrong. If solutions are not available or obvious, if the presenting difficulties are not amenable to usual solutions, labeling as BPSD and medicalization of normal human responses to Dementia should only be used as a last-ditch effort but should be avoided unless absolutely necessary. 

We should work on looking for better solutions, increase staffing so time is available to listen and to look for solutions, provide more training to staff, but sometimes know that we can only do the best we can do in caring for people who are at advanced stages of Dementia/ Alzheimer's, always being mindful that no matter what stage, they are human beings who deserve the best care possible!!!

LGBTQ

I have grown up. Again! When I was a young man, I would look at a change in or new understanding about myself and say, “My, I was so naive! I will never let that happen again.” Ends up, my life, which is now in its 70’s, has been a series of “being naïve again!” Maybe that is not so bad as it shows I am continuing to grow and become.

My recent visit to San Francisco, Gay capital of the USA to attend the Frameline 40 Film Festival where I experienced my documentary ALZHEIMER’S: A Love Story screen in front of a warm, accepting audience of 1,300 gay and gay friendly people; viewing over 25 films (shorts and longs) dealing with gay issues, and meeting a wide variety of people; has brought a new sense to my homosexuality.

I have been Gay all my life. In looking back, the signs were there since my earliest memories. I "came out" at the age of 18, meaning had my first sexual experience, and began to understand why I was different than most other boys. I had known it for a long time but didn’t understand why.

I probably did not fully accept with confidence that I was Gay until I was 40 years old when I informed my mother that I no longer was going to lie to family and friends about my sexual preferences or my male lover. Everyone knew anyways but just weren't acknowledging it.

During the first fifty years of my life, the 1950's through the 2000's, society's attitudes towards Gay people, men and women, were quite different then they are today. Life for gays was closeted and characterized by the expression, "The love that dare not speak its name." Older role models did not exist. Most Gay activites and socialization was underground.

Things today, while not perfect, are amazingly different with same sex marriage legal at the national level, wider acceptance of homosexuality by more people, greater visibility of Gays in the political, entertainment, and sports worlds, and perhaps more understanding in religions arenas.

This scenario brings me to the discussion of some current realizations I have had as mentioned in the first paragraph.

Most of my younger life I liked other younger men and found older Gay men disgusting. Now I am an older gay man! I now understand that while age affects how beautiful a person's body might be, it does not affect the beauty of a person's soul. While I look pleasant enough, my physical beauty is gone, my sexual needs not as easily met as when I was in my twenty’s. A little late, now that I am in my 70’s, but I can accept this. I wish I had been a little more “generous” to older men when I was young.

As a young man; Drag Queens, Transsexuals, Transvestites, Leather Men, Butch and Lipstick Lesbians, and probably a few others were embarrassing to me. I wanted Gay men and women, including myself, to be well-behaved, normal, milk-toast, etc.

I thought that if only these extremely visible groups would calm down, gays like me in general would be accepted into society or at least go un-noticed. This was based on little or no knowledge of who the people in these groups were emotionally, physically, or belief system wise. I had few if any friends in these groups and knew little of who they really were. This belief was pretty common, I think, among many gay men of that time.

After Stonewall, during what is known as the Gay Liberation Era, there was a huge spit between Gay men and Gay woman who wanted to be known as "Lesbians" not "Gay Women." At the time I thought this was foolish. I understand this now and give the Lesbian community credit for being among the first groups (including the early suffragettes) to fight for equality for women in general. The battle continues.

Until then, and somewhat still now, men were the dominant sex; making most important decisions, holding most important roles in business, government, religion and making decisions about who and what women could be. During Gay Liberation, the Lesbian women said, "Hell no! We are in charge of ourselves and will make decisions about ourselves ... men will not be in charge of us and we do not want to be dumped into the group with them known as “Gay!”

My next awareness was that seemingly "outrageous" expressions of self by Drag Queens, Transgender People, Leather Men, and Butch Dykes turn out to be honest outward expressions of how these people see themselves, how they want to live their lives, and part of their fight for equal rights and protection under the law. I now understand and accept that. I now have a wider range of friends in my social groups.

Slowly society is becoming educated and more accepting of these groups. Just because I am not part of these groups does not and should not mean that they are wrong, or bad, ... or embarrassing. I have become more accepting myself in this area.

The initials GLBTQ reflect a long, successful journey! In the beginning it was "being Gay." Then it got to being Gay and Lesbian. Slowly Bi-Sexual was included. Over time T for Transgender was added and is becoming a lot more visible today.

Q seems to have two groups to identify. One is buying back the word QUEER but with confidence and self-love and remembering the resolution of the Rainbow Flag that we will never go back into the closet again.

The other is Questioning, which means that sometimes people, whether young or old, must figure out who they are, who they want to be, and how they want to express themselves and their sexuality. Being open to possibilities that enable one to question fixed societal beliefs is necessary. Some groups are playing around with "I" for Inquisitive to replace Questioning. GLBTQI

Some say that we should not have to categorize or label any of us, gay or straight, and that is the problem. Ellen DeGeneres, who usually avoids discussing political issues on her TV show, did talk about why we still needed to address marriage between two men or two women as “Gay Marriage.” We do not need to describe “Straight Marriage?”

In the beginning I had trouble referring to my life partner Gregory as “my husband.” Based on my early coming out, and societal norms of the day, if he was my “husband” that must mean I was the “wife!” And that was not true. With the passage of time, and laws, and common usage it feels OK to me to talk about two husbands, or two wives, two mommies or daddies. I have been able to leave the old thinking behind.

I believe that through flexible, open labeling we are able to gain a larger understanding of who we are and that we will all be better able to accept that "we are all one" deserving the respect and privileges of being human. Stereotyping no, but understanding our life through categorizing and labeling is how we make sense out of complicated issues.

The world is so torn by strife among ethnicities, races, religious beliefs, political affiliations, etc. Human rights including those of the GLBTQI community are part of this strife.

We all speak to the need to DO SOMETHING in a world that looks the other way when innocent black people are killed for little or no reason; when innocent police officers are ambushed; when innocent people are blown up to support other's political beliefs; when just to make a statement - theater audiences, college students, and children at school can be mowed down by assault weapons; when a Gay boy can be tied to a fence, tortured, and left to die; or when a woman or transgender woman can be raped and brutally beaten.

The Orlando massacre of 50 Gays and Lesbians and friends brought yet another and seemingly greater out roar about the need to stop the needless slaughter of people and the need for improved gun control and back checks.

It was billed as the worse mass murder in U.S. history and this was quickly followed by lists of hundreds of Native Americans who were killed by our government for fighting for their own beliefs and for freedom to continue their way of living which certainly pre-dates our own.

Society is slowly realizing that something must be done. But in a world that seems to have always contained violence and war, what will it take to change this and how long will it take? With each new occurrence we hope that this time something will be done but when?

Perhaps everyone needs to wave the RAINBOW flag to signify never again. Never again. Never again.