01 Feb

Best Practices

A few years ago I was getting the mandatory orientation to all the paperwork (full Medicaid) in the first week of my new outpatient clinical job at a community hospital.  As the forms just kept coming I mildly rolled my eyes, and the guy orienting me noticed. He wasn’t particularly bothered – he just shrugged and said, “We are supposed to be treating the truly sick, not the worried well.”

I appreciated his loyalty to the underlying rationale:  we providers treat mental illness, which is increasingly seen as a brain disorder, under the medical model.  We make a psychiatric diagnosis (requiring a specific DSM code), we create a treatment plan with goals to address that diagnosis, and we document (paperwork) treatment progress toward those goals.

Here’s the thing. I can’t count the number of times I’ve had some version of this encounter: a client comes in for the initial session and says, in essence, “As far as back as 12, I’ve been told I’ve got ADHD, Bipolar Disorder, OCD, Generalized Anxiety Disorder, and Major Depression. I can’t remember when I didn’t have a Case Manager. I’ve been on so many medications I’ve lost track, and I can’t tell you what I’m on now, either. I don’t remember much about all the counseling I’ve been in – except that there’s been a lot.  I’m here because I have to be.  Either I’m on SSI mental health disability and need to be evaluated to keep it going, or I’m applying for disability and I need to show that I have a diagnosis and am in treatment.  I definitely have issues, but I can’t remember what they are.  What’s your question?”

I’m not exaggerating, but if you thought I was going to go on a rant over waste or fraud in the system, or attack the medical model of mental illness, I’m not.  My beef is with my fellow professionals and myself. The main treatment is medication.  Talk therapy (whether called psychotherapy or counseling) doesn’t have nearly the cachet, positive intellectual energy, or capacity for engagement it once did. So many clients have done so much counseling and, so obviously, not gotten better – sometimes after hundreds of clinical hours paid for by taxpayers – it’s entirely reasonable to ask  whether it’s a good use of public funds. “No shows” have become endemic.

I’m particularly concerned about how dispirited my colleagues have become, how everyone’s heads are down, and how much we’re focused on news about how much or how little funding has fallen under the budget axe.  There’s also the tendency to give diagnoses as a vehicle for receiving services – well-meaning and compassionate – but then those diagnoses become a basis for establishing long-term disability.

I’m discouraged that one major conversation we’re not having is the one among professionals about what we’re seeing out there – and what we might do about what we’re seeing.

If all we do is complain about heartless politicians, we’re missing a major truth. Taxpayer skepticism about the system as it exists is essential – no matter where on the political spectrum that skepticism originates.

We should be talking about the delivery of our services frankly, pragmatically, and be far more clear-eyed about needing to pull the plug on expensive services not bearing fruit.  There is cynicism all around, not just from angry critics.  I worry that many mental health professionals have given up, but just aren’t saying so.  This is something I’d love to be wrong about.  Please persuade me.


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