The Challenging Climate of the Mental Health System
Enormous Stresses for Clients and Dedicated Social Workers
Sue Matorin, MS, ACSW; Treatment Coordinator, Payne Whitney Clinic, New York Presbyterian Hospital; Weill Cornell Medical College (Faculty)
Social work clinicians who work with clients with mental health problems know first-hand narratives of resilience, as well as the professional gratification of being a conduit for recovery from crippling symptoms. Clients with severe and persistent mental illness face many obstacles in obtaining needed support and care.
Ultimately, it is often only those with poor treatment compliance and readmissions who have the chance of being assigned to a skilled compassionate case manager to help navigate a challenging health care system. That this one segment of all clients living with mental illness may actually experience this “silver lining” is both ironic and unfortunate; the large majority does not qualify for such oversight and are left to fend for themselves. The impact of a punishing economic climate in which those able to work can't find any work, combined with amplified pressures to cut costs by "managing care”, have created enormous additional stresses for clients and dedicated social workers.
The following is a case example of the impact of multiple elements at play in the current climate of the mental health system. Ms. M, a single African American woman with some college education, kept herself afloat for years with supportive counseling and medications, despite a chronic psychiatric illness. She had no hospitalizations. A skilled cosmetician, she was always able to work part time. (Clients on social security disability and medicaid risk loss of that benefit base if they work full time. ) She was proud of her apartment, an avid reader, gave generous cosmetic treats at Christmas to group members, and kept distance from family members who had traumatized her as a child.
Not having work ushered in a downward spiral: loss of her apartment, life on the streets, and irritability outbursts which led to an arrest for an offense which no one took the time to understand. Despite aggressive advocacy, she entered the criminal system: a long stay on a unit at Rikers, then the state hospital system. No efforts, clinical or legal (she was “represented” by an overworked inexperienced legal aide lawyer), were made to collaborate with the treators who had cared for her for years. This is arguably a far costlier outcome than ambulatory care. More alarming is the callous disregard for a life which unraveled with stress, a person defeated by poverty, and the failure of the mental health system to provide humane, evidence-based, integrated treatment.
Recently, many clients have been overwhelmed by a Medicaid initiative to manage pharmacy costs. They have received letters from the State Heath Department that are alarming. The letters warn that certain medications may not be covered, that clients may need to change pharmacies, etc. These letters are not user-friendly and are difficult to comprehend, and much patience is needed to access the State Health Department phone line. While this initiative may seem well intended in an effort to curtail cost, its execution, in fact, has added enormous stress for clients who depend upon a vital medication regimen for stability, and may have a relationship with a neighborhood drug store. Additionally, clients are forced to ask their busy doctors who have already elected a medication regimen that works, to now spend valuable time requesting authorizations for what had been previously prescribed.
Clients with psychiatric illness also suffer stigma – sadly, even among health care professionals. A study of social work student attitudes towards individuals with psychiatric illness reported in Social Work (Covarrubias, October 2011) that stereotypes of dangerousness, in actuality a very small component, can perpetuate stigma. Recent material in the New York Times highlighting one individual's capacity to overcome crippling psychotic delusions, and riveting first-person accounts of recovery in Psychiatric Services counter stigma and highlight the person buried within a diagnostic label. Furthermore, diagnoses are lumped together, undermining a knowledge base of current treatments and potential positive outcomes now available for specific disorders. It also remains a challenge to find integrated programs that address medical health issues as well in a user-friendly accessible manner.
In sum, clinical practice with individuals and families who present with behavioral health issues remains an intellectual and emotional challenge. Even when dealing with a high risk suicidal person, the opportunity to marshal one's skill to offer a life line and tap resilience is daunting, but rewarding. Advocacy – always a component of the work – now seems adversarial and an exercise in damage control as clients already challenged by serious stressors navigate an increasingly bureaucratic climate which is heavy on rules and regs, and short on empathy, an essential ingredient for stability and recovery.
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