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Tue Dec 18, 2012, 11:00 PM

Dispatch from the trenches of public mental health.

I wrote this last night here: http://www.democraticunderground.com/10022016792#post22

As a preface, the discussions on mental health this week have gotten me where I live. On April 20, 1999, I was working a few counties away from Columbine High School, in the juvenile division. I had several clients who were either expelled or suspended from school in the days after -- not for anything they did, but for being different, under care, or just part of the geek/goth sub-culture. My clients bore the blame for the actions of others, and that blame did not help anyone -- not community, not clients, not the victims. I'm seeing that exact same pattern again. We have done this, and the collateral damage endures.

These are my experiences -- the stats have probably changed since my colleagues and I last compiled our numbers, but they haven't changed much, and in many cases, not for the better. I don't have accurate numbers for 2008-forward, but given the slashing state, county and city budgets have taken, I'm not hopeful for better.

~~~~~~~~

I used to be a clinical psychologist in public mental health. Burn out is the brontosaurus in the living room. Here's a snapshot of the trenches. The average public mental health clinician has been in the job for less than five years, and has been licensed for about the same amount of time. They're mostly young and new. 65% leave public service for either private practice or get out of the field entirely. I was lucky -- I had excellent scholarships and fellowships through grad school, but some of my peers self-financed and left grad school with debt they will be paying until they hit Social Security age. Starting salary at the county level (which is the majority of public mental health clinicians) averages less than the average first year public school teacher. (A psychologist, by the way, usually has 7 years of post-secondary education; a K-12 teacher has 5-6.) We don't have a union. In some counties, we're not even employees -- we're contractors, so no benefits. We don't go into psych for the money -- we're there because we want to help others. And it kills us -- we're 3 times more likely to commit suicide than our peers. We're 6 times more likely to be on anxiolytics than the general population.

In my last year before going back into research, 95% of my clients were court-ordered. The few who were there voluntarily were as compliant as their circumstances allowed, but a court order drops compliance by at least half. A therapist can't help a client who doesn't want help, and often clients work against court-ordered therapy. For the court-ordered client, the therapist is the avatar of a power structure where the client is entirely disempowered. The therapist seems to have the power to send a parolee back to prison for a beer or mouthing off, to place zir children in foster care, to force them to abandon anyone we determine to be a "bad influence" -- which in a lot of cases, means most of the client's social network. In most counties, the client is forced to pay for this. In most places, public mental health services are set up to fail comprehensively. I worked in a red county, and believe me, the county board of supervisors wanted us to fail. If we failed, they could stop paying us liberal commie bleeding hearts and just send all that human garbage to rot in prison (and that prison made a lot of the local power structure a lot of money...)

Our clients' median household income was less than half of the local median household income. Poverty makes compliance harder. Pop quiz: go to therapy or go to work -- when skipping either violates parole? Buy court-ordered meds or buy food? Use one's 9th grade literacy skills to write in one's therapy journal or get an extra half-hour of sleep after a triple shift? Pick two: rent, therapy, or kid's root canal? Clients have a lot of dreadful algebra every day. For a lot of my clients, poverty was both the cause and effect of their dx. Public mental health made me a socialist -- fix the social safety net and half of the client load vanishes because half of the client load is situational. If every kid has enough to eat, safe and comfortable housing and an effective school, if every adult has safe shelter, valued, meaningful work and sufficient leisure, depression and anxiety plummet. It's not a panacea, but our deficits in the safety net magnify our problems.

I spent most of my time in the trenches deeply worried about my clients -- I took it home with me every night. If a client was non-compliant and I reported it, my client could have gone to prison (or gone back for parole violation), which ends any hope of effective treatment. Non-compliance can mean anything from skipping appointments to not doing the work to skipping meds to self-medicating. I was supposed to report every beer, even with clients who had no addiction problems. Do I report someone because zie blew a long-bald tire or got a chance to work extra hours so zer kids actually got new shoes, but can't call to reschedule because zer boss doesn't allow personal calls (or maybe doesn't know zie's in therapy -- people still get fired for mental illness, especially in right to work states)? If I didn't report it, that's my license... And possibly a suicide, or domestic violence, or a relapse. Believe me, that stress eats therapists alive.

Without a license, my master's degree won't get me a job at a call center or flipping burgers. But pissing off a client by reporting non-compliance earned one of my colleagues a severe beating. I had my tires slashed (which were bald, but I couldn't afford to replace them.) I was salaried, scheduled for 30 one-on-one appointments a week, plus 10 hours of group, plus 75 welfare calls (6-12 hours), plus on call for 24 hours a week. Yes, 70-80 hour weeks, for which the county paid us $27K a year plus medical and dental (but I couldn't take the time off to actually see my doctor or dentist...) Unlike teachers, we don't even get summers off. The year I left, the county I worked for cut 3 of the 27 positions and the county judges ordered 21% more therapy. Which meant worse service, worse outcomes, more recidivism, which gave the county board of supervisors more incentive to cut the budget.

This country doesn't care about public mental health, either the clients or the therapists. We're first responders -- and the first rule of first response is don't be a casualty. I was terrified I was going to kill myself, or screw up so badly that a client or someone else got hurt. I cried every night for three years. I am in research now so I have the energy and time to fight for better conditions for clients and colleagues. I still have 80 hour work weeks, but half of that time is lobbying on their behalf. It's the only way we'll ever change it. Public mental health is like juggling burning napalm.

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Arrow 21 replies Author Time Post
Reply Dispatch from the trenches of public mental health. (Original post)
politicat Dec 2012 OP
theinquisitivechad Dec 2012 #1
cliffordu Dec 2012 #2
joeunderdog Dec 2012 #3
politicat Dec 2012 #18
nenagh Dec 2012 #4
politicat Dec 2012 #17
nadinbrzezinski Dec 2012 #5
Mnemosyne Dec 2012 #6
Fire Walk With Me Dec 2012 #7
politicat Dec 2012 #16
HiPointDem Dec 2012 #8
snot Dec 2012 #9
ellisonz Dec 2012 #10
politicat Dec 2012 #13
lindysalsagal Dec 2012 #11
politicat Dec 2012 #14
Denninmi Dec 2012 #12
politicat Dec 2012 #15
Denninmi Dec 2012 #19
KittyWampus Dec 2012 #20
politicat Dec 2012 #21

Response to politicat (Original post)

Tue Dec 18, 2012, 11:33 PM

1. Wow

Had no idea it was like this. Hats off to you and folks like you that spend their effort on others in such a drastic way, even if only for a few years. That is more than most of us could ever emotionally handle. Thanks for your input and shedding light on this issue.

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Response to politicat (Original post)

Tue Dec 18, 2012, 11:39 PM

2. Having been on both sides of this conflagration,

K&R.

EVERYONE should read this.

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Response to politicat (Original post)

Wed Dec 19, 2012, 12:14 AM

3. Boy, I could tell some stories...

25 years in State work. My caseload is community followup with a primarily forensic population.

As long as you do your job and everything goes well, no one even knows you're out there.

But if something goes wrong, the headlines are a source of great discomfort for your agency and someone will be asking you a lot of questions real soon. It's a high stakes game.

And of course they just keep cutting services and raising expectations.

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Response to joeunderdog (Reply #3)

Wed Dec 19, 2012, 11:00 AM

18. +1000

Thanks for staying so long!

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Response to politicat (Original post)

Wed Dec 19, 2012, 12:53 AM

4. Politicat, I read your comment last night and it is just as awful to read it again tonight.

Recording a beer! a missed medication dose... I suppose they are trying to assess non compliance..

But the work load, the judgment calls where everything is a grey area, operating in a zone of economic desperation



Living in Ontario..where health care is a covered... We are so lucky...

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Response to nenagh (Reply #4)

Wed Dec 19, 2012, 10:59 AM

17. All systems are accretive - policy collects like barnacles on a hull.

So the why of the records and reporting goes back to a previous generation, when public mental health was somewhat better funded, more focused on addiction issues, and given earlier drug regimens, booze could be a serious problem. Tri-cyclics and early anti-psychotics were incredibly dangerous when mixed with alcohol, and the standard treatment for addiction was the ____ Anonymous model, which requires abstinence. Those policies were written then, but treatment has changed, meds have improved, and we've moved past Just Say No and DARE and _A is no longer the gold standard. But the policies didn't change. Some were mandated, some were just "the way it's always been done."

Here's the other key -- my area was comfortable economically as a whole. Both the correctional system and the public mental health system were used as clubs against the lower class as a means of profit extraction and a means of control. That's why the Powers That Be don't want a healthcare system like yours -- it empowers the individual, who is then much more likely to demand that other imbalances be addressed.

We're getting closer to parity. Just not fast enough.

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Response to politicat (Original post)

Wed Dec 19, 2012, 01:01 AM

5. Yup,

Do the best you can,,,while we pull the rug out.

I call this one more form of violence, against both you and your clients.

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Response to politicat (Original post)

Wed Dec 19, 2012, 01:41 AM

6. Thank you, politicat. K&R nt

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Response to politicat (Original post)

Wed Dec 19, 2012, 02:13 AM

7. "...half of the client load is situational."

 

Thank you. The Los Angeles Project 50 and other studies shows that homelessness and associated mental health issues may be headed off through permanent housing and care at a genuine savings to the city. Support and care are very important and they are NOT supported as you detail, by red states and politicians. For-profit prisons are, however, so make the connection, everyone.

Thank you for your caring efforts on behalf of those who need your work. I'm so sorry for your suffering as a result. Please help us be safe from even "well-meaning" democrats who would seek to use force and "lists" upon us (the same people offering these "solutions" would hopefully scream if the "tea party" demanded the exact same thing).

You may enjoy reading more about Project 50's positive results here:

http://www.democraticunderground.com/10022007213

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Response to Fire Walk With Me (Reply #7)

Wed Dec 19, 2012, 10:39 AM

16. Thanks! I <3 Project Los Angeles 50

We're seeing more integrated, structural shifts slowly coming on line, and I expect that to ramp up in the next few years as my generation comes out of the trenches and into leadership. We Xers tend to be very practically minded, and the advantage of feeling alienated from existing systems is that we're willing to abandon what's broken for something that can be proved to be objectively better. But also not being idealists, we'll take incremental change, and we're data-driven.

The prison industrial complex and the insurance industrial complex... Those are the big dysfunctional structures.



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Response to politicat (Original post)

Wed Dec 19, 2012, 02:25 AM

8. Big KR. I have a friend who's a social worker who told me a similar story. The system is about

 

*punishment* & setting people up to fail, not rehabilitation -- & even if it were about rehabilitation, there is little hope that most people in that situation would ever be able to channel into decent stable living wage work.

My friend said she would *never* work for welfare, for example, because they are basically trained to find ways to deny their clients needed services.

It is so fucking criminal. Criminal not only to the clients, but to the people like yourself who go into the system wanting to help people.

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Response to politicat (Original post)

Wed Dec 19, 2012, 02:41 AM

9. K&R'd!

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Response to politicat (Original post)

Wed Dec 19, 2012, 03:29 AM

10. K & R

I suggested to a recent PhD psychologist student interested in the public policy end that practice might be a good start, now I feel kinda bad about giving such advice.

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Response to ellisonz (Reply #10)

Wed Dec 19, 2012, 10:08 AM

13. No, it's not.

If someone is ultimately interested in the public policy aspects of public health, that person has to be in the trenches, at least for a while. One can only assess the true state of the system by seeing how the system affects those with the least power . The best advocates we have know the system from the inside -- because their experience has made it visceral for them.

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Response to politicat (Original post)

Wed Dec 19, 2012, 03:35 AM

11. What? You mean it's not like on TV?

3 visits to the nice shrink in the leather-upholstered office with fresh flowers, and everything is resolved in 30 minutes?

Honestly. TV has warped our minds. We've lost our collective grip on reality. It's like a bad Twilight zone episode.

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Response to lindysalsagal (Reply #11)

Wed Dec 19, 2012, 10:09 AM

14. +1000

This!

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Response to politicat (Original post)

Wed Dec 19, 2012, 04:26 AM

12. My experience was not in the public mental health system, with a private physician and hospital.

Well, the hospital was private in the sense it wasn't owned/operated by a government. Not private in the sense of one of those little hospitals/clinics that are now actually ADVERTISING on television and online (at least they are here, I've seen several TV commercials for a couple of different ones). The hospital I was at, I don't want to name names because it is too much of a clue to my identity, is Michigan's largest private health system (to my knowledge, might be surpassed in total beds by the Detroit Medical Centers system, but not by much if it is). And trust me, it's no down on it's luck, urban hospital. This place is upscale, everything about it screams "big bucks" coming into the system, even the psychiatric program. The facility is ... breathtaking is the word that comes to mind, like a city unto itself, all kinds of services and amenities -- valets, concierge, shopping area, food court in addition to enormous cafeteria, florist on site, big chapel, etc, you get the picture.

And, with all of that money flowing in from patients and their insurance companies, I found some things quite lacking in their Partial Hospital Program, and other things done really well. Mostly, it seemed to be the staff, good or bad, that was the difference. I could tell who really gave a damn about their patients and their jobs, and the ones that were just phoning it in at best. The "house doctor" I saw during this period, not sure of the right term, he was WAY too old to be a resident or attending, was a total, useless idiot, not helpful, not supportive, I actually had to almost fight with him on meds, on getting my stay extended a few extra days so I could "finish out the week", and so forth. Weird, I hated going there, was terrified, once I kinda calmed down it became a bit of a sanctuary, didn't want to go out and face the real world so I extended it a few extra days beyond the original plan. Thank God my Blue Cross covered it.

Mostly, though, the other patients really broke my heart. I honestly, IMHO, was not really "there" in the sense I didn't feel I needed that type of program, I could have been treated adequately on a strictly outpatient basis, since I wasn't going anywhere, and I was the only one who even knew of my approaching a psychiatrist for treatment, so it's not like I was dragged there against my will. But, due to circumstances beyond my control, i.e. a physician I later found out had an absolutely terrible reputation among patients per a number of those "rate your doctor" sites, I was pretty much coerced against my will into doing this day program under threat of "or else." Which is why it was so traumatic to me, to think that I approached this doctor, based on reputation of this hospital system which brags in their extensive advertising campaign about how superior their physicians are, with the tagline set to dramatic music of "Do You Have a ******** Doctor?" -- to think I went to her looking for help and support, and left an hour later under threat of "psych ward or I have the cops show up and throw you in the back of a squad car in cuffs and take you against your will" -- that almost literally destroyed me. I had no "suicidal intent" when I went into that office, I was damned, damned close to really doing it when I left. But, water under the bridge. The hospital program, once I calmed down, helped a lot, and it really did "fast forward" this thing for me, I'm sure I made progress a lot faster, and began to repair the damage this woman did to me faster, because of it.

Back to the other patients, it seems most were caught in this spiral of "buying into it" so that their lives were permanent mental health crisis and that is what they lived for. Multiple suicide attempts, multiple hospitalizations. It was heartbreaking. I can understand that people GET sick, many of these conditions, probably all, have a neurobiological basis in the brain, but what I can't understand is why people would buy into it, wallow in it, some almost seemed to wear it as a badge of pride. And make NO EFFORT to get out of it. Don't get it. Anyway, not me. I'm never going back to that, I didn't have room in my life for ONE mental health crisis, and, Oh Hell No, never again.

Sorry I keep ranting about this on post after post, but I was one of the "bigger" things that has happened to me, in a life that was far from easy, and I guess it just helps to get it out.

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Response to Denninmi (Reply #12)

Wed Dec 19, 2012, 10:26 AM

15. Please talk about it.

You know how in pro-choice circles we say, "trust women"?

In advocacy circles, we're just getting to that point of saying "trust the patients."

I agree that advertising is a problem -- across the board, but in healthcare and mental health care especially. One, it diverts essential funds. Two, it's manipulative, and is most effective in situations where the target of the advertising has the least defenses against it.

I'm really glad you got effective help, and I'm sorry it came wrapped in a big ole shit sandwich. And if nobody else has said this... It's perfectly reasonable to feel ambivalent about your experiences; ambivalence is a sign that all sectors are working.

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Response to politicat (Reply #15)

Wed Dec 19, 2012, 11:45 AM

19. Thanks.

I'm always leery to read replies. Most are kind, supportive people such as yourself, but some are ignorant haters. Thanks again.

Yes, the circumstances were hard, the outcome very good. I feel like I've been given a fresh start in life, I have a great therapist, and I found a doctor who is just the opposite of the first one, kind, considerate, personable.

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Response to politicat (Original post)

Wed Dec 19, 2012, 11:51 AM

20. So much of the system is geared to handing out drugs. So little to other therapies.

Both my brothers had/have serious episodes.

One lives in a county that has half way decent support sytems.

The other lives in a county with next to none.

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Response to KittyWampus (Reply #20)

Wed Dec 19, 2012, 01:09 PM

21. so... orthopedics are geared towards handing out casts, and optometry towards glasses.

Drugs are our emergent care tools. Think about them as a cast for a broken leg -- the bone has to heal, but afterwards, there's physical therapy to repair the damaged soft tissue and atrophy. Until the bone is healed, nothing else can be fixed, and trying to rebuild the soft tissue with a broken bone will make the soft tissue damage worse. Not to mention HURTING.

Drugs are also our long-term management tools -- like glasses, or insulin. No physical therapy will fix myopia, and nothing will convince a pancreas to produce insulin after it has quit.

Drugs are tools, but because we can't see how the brain is mending -- unlike a broken bone -- on an xray (though we're getting close with fMRI) each patient ends up being zir own personal experiment. And yes, it's frustrating when nothing seems to work. I think of it as everyone in the world running a slightly different version of a computer operating system, and trying to install a patch. Most times, the patches work -- but some people are using an obscure Linux distro, or still on MacOS 7, or Windows 3.1 because those systems work most of the time for them.

When we find the right drug therapy, it provides the patient with support, to take time to deal with either the habits of mind that have helped trigger the dx, or to come to terms with a long-term chemical issue and re-establish functional habits within the new limitations. (As in, I have to grab my specs every @$%*&^% morning if I want to get from bed to bathroom because I'm really near-sighted. As in a bi-polar II dx means learning more functional ways to cope with stress and backing away from substances that can trigger an up or a down. As in a major depression dx means de-programming the negative subroutines that have infected the system.)

But in public mental health, we're essentially the ER -- not the place to be getting long-term and preventative care. So yes, we give out SSRI and neuroleptic "casts" as the first line. In private care, insurance companies limit the number of visits and usually charge far more than the co-pay. Imagine a brittle diabetic trying to get zir condition under control, but the insurance says only ten visits a year, and no labwork. We know that drugs alone aren't the answer, but the systems we have to work within (and again, if we go outside, we're likely to lose our ability to pay rent and possibly our ability to practice at all) are set up to make our jobs more difficult. Drugs offer a better chance of improvement over nothing at all.

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