‘What do you mean I’ve been discharged?’
‘You’ve missed two sessions. We talked about attendance, and in this clinic, if you miss two consecutive sessions, it will result in your discharge.’
‘Discharge? I’m going end up in the hospital.’
‘You’re always welcome to reapply for treatment when you’re ready to commit to your mental health.’
Tell me: Is your skin crawling? You’ve heard this before. Or maybe you were complicit, or even worse, believe it. Remember, commitment to therapy is a two-way street. Invest in your care as a patient is not just a reflection of attendance or frequency of psychotherapy sessions. In a system where contact and numbers are driving clinic scheduling and reimbursement for therapy, ‘welcome’ and ‘ready’ reflect financial incentives.
The conversation that just transpired is common practice in many outpatient mental health clinics operating on state Medicaid benefits and insurance to pay for treatment. In New York, the ‘Article 31 clinic‘ (free-standing mental health community clinic) continues to be the semiotic locus for mental health treatment for impoverished, low-income, and disabled Americans seeking psychotherapy or medication management for psychiatric illness.
Clinic directors are under the clinical gun, ‘wire’, and mandate to move non-payers or ‘unreimbursable’ sessions and the clients that need them off their census to lower deficit and overhead.
This overhead eats into profits, hiring, staff retention, and other clinic operations needing money to keep the doors open. The management issues around Medicaid are numerous, and the system is broken. The fix, or solution by the NYS Office of Mental Health, has not been the loosening of regulations around line items keeping a patient enrolled in treatment.
Instead, the government launched studies and other programmes to fix the deficits and cracks within the NY Medicaid system. Programmes like HARP, after the silos, fell, and the rise of care management is now out there evaluating and reevaluating the impact of these cracks on the care and provision of treatment inside mental health treatment centres and clinics. The system is looking at itself, albeit slowly. Internal affairs are at work in the system. HARP (Health and Recovery Plan) redesign will see if the system is able to correct itself. Future investigations by independent researchers to revise Medicaid further will look at HARP outcomes to chart a new course for Medicaid and benefits associated with being under the auspices of the ‘system’s care.
Initial findings suggest more flexibility. Well, ask any provider already treating African Americans and other oppressed populations which historically have connectivity issues with outpatient free-standing and hospital-based clinics with rigid rules for treatment is a gosh darn no-brainer.
I mean, who would have predicted folks without cars, and a few dollars to their name, can make the time to take four busses after work and get to therapy when the pressing need at the moment is putting food on the table. I can tell you one thing if a child went without dinner and CPS (Child Protective Services) got involved, which is more likely if you are an African American family, there is no right path forward. Treatment or dinner? Wait for a second, aren’t both requirements for survival?
African Americans and low-income service recipients are NOT given a VIABLE way ahead in treatment. Certainly not stable enough to reap its benefits.
Instead, all too often, barriers and cracks within the system, which continue to be a problem today, are working at the cross purposes of the people seeking its very care. Ladies and gentlemen, this isn’t inaccessible. It is dangerous to the consumer. We need to loosen regulations in treatment, and we need to do it today. Forget moving the problem patients into the hospital into some psychiatric limbo until a paperwork nightmare and systems snafu is worked out. Passing the problem along is too easy, and asking why this happens is far too often a question we forget to ask as advocates fear ruffling and creating waves in the system.
We need answers to the disparities today. If not now, when? Ask yourself and your colleagues: Why do these systematic issues exist? Where are they coming from? How do we eliminate them?
In the end, it might not even be a program or internal mechanism to correct our failing mental health system and the inherent disparities. It can be as simple as offering more ‘solutions-focused therapy’ as a billable treatment or medical intervention for insurance reimbursement, allowing consumers to come to treatment when they need treatment and not just when prescribed for them.
Following NYS regulation is a double-edged sword, though. How would this work in terms of therapy and conducting treatment? In most Article 31, the frequency of contact a therapist has with a patient has implications. First, it is considered bad practice to have erratic contact with a client. If contact is sporadic, there must be a clinical explanation for the irregular intervals between therapy sessions.
I suspect, in the end, this goes back to issues around Evidence-Based Treatment (EBP).
NYS Office of Mental Health (NY OMH) and other state unregulatory commissions in Mental Health push EBT as the gold standard in care. Wait a minute, why is EBP the gold standard of care if it isn’t the best treatment fit for BIPOC communities? Why should the push be to keep clinics to ‘best practices’ to keep their doors open and -licensed by the state commission to operate if therapy doesn’t work for everyone? I recommend keeping these questions front and centre when evaluating the disparities in NY and other states for black and Latino communities in the community mental health clinic.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.