By Jessica Rosenberg, CSW
(January 2000)

The treatment of the seriously mentally ill is receiving a lot of attention, both in the media and by politicians. The death of Ms. Webdale and the subsequent signing of Kendra's Law sharpened the public's awareness of a mental health system that is in serious disrepair. Social workers, who work with the seriously mentally ill, whether in outpatient or inpatient settings, are forced to try to provide services within an organizational context that often prohibits adequate care.

Social workers are under tremendous pressure from administrators to discharge clients. They are being pushed to empty beds so that new clients can be admitted. Administrators, in turn, are under pressure to generate revenue for the hospital. Many insurance companies routinely refuse to pay for treatment that lasts more than a short time. Trying to get them to pay requires endless phone calls and chart work. In outpatient settings, the advent of Medicaid managed care means that insurance companies have to authorize treatment before it is provided. Seriously mentally ill people may be allotted limited sessions and social workers may be directed by their administrators to withhold treatment when the hospital cannot collect reimbursement.

Another dimension of the workload that impedes quality services is onerous charting requirements. These demands amount to a catch 22 for social workers. On the one hand, documentation is an important mechanism for accountability. On the other hand, the excessive paperwork reduces the time that could be used to treat clients.

In addition, many social workers carry case loads that are so high that it is extremely difficult, if not impossible, to adequately provide treatment.

Because of scarce resources, waiting lists for important services like intensive case managers, housing, and substance abuse treatment, far exceed the limits of most inpatient hospital stays. Prior to pushing Ms. Webdale into the subway, Mr. Goldstein's social worker tried unsuccessfully to get him an intensive case manager. Mr. Goldstein's mother had also begged the hospital not to discharge her son and to transfer him to a long-term facility. Hospital administrators refused. The clients are underserved and the social workers are getting squeezed.

Recently, Ms. Teena Brooks, a social worker employed by the Urban Justice Center's Mental Health Project, described her work advocating for the homeless mentally ill in inpatient psychiatric settings. She related her frustration with the inpatient staff, including social workers, when they fail to develop adequate discharge plans for their patients and discharge them to shelters. For example, an inpatient social worker recently told Ms. Brooks, "I have a caseload of thirty clients, I don't have time for this client's problems. I arranged to have him discharged back to the shelter, let them worry about what to do next."

The client in question has a history of mental illness and has cycled between psychiatric hospitals and city shelters for over five years. In this case, the discharge plan is replicating a pattern of a failure to meet the needs of a vulnerable and at risk individual. Where does this leave our profession? Social workers have a Code of Ethics and professional standards that must be upheld. When social work practice falls short of these standards, social workers place themselves in professional jeopardy and render our profession vulnerable to criticisms.

Advocacy groups like the Urban Justice Center play an important role in protecting social workers and their services. It is not easy to withstand pressure from administrators when you feel overwhelmed and are fearful that if you do not cooperate, you could lose your job. For social workers, there are options. It helps to develop a comprehensive understanding of the pressures shaping practice. Increased caseloads and paperwork are consequences of the lack of funding for mental health care. Similarly, the shrinkage of resources like supportive housing and entitlements reflects funding cutbacks. Social workers can also experience empowerment through dialogue with one another about workplace pressures. Dialogues can occur with coworkers and with other social workers through involvement in professional associations. Other options for social workers to protect themselves and their services can include advocacy groups and unions.

This issue of Currents focuses on mental health treatment. An interview with the New York State Commissioner of Mental Health examines the State's vision for the future of mental health and the role for social workers as key providers. Social workers provide 65% of all mental health treatment in the United States. This issue also provides a debate on Kendra's Law, a controversial new law enacted by the State legislation that will have a profound affect on mental health care. A consumer perspective on serious mental illness is featured.