9/28/2010

State funding will never be enough

Louis Josephson, CEO of the Riverbend Community Mental Health Center in Concord asked voters to “make mental health care an election issue” in his Sept. 27 Concord Monitor column.   Here’s why his heartfelt appeal, which is true in every detail, won’t work, and how it might be made to work:

To survive, community mental health centers must find alternative sources of funding. They will always need state funding, but that stream has been slowing down since 1997, long before the current fiscal crisis began in 2007.

Community mental health centers depend almost completely on Medicare and Medicaid money. They do little to attract clients with private insurance. Yet they offer marketable services unavailable in the private sector, like case management,  job counseling, and supported employment for people who want to work, but have spotty resumes or have been out of the workforce for an extended period.

If all the community mental health centers do to survive financially is beg the state for more money to do what they’ve always done, the way they’ve always done it, their only future will be shrinking appropriations, more downsizing, and cuts in essential services. Level-funding a community mental health center is really a budget cut of 10 to 15 percent, because the agency’s expenses are not frozen. For the past decade, community mental health centers have been level-funded in good years. Downsizing is not a viable plan for the future. The state will never restore the money and services lost in those years.

We need a revolution in mental health care. We need to stop telling people what’s wrong with them and start asking what happened to them. The fancy name for this is “trauma-informed care.” The goal is recovery – getting well and staying well.

Psychologists Kim Meuser and Stanley Rosenberg of the Dartmouth Psychiatric Research Center, who have done pioneering work in the role trauma plays in mental illness, estimate that two-thirds of the adults receiving community mental health services – four-fifths of the adult women – have experienced previous trauma.

Yet post-traumatic stress disorder does not respond to psychiatric medicine like schizophrenia, bipolar disorder or clinical depression. It is not a biologically-based disease like those other three. It is a normal human reaction to abnormal events that really happened, like combat, natural disaster, abuse and neglect by a caregiver, domestic violence, rape, or other crimes.

Not everyone who experiences these traumas develops PTSD, but most people in community mental health centers have it, in addition to anything else they might have.

Community mental health centers already offer a cognitive-behavioral treatment for PTSD called dialectical behavioral therapy (DBT).  It is a highly structured, evidence-based group intervention that helps many people. But for many others, it takes too long (a year) and is too structured, or it does not allow time for an individual who has a long setback during the year. Training to conduct such groups is expensive. Typically, community mental health centers train one or two people. The system must offer more than one treatment option, and train their regular clinical staff to work one-on-one, and in less structured support groups, with clients who have PTSD.

People with PTSD might still need medication for their biologically-based mental illnesses, but they can become more satisfied with who they are and the quality and balance of their lives, relationships, and connections to the community. Recovery-based, trauma-informed services turn many people from tax consumers to taxpayers. They can graduate from being high users of state-funded services and become low users, spending far less time in hospitals, emergency rooms and expensive one-on-one home visits with their case managers.

Few people graduate from today’s community mental health centers or become low utilizers. People graduate from our network of 10 consumer-run peer support agencies. Combined, they cost the state a tiny fraction of just one community mental health center. Peer-support agencies can’t replace community mental health centers because they can’t prescribe medicine or offer one-on-one psychotherapy. But their programs are recovery-based and somewhat trauma-informed. People become less dependent on expensive state services. Peer-support agencies also help many people, but not everyone. The more different trauma-informed recovery-based options the mental health system offers, the more people will get well, stay well, and become less expensive to treat.

Community mental health centers and peer-support agencies should be training their workers in trauma-informed care. The state should pay for it because it will save money over time. They can demonstrate that saving to the Legislature.

If community mental health centers start losing revenue when people graduate or become low utilizers, I guarantee they will find plenty of other people to serve, maybe even some with private insurance. And they will have success stories to tell the Legislature, and successful graduates to tell their own stories, as our PSA successes do. People telling their own success stories in their own words will impress the Legislature far more than any tale of woe from a paid lobbyist or agency director about people who will always be sick, dependant, and helpless.

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