xxAACP Newsletter, Volume 12, Number 1, Winter 1998
President's Column: Preventing Drowning
The mentally ill have always seemed to be exempt. They should be protected because they are ill and need society's protection. But example after example comes to our attention of bad management leaving the mentally ill in dire straits. This week we heard that four centers caring for mentally ill SSI clients were closed down in Prince George's County Maryland leaving many mentally ill patients without care. In California, we learn that their Medicaid mental health program will require psychiatrists to get approval to use almost all psychiatric medications from the patient's primary care doctors due to some insane attempt to coordinate care. Patients won't be able to get their lab work without approval of their medical clinics.
Tennessee's failed health care reform continues to inflict pain on the mentally ill. The passionate discussion of the mentally ill in our jails which shot over our e-mail network reminded us of that growing calamity.
Some of our upset comes from hearing that an old patient at my former agency was found drowned in Puget Sound. This man in his late forties had populated our day treatment programs and club houses for years. He was very disabled and periodically deteriorated in gross psychosis. At his best he was very tangential and bizarre, but affable. His demeanor was that of a graduate student as he studied his elaborate explanatory systems struggling to make sense of this world. He responded well to warmth and caring from the staff and came to trust us. When he was in trouble many of us would go out of our way to care for him. That was when we had a stable core of workers in our club house and outreach programs. Now the staff turn over is such that there is little collective memory in the program. New staff are not being acculturated to the patients. They don't really know them as people. I don't know what happened to this old patient of ours in recent years. Who was caring for him now? I heard his mother had died and I don't think there was other family. What loneliness had he experienced and what fears must he have had? Did he suicide or was he thrown into the cold water by those tormenting him. He is one who should not have met such a fate. He was a good person who was cared about by others in the community.
It has always been clear to me that community is a fragile thing. All the more so for the mentally ill. As men and women with serious mental illness walk the streets of our cities they can be so horrifically isolated that any notion of community is a farce for them. With clinically sophisticated case management and assertive community outreach our teams can build a sense of community for our patients. This is old news. The "technology" has been demonstrated and written about for the last 25 years. It revolves around human contact, caring and continuity of relationships. It is the very thing that is so poorly understood and devalued by those system planners who are beholden to legislative demands for efficient care. When we are really part of the community we are known not only to our patients, we are known to their landlords, the shop keepers, the other members of their AA group and to those occupying the neighborhood branch offices of the state public assistance programs. It is this type of touching the earth in our jobs which keeps smart young people working in human services. It is what grabs the interests of the more humanistic medical students and engenders an interest in psychiatry.
Rather than retreat into a dispairing silence the AACP has been loud in its protest of bad planning and its anti-human consequences. We will continue our advocacy, drawing ever closer to our partners in other professions and in advocacy groups such as NAMI. We must remain positive and proactive. It is the genius of community psychiatrists that we invent ways out of the box. We accpet the premise that a resource poor system must be managed efficiently. But we are certain that quality care is the most efficient care. Well cared for clients don't deteriorate as much or so badly as those who are poorly treated.
Our recent accomplishments have included the development of LOCUS and Formerlary Guidelines for Managed Care. We are building on these efforts with our work on psychiatric staffing guidelines, appropriate definitions of medical necessity, and application of principles of cultural competence. I believe the excitement and energy we felt at our recent AACP meetings and our reception at IPS reflected our positivism. We believe that things can be turned aroud and that a spirit of humanity can prevail. We can be a powerful force, though we are a small group, because we have the ideas and the spirit. Help us to shape our ideas and take them to our centers and to planners. Let us take our spirit out into the larger community; into the political arena to argue the wisdon of positive social and health policy. It is for our patients and their families and our team members who struggle so hard to be of service. It is for the others who face the cold waters of neglect and despair.
Charles Huffine, MD
President
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