Here's a good (but long) letter recapping what went horribly wrong with North Carolina's mental health reform and imploring lawmakers not to cut community support. An excerpt: I have to say that I have never come across an individual with schizophrenia recently released from John Umstead who feels like an empowered "consumer" with choices of where to get services. Legislators looking down from 30,000 feet could not realize that someone with florid psychotic symptoms does not ponder his service options as if he were picking Target v. K-Mart.
In 2001, mental health reform hit the public mental health sector like a sledgehammer. The idea was that county government, which at that time was administrating and serving public mental health services, should not be "in the business" of providing services. Administration and service provision should be separate.
Another underlying concept was "private agencies can be more efficient" at providing services and that by privatizing "competition" between private agencies would encourage better service provision. Despite client advocacy groups, professionals and independent consultants warning against this, the reform went forward. Let's review what has happened ...
First, many seasoned therapists were cut to the wind. They were "divested." Some found new jobs in county government, some left mental health altogether, some went private. Thousands of clinicians who knew their clients and knew the resources were cast off, kind of like the current state furloughs and layoffs. The system went into turmoil like giant tectonic plate movements
Next, we have to review the concept of "competition" making the private agencies perform better. How can a private agency excel compared to another if ALL of the private agencies are subject to the same policies, procedures, restrictions, paperwork, mandates and licensures as all other private agencies? Flawed from the beginning is the idea that public can be done privately. Currently, private agencies are subject to public restrictions, which levels the playing field and goes against the free market concept of improved quality of care through competition. I remember a while back there was talk of "privatizing" Social Security with the same underlying ideology as mental health reform. Looking at how our economy has turned out, I am sure many people are sighing relief that this was not put in place.
Reform also turned clients into "consumers." Consumers? What are they consuming? Once again this throw-back to a Bush-Reagan free market ideology was so far from the mark of what mental health services are all about. They are clients, not "consumers" as if they are getting a happy meal. At the risk of being politically incorrect, I have to say that I have never come across an individual with schizophrenia recently released from John Umstead who feels like an empowered "consumer" with choices of where to get services. Legislators looking down from 30,000 feet could not realize that someone with florid psychotic symptoms does not ponder his service options as if he were picking Target v. K-Mart. The mentally ill need rapid care from the persecutory voices in order to prevent decompensation.
Another unfortunate and unforseen consequence of reform/privatization is that the pop-up agencies were focused on profit. Key services were cherry-picked where the most profitable were emphasized at the expense of other clinical services. Just like the private defense contractors billing the Pentagon $500 for a toilet seat, private mental health agencies went for the "product" that would be most lucrative ... hence the current fall out over "millions wasted with Community Support." In the current budget melee, Community Support Services are being lasered for elimination. If this occurs, thousands of individual employees will lose their jobs, many private agencies will go out of business, many clients will be unserved, the ERs will flood and lawsuits (like Thomas S. or Willie M.) will be levied. In Chapel Hill, when a large and key agency with hundreds of clients could not make good quarterly profit margins, they simply packed up and closed shop giving a 30-day notice. Everyone was left in a lurch. Haven't we learned from this experience?
Change in the current system is required, but it is necessary to move diligently and slowly. Gradual redefining of community support is wise. Pulling the plug reactively or punitively for the past expenditures is disastrous. One of the foundations of clinical work is consistency — consistent taking medication, consistent parenting, consistent attendance at support groups, etc. etc. We can see the effects of past radical changes leading to horrible inconsistencies in the system with concomitant negative impact on our clients.
I encourage the House and Senate to learn from the past and support posive gradual change as opposed to another sledgehammer.
Geoffrey Zeger, ACSW, LCSW