The Politics of Mental Health
Before I start discussing this topic, I want to notify our readers that this is an opinion piece based upon my 10 years working in the mental health field. I’m going to bring up issues we witness at both the federal and local levels. And, I may make you mad. But I think it’s worth it. Feel free to let me know in our comment section below.
The problem:
- Mental health is in the news and on social media as a “hot button issue”—aka something to blame. We are having lots conversations about how mental health is the problem or the cause of massive atrocities like school shootings, attacks on public places, or any other act of violence. We are not having conversations about:
- How mental health is hiding in silence behind stigma, and how THAT is killing people
- How mental health is the most under-funded sphere of health care in America
- How the average life expectancy for people with major mental illness ranged from 49 to 60 years of age in the US
- How 1 in 4 people suffer from a diagnosable mental illness
- How many insurance plans do not include a mental health portion to their plan
- How the DSM V is a culturally insensitive manual
- How mental health is seen as something to be ashamed of in our society
- How grief/trauma/neglect/genetics are not worth discussing openly because they should be handled quietly
I could keep going, but I feel sated (and I bet you do too). The take away point is that we are happy to use mental health as an excuse, but when it’s time to tackle the complex issue, we shove it to the corner and tell people to “pull themselves up by their bootstraps.”
I’M NOT OKAY WITH THIS…
I’ll never be okay with this. But I live in a state that is number 49 out of the 50 states in the US for mental health services (yes that is true), and it’s a reality I have to face every day being a clinician in this state. Historically, Colorado clinicians combat: Columbine, the James Holmes massacre at the Aurora movie theatre, the school shooting at Arapahoe High School, the school shooting at STEM Highlands Ranch, the shooting of police officers off of E470, the threat of a school shooting by an 18-year-old girl from Miami…and so much more. The common thread? Guns. Yes, these individuals most likely suffered from ridicule and isolation. Yes, these individuals probably had histories of trauma. Yes, these individuals probably didn’t see any other way out. But why did they have access to fire arms and not mental health services?
The (very brief/shortened) history of mental health in America
Why is it hard to access mental health services?
- In the 1980s President Ronald Reagan cut public funding to mental health. He broadcasted it as deinstitutionalizing mental health. The next big blow to mental halth happened during President Bill Clinton’s administration when he cut funding to mental health to reduce the Federal budget deficit. We continued to struggle to advocate for mental health during the Bush administration, and then President Barack Obama worked tirelessly to get the Affordable Care Act passed during his last term as president—which was attempting to reverse 20 years of public policy and American values/beliefs.
- With the Affordable Care Act in place, Colorado (and other states) worked vigorously to make sure that the physical health industry was ready for an influx in new patients. Colorado expected that more people would be seeking care with the new coverage policies in place. We did not, however, anticipate such an influx in individuals seeking mental health services. Our mental health centers WERE FLOODED BY PEOPLE. The public funding wasn’t enough to meet the need.
- Making a complex issue even more complex, mental health is not like an acute physical illness. When someone is diagnosed with a chronic physical health diagnosis, they are either treated and released or they pass away. When it comes to mental health, individuals can live a long life from adolescence to late adulthood with a chronic mental illness and need consistent and ongoing treatment with intermittent hospitalizations and inpatient treatment. This costs a lot more money.
- Furthermore, many insurance companies are reluctant to pay for the services needed to successfully treat someone with a mental health diagnosis. For instance, someone who has been diagnosed “primary substance use” cannot access inpatient level of treatment (adequate treatment) with most insurance companies—even Medicaid. Inpatient treatment and residential treatment—considered the most successful way to treat individuals struggling with substance use issues—is often not a covered benefit with MOST INSURANCES. There is some public funding for these services, but these funds are spent QUICK. As a previous care coordinator, I was told on a consistent basis that I should call back in July when the funding was redistributed.
What happens to someone who goes into the hospital with a mental health issue?
- Let’s start at the beginning. When someone makes a call to 911 for a welfare check, by law the police have to show up…as well as the ambulance…as well as the fire department. It’s quite the show for the neighbors. The police are legally obligated to handcuff the individual and put them in the back of their vehicle (as long as the individual is not undergoing a medical crisis or they are not underage, in which case they would be transported via ambulance). So in most instances, the individual who is going through a mental health crisis is cuffed and put in the back of a police car. This is VERY TRAUMATIZING.
- If the individual arrives at the ER (and not at a jail), they have most likely been put on an M1 hold by the police officer and have been placed in a room with a security officer at their door. And then they wait.
- The individual is then assessed by a crisis evaluator (a mental health clinician), and that individual determines what level of care is needed. This evaluator then communicates directly to the insurance company’s utilization management (UM) team about the outcome of their assessment (assessment is sent to UM for review). A final decision is made by the insurance company. They either recommend a higher level of care (inpatient or otherwise), or they recommend sending the individual home with “resources.” This process can take DAYS….yes days. That means that the individual is just sitting in an ER as if it’s a holding cell.
- Once a determination has been made, they are either released or plans commence to place the patient at an inpatient unit. This is a delicate dance between the hospital and the insurance company. Finding an open bed at an inpatient unit is tough. Generally, there are shortages of open beds. If there is an open bed, the inpatient hospital has the option of denying a client due to acuity, complexity, or any other reason they want. Something worth mentioning: the hospitals that frequently have open beds are also not necessarily the best option for the client. Then the ER hospital has to make sure that the inpatient hospital is contracted with the individual’s insurance company. All of this creates more wait time in the ER (which is very expensive and traumatizing to someone struggling with a mental health issue).
- Let’s say they finally arrive at the inpatient unit (YAY). They are treated with meds and (very rarely) intermittent therapy. The point of a hospitalization is medical stabilization. Furthermore, the social workers and psychiatrists have to consistently check in with the assigned insurance company and prove “clinical necessity” for that individual’s ongoing stay at the hospital. What does this mean? The individual has to be making progress but still remain sick enough to continue receiving treatment there. So, they have to be sick, but not too sick to keep getting treated.
- Once they are “well enough” to discharge (or they are deemed to be no longer receiving medical benefit from being at that level of care), the social worker comes up with a discharge plan with the client. The social workers schedule the client med appointments (could be as much as 6-8 weeks out), therapy appointments, and connect them with other helpful resources. Time, access, and client motivation can all disrupt this part of the process.
- Once the plan is in place, the individual discharges. They leave with a piece of paper with the information about their post-hospitalization appointments and other clinical recommendations. The individual gets into a cab (or a family member picks them up), and they go home, or to the street, or to a step-down program (if they’re lucky).
- Average length of stay at an inpatient unit is 5-7 days. The only long-term stabilization facility in the state available to mental health clients is the Fort Logan Mental Health Institute (length of stay ranges from 1 month to 10 years). But there are rarely beds available due to lack of funding and the new prioritization of forensic clients (individuals with mental health issues who have a prison sentence)—Click here for more information about why this is the case. Because of these constraints, the timing and symptomology has to be pretty faultless in order for a lateral transfer to be successful.
“The individual has to be making progress but still remain sick enough to continue receiving treatment there. So, they have to be sick, but not too sick to keep getting treated.”
I went into too much detail there…I get it. But my hope was that you all noticed the amount of opportunities for miscommunication, inconsistent messages, miseducation, lack of trust, and lack of support in our current system. These things get in the way of someone successfully discharging and getting the ongoing support they deserve and need.
What we need:
We need better continuity of care. We need to eliminate as many of the administration barriers as possible. We need to be able to trust the people treating these patients with proper length of stay protocols. We need to break down the barriers of people accessing helpful supportive services after they discharge (6-8 weeks is too long to wait to see someone). We need to have more step-down options for people after a hospitalization: partial hospitalization, partial residential, intensive outpatient therapy, group homes, or something that has never been done before. Something has to change.
Please leave questions, insights, stories in the comments section. We can use this anecdotal information to continue to write to our legislators and demand change!