Sunday, June 29, 2008

The Future of Mental Health Care in NC: consumer driven / diminished provider input & loss of mental health providers

There has been a very informative discussion taking place amongst mental health advocates/ consumers and this provider as associated with the establishment of NC-CANSO, a consumer driven group being supported by NCCCP, the lobbying arm of the LME's in NC.

Consumer driven mental health groups have as their advantage the creation of social support and disbursement of psychoeducational model information e.g., Dialectical Behavior Therapy, for instance.

Consumer driven mental health groups have as their disadvantage the creation of groups without professional knowledge or expertise except as associated with the 'hidden hand' or the creation of the psychoeducational body of information which is disbursed by the alpha/ leader consumers.

The hidden puppeteer's hand is more cleverly disguised without the direct input of the mental health provider groups. Unfortunately, consumer groups and those who benefit the most, the LME's or the administrators of mental health benefits, cannot, or will not, state what the activity is that is taking place behind the stage.

Consumer driven groups are tethered to the notion that they need to be more empowered as re: their own mental health welfare and so grasp at the reigns of power.

Meantime, the LME lobbying group has basically won the day by maintaining a stance of 'we're glad to help you if you want our help.'

Its hard to bite the hand that feeds you, it seems.


remember: just because it is 'consumer driven' does not mean that someone is not sitting the background scooping up the $$ re: the development of materials and issues which they, as 'expert', deem to be appropriate for this consumer driven model. Thus, is the 'consumer driven' model disingenous in terms of who is moving the puppets around on the stage. The hand is simply not as evident.

Let me advise people how this consumer driven model has been used in Smoky Mountain Center LME. Joe Ferraro, retired employee of SMC LME, created Meridian Behavioral Health. Given his connections (my speculation here, to be sure, and I am not on the inside of any of this information), he has garnered most of the mental health $$ flowing from NC DHHS----best I can tell.

Yes, there is the ACTT people (also part of Meridian) and the 'core team' associated w/ staying up with people who have recently attempted suicide (also part of Meridian); there is Summit Counseling, founded by the very trustworthy Carl Losacco (who, incidentally was also a SMC employee), that has a contract w/ Haywood County Schools system.

In that I no longer (as of about 9 mos ago) participate w/ the provider gp of SMC LME, if there is newer information, I do not know it. However, the players at the LME are all the same in terms of the administration and they marked their territory long ago.

When I, a doctoral psychologist, licensed in NC, have been forwarded former ACTT clients, who did not have Medicare or Medicaid, in other words they were state funded clients, Steve Puckett, PhD, the clinical director of SMC LME, has INSISTED that clients be moved into the REC. Yes, SMC LME would authorize me to see them for a very short period of time, but basically, they were to go to Meridian and participate in REC.

I have quite a few clients who participate in REC. It is helpful to them. It is a psychoeducational model which utilizes cognitive therapy thinking a la Marsha Linehan's Dialectical Behavior Therapy and such. Indeed, all good therapy has some components in keeping with these psychoeducational models. I assume that there are components of this in the talk to which you allude that was sponsored by NCCCP.

Given the SMC LME clinical director's insistence-----which was the policy of the LME-----I could not obtain authorization to see clients who were state funded clients. I gave up; many providers have given up working w/ clients in SMC LME catchment area.

My client did not move into REC; it is not convenient and it is far away; she did not want to expose herself to grp therapy. I have pushed her towards Medicaid; she has been denied (of course); she is appealing it; that will take years. Meantime, she gets very minimal therapy fm me which as per her statement has been helpful. At the very least, I have encouraged her to take her meds which keep her anger intact so that she does not (hopefully) suicide. I believe we were making good progress in therapy; we have moved through a lot of the abuse in her history. This is intimate knowledge. Could this have been done utilizing a psychoeducational model? NO, I do not believe so.

NC Mental Health Reform is also about power relations. : who gets the authorizations; who is put into a position of seeing clients; how to clients 'get better'? how do clients stay better? what are their main concerns? how independent are they seen to be in terms of making their own choices? what are the social pressures to 'keep them in their place'? how are policies created which in fact DO keep them in their place? what are the rolls of professionals vis a vis the clients w/ mental health issues?

While mental health consumers need to be very invested in their own mental health welfare, there is a tremendous struggle taking place here which is under the table as associated with how this will take place.

The State is, of course, invested in the cheapest option or perhaps better said what is the maximum number of people who can be serviced using the least amount of $$. Thus, will this mental health consumer empowerment issue rule the day----and maybe it should.

However, the price is this: you will lose your mental health provider base.

Meantime, until this culture evolves into a place wherein people w/ mental health issues are considered to be 'idiosyncratic' (something which takes place more in British culture, for instance), and wherein people can compassionately assist their not so well neighbor, what is the useful combination of use of professional time and psychoeducational approaches which are much more consumer driven.

And so the question is this: when/ where is it that clients, w/ their mental health issues, need/ should utilize the services of a professional?

The professionals are being shut out of mental health care in NC. These matters of what role do the professionals have re: mental health care in NC, are not being overseen by:

a. NC Psychological Association (long story there; see Defarge)
e. some support and interest re: NC Psychiatric Association (but frankly psychiatrists are the least impacted by all of this and so interest within that group does not trickle out into the larger professional groups).

Have concerned providers attempted to coalesce and move together in order to address some of these issues? Yes, and it was unsuccessful. Why was it unsuccessful? We are all busy people.

I maintain that NCCCP created via channeling funding for NC-CANSO in order to support the notion of 'most lives covered for least amount of money.'

That is the tension between this matter of patient/ consumer sponsored and run psychoeducational processes vs professional expertise. I don't know the answer.

In the best of all possible worlds, consumers would have open access to both and could choose a la carte. However, that is not the way the mental health $$ flow : there is a tug of war re: the authorizations and what will win out is that the cheapest option will continue to be pushed by the likes of SMC LME.

Yes, I am very much in the position of defending the worthwhileness of my training: what is its value; does it have value? for whom does it have value?

I understand and completely agree that it is important for them to be invested in their own welfare. However, also bear in mind that mental health reform was SUPPOSED to be about patient choice (that is long long gone).

Meridian is paid to oversee a person's mental health needs. (I do not know anything about their actual contract and I am speculating here). I believe they have what is called a 'capitated' contract. That is, they are paid a certain amount of money for the state funded clients, and no more. However, they must be paid on a 'head' basis, in some way.

So, here is my prophecy: mental health reform in NC will move the way of this NC-CANSO/ NCCCP LME supported model which is consumer driven; fewer and fewer mental health providers will be utilized and so they will not stay in state, regardless of all the educational programs that Perdue would recommend. Some time in the next 20 years, groups will look around and wonder: where are the mental health professionals? And it will then occur to people, who have some sense of the history of what has taken place, as to what has happened.

But maybe things will be better if matters are consumer driven.

There will still be the stigma of mental illness, however, given the very real different kind of functioning that people w/ mental health issues can, at times, have, they will still be cut out of the decision making process for the most part, for humans are social animals and they react to herd members who act differently.


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