Full access and integration is the freedom once realised by the first reformers in the mental health movement of the 1970s and 1980s. Access and integration translate into ramping up entry points into local community health networks, connecting mental health treatment to all goods and services targeting healing and health-related issues and total wellness. The rise of the modern health home and the fall of the silos gesture to the system’s attempt at integrating care but, like most new turns in treatment, the outcomes reflect the care management philosophy and regulations’ clumsy practices. To be concrete, rectify these awkward practices, and make full access and integration a reality, these entry points at the county level which control access to specialised services need to be reformed and revised. Under the auspices of the local DCMH, the county entry points use SPOA/SPOE (Single Point of Access/Entry), filled out by clinicians applying for services for their patients.
I have had the task several times of filling out an SPOA application. SPOA applications mostly collect compiled EHR records with a few short blurbs filled out by the referring clinician. Well, to get right down it, these applications are a shining example of clumsy ‘clinician-crat’ work that is mucking up access to patients that need it the most. I have not only had applications rejected for purely political reasons, I have also sat at SPOA meetings and listened to the politics of mental play out in all its fury in a small room with clinicians with large, ego-inflated heads. All of them talking about patients and clinical work in less than humane and very subclinical language, if you catch my meaning. At these meetings, I acutely observed clinical input passed over for political reaching from different agencies involved, over-involved in some instances, and in the end totally failing their patients.
I am talking specifically about referral packets that go to one agency instead of others. Patients that qualify for multiple programmes and their fate bound up in the political leanings, and even apparent stigma of certain disorders over others, to decide which service they would be eligible for in the end, if any. At some of these SPOA meetings, sub-meetings were even called to correct, add ‘oversight,’ and make forgotten cases that were failing more visible. I have sat at these meetings too, termed ‘support circles’ in my local county. At these support circles, patients would complain about their workers, and everyone would point fingers at the service provider failing them the most. This person was usually left in the precarious position of explaining himself, even if he has done no wrong, but was the scapegoat of terrible treatment and care coordination.
Most importantly, I want all this politics and regulation to end. I want to make referrals for needed services and have my patient’s fate be a product of the necessary treatment, not what looks best on paper to justify a county service.
Programmes need to stay open and operate under the highest level of professional scrutiny, which means no longer deferring recovery and long-term independence goals for politics – the end of top-down forms of treatment in which patients access care based on their treatment success. Years ago, the level of care philosophy made sense, but does it still make sense today when installing choice and nuanced person-centred care into the framework?
We must pave the way to end long-term in-patient treatment and funnel consumers back into the community for the long-term on their roads to recovery. Treatment and services must genuinely be centred on the patient’s needs and not exist to engrain the guise of neo-institutionalisation, passing it off as a reform and a functioning mental health system.
Maxwell Guttman teaches social work at Fordham University. He is also a mental health correspondent for Psychreg where he shares his insights on recovery and healing.