Editor's Note: We've received several longer letters and essays on the mental health issue recently, the first two in response to Bob Geary's story "Mental Health: We know what to do" (Independent Weekly, June 2), and a third about plans to close Dorothea Dix Hospital. We've decided to forego our usual length limits this week to continue the debate.
Community mental health centers were not the problem
As one of the last remaining child/adolescent therapists at a Burlington community mental health center, I have a front row seat on the impact of new mental health "reform."
It is a debacle. Here on the frontline, "reform" has manifested as the outsourcing of treatment to less-trained, non-licensed practitioners (hey, they're cheaper!), treatment chaos caused by splitting up providers (case manager here, psychiatrist across town, therapist there), limits on the amount of care available (a maximum number of visits before getting treatment "clearance"), increased obstacles to actually getting care (under target populations your kid is just not sick enough to qualify for treatment).
Our community mental health centers have served as the critical infrastructure to frontline treatment, crisis resolution, and preventive care (i.e. non-hospitalization). If the community mental health centers have failed in delivering care and prevention, it is not because they were recklessly spending. These centers have been slowly starved to death, both fiscally and physically. The centers are understaffed, under-resourced, and have been for years. For example, clinicians here carry caseloads of 90-120 patients, far above any best practices standards. Our center never had funding to hire more treatment staff to meet the burgeoning need, so children needing treatment had to wait for appointments, be it weeks or months (and in mental health care, timely responsive treatment is critical to quality care, avoiding hospitalization--plus it's just ethical). The physical starvation of our center is evident in the clinic; here the building pre-dates mandatory sprinklers, is lined with asbestos, has missing ceiling tiles with exposed insulation, offices have walls with active mold, the ancient phone system routinely breaks, etc. etc.
The new "reform" has it wrong. The community mental health centers were not the problem--lack of support and investment in these agencies has been the problem. Destroying the community mental health center infrastructure is a colossal mistake. This critical community resource is being eradicated, and what is left of it is being delivered into the hands of largely for-profit entities. It is pathetic and sickening that the mental health care of children and families is treated as a commodity for businesses to bid on, but that's capitalistic health care. I hope for some visionary legislators and/or motivated activists will stop this ill-conceived "reform" and see community mental health centers as the infrastructure to build upon rather than destroy.
Privatization for profit, not patients
I found your article on mental health "reform" interesting and although this legislation is water over the dam, at least for now, I still felt the need to comment.
It is important and necessary to examine this "reform" from a monetary point of view because the extent and quality of service to clients, despite the corporate rhetoric, almost always comes down to money. This "reform" claims that privatization will afford mental health clients more services for less money, but the data in Durham and other places in which this has been attempted does not support this assertion.
At the Durham Mental Health Center, the number of doctors available, the number and types of groups, the amount of individual counseling, the degree of case management, housing, transportation, medicines, any services afforded to a client always depended on money. Lobbyists for the "reform" claim that the county mental health system was not efficient. Lets look at some numbers. For a client who needed traditional case management, the Durham Center was seeing this person approximately weekly, and more often if necessary, for a cost of about $95 a month per client. The local agency that now hires the private service providers (or LME, for local management entity) has contracted with Telecare for intensive case management, and their Assertive Community Treatment, or ACT, team is charging the state $877 per month per client!! The minimum service for this fee is a one-hour visit to the client per week; some get more, but most do not. This doesn't sound efficient to me.
Your article states that this ACT team service is only transitional. Under a county mental health system, yes, but with a contracted private provider it does not appear to be that way. The ACT program in Durham was contracted to manage 100 clients (an arbitrary number) who they have managed now for more than a year. They still have almost the same 100 clients, no openings and almost no turnover. Now, new acutely ill clients who really do need intensive services are denied. Despite Mrs. Holliman's negative statement that the county system was underserving Durham, the Durham Center never denied clients the necessary services. It always found a way. This new quota system and the denial of services, I fear, is a harbinger of things to come. The LME's answer to this problem is to bring on board a second ACT contractor at $877 a month per client. This is not efficiency.
Speaking of the LME, in Durham County the LME is recruiting for a minimum of 46 positions at an average cost of more than $50,000 a year per position. That is $2.3 million of yearly and totally new, bureaucratic expenses. The LME also purchased software for $750,000. It has taken over one of mental health's best buildings, not to mention all its computer hardware and software (soon to be updated), which previously housed client mental health services. This is costing at least another million dollars a year in new overhead expenses.
Durham County has invested a lot of time and money in training its well-seasoned and highly skilled staff. But these employees are not likely to work for the private provider due to the significant loss in income paid as starting salaries and reduced benefits. Consequently, at least initially, the quality of mental health care in Durham will definitely suffer. The LME had the option of using existing staff as one of the providers but declined to do so. Failing to utilize available highly trained staff and retraining new staff for the same job is certainly not efficient.
Finally, the separation of mental health services among different venders will eliminate one-stop shopping at a cost of convenience to the client and increase the costs of overhead to the county through the vender fees.
Every place this privatization approach has been tried, the added expenses of corporate profits plus the immense amount of bureaucratic procedure and expenses has sabotaged any good intentions that privatization reform may have intended.
It is important to note that this ill-fated legislation, sponsored by Rep. Verla Insko of Chapel Hill, was supported and voted for by all the state politicians of Durham County including Wib Gulley, Paul Miller, Mickey Michaux, Jim Crawford, Paul Luebke and Jeanne Lucas. I doubt any of them ever came to the Durham Mental Health Center for input, apparently did no independent research, and I assume put their total trust in the information of lobbyists.
Editor's Note: At the request of the writer and after discussions with the editors, the writer's name is being withheld.
Save Dix, and save its patients
After Dorothea Dix made it her sole purpose to change the lives and the situations of the mentally ill here in Raleigh by opening up Dorothea Dix Hospital in downtown Raleigh, it would seem that she was successful in doing just that. After viewing the hospital in 1847, superintendent Eugene Grissom proudly proclaimed, "It was discovered that the insane were not beasts and demons, but men whom disease had left disarmed and wounded in the struggle of life and whom, not unoften, some good Samaritan might lift up, and pour in oil and wine, and set anew." This quote is displayed proudly on the Dorothea Dix Web site. Why, then, would Raleigh want to turn Dorothea Dix into 300 acres of real estate, with thoughts of turning it into a dog park or condos for the well-to-do? What happened to all of the progress that Dix and her like-minded comrades made, that the mentally ill were in need of help? Is Raleigh more interested in a dog park than in keeping not only a valuable and indispensable institution but a beacon of humanity and kindness open?
I argue that mental illness is simply not the cause du jour--it has not been trendy to speak up to protect the mentally ill. This is not surprising in a world where the mentally ill are portrayed in an exacerbated manner on television and in the movies at every turn. Even here in an area with the best kinds of medical care, the mentally ill remain at the bottom of our list. It has become acceptable to medicalize and even discuss at the dinner table "penile erectile syndrome" while Bob Dole and other "sufferers" of this so-called syndrome garner our sympathy, but to make human and real the plight of the mentally ill is still not palatable.
I argue that mental illness is not determined by the DSM-IV, which is still not a perfect diagnostic manual but, rather, uses a method similar to a line-of-best-fit to determine what might be the name for that which someone wrestles. Rather, the severity of one's mental illness and the impact which it is going to have on their lives is determined by social class. The same people that drive by Dorothea Dix Hospital securely in their SUVs and steadfast in their suburban lifestyle could be in that hospital if they had no financial support. Mental illness or diagnoses for the upper-middle class are merely a facet of someone; just as they have brown hair and a sweet tooth they also happen to have a touch of bipolarity or social anxiety disorder, making it a part of who they are but not hindering them in any way. We are quick, even, to diagnose our children, labeling them ADD in order to explain what might simply be a lack of discipline. But the poor don't have this option; their mental illness is not part of who they are but the entirety of who they are, and they are stigmatized. They cannot seek costly counseling and afford overly priced medication on their own, so what exactly does Raleigh think that they are going to do, those who are not relocated in 2007 when Dorothea Dix shuts down?
It is a shame that we call the Triangle a place of progress, where every day new innovations are made, be they in technology, medicine, academia. We have all of the tools at our hands for progress, but we lack heart. As Dix herself argued for the plight of the mentally ill, so now someone needs to stand up and fight for Dorothea Dix Hospital to remain fully functioning. I am not arguing that the treatment of the mentally ill, even in hospitals such as Dix, is perfect, but we should be ashamed of ourselves to shut the doors on these people and leave them lost, confused and most of all stigmatized. If we are indeed the place of progress that we claim to be, then progress needs to be made in our thoughts and in our hearts. Raleigh may need another dog park, and it may need more condos, but it also needs to step up and take a stand for those that can't help themselves.