Saturday, August 8, 2009

Last Day At Work

Today is my last day at work. Next week I have surgery, followed by two weeks of recuperation, and then graduate school, internships, a new chapter in my life begins. Just: not before I close this one.

For the past year and a half, or so, I have been a mental-health paraprofessional in a group home for people with mental illness and co-occuring substance-abuse problems. When I started this job, it was exactly the line of work that I wanted to get into: helping people overcome their addictions, begin the long and slow process of rebuilding their lives, getting in on the ground floor of bottoming out and hopefully being helpful. I came to the work armed with personal experiences, healthy realism, and buckets of hope.

The last of these is the only thing I leave behind, now.

The reason, interestingly enough, isn't the clients I've had. That healthy realism that I had meant that I brought no expectations that they would be returned to health, give up their addictions, magically become 'productive' members of society. Mental illness, and substance abuse, can be oppressive; recovery from them is a long, ongoing process that likely consumes the rest of one's life. Add on to that poverty and the stark racial segregation of Connecticut which goes along with poverty in this state, and the difficulty is compounded exponentially.

I knew all this, though only dimly, when I started. I knew that my job would be to attempt to empower my clients as best I could by creating a relationship and an environment in which they could regain autonomy over the course of their lives, and accept responsibility for the actions they take. Both are, I think, the essential ingredients of the act of recovery: taking control and being accountable.

What I didn't realize, and the reason which led to my current state of burn-out, is the systematic way in which my clients have been, are, and will be disenfranchised. I came to the job with a naive optimism that the mental-health system, and mental-health advocates, worked for the recovery of their clients (the current preferred nomenclature is actually 'consumer', which I find dehumanizing; I shall stick to 'client'). That's not the case at all.

Mental healthcare is underfunded, I think it is fair to say. Mental healthcare is a part of healthcare, of course, and suffers from the same set of problems. I'm not entirely sure how insurance corporations, which are legally obligated to seek the highest return on investment to shareholders, are the best instrument for providing the best healthcare to those they cover. If I need a test which is expensive, insurance companies must perform some strange calculus to determine whether it is better to let me have the test or to add some profit to their bottom-line. Given the legal obligation to add profits, one cannot entirely blame them for choosing the latter. Insurance companies are not evil; they are simply a construct of the business world applied to the medical world.

But this does, of course, have impact on mental healthcare. Go check your benefits; you are likely to see that they will cover short-course, or 'brief' strategic therapeutic help. You shall have a limited number of sessions in which to deal with your mental health issue before coverage is up and you're on your own. Brief, strategic, targeted therapy or counseling sounds great, only some mental health problems are anything but brief with identifiable targets.

Substance-abuse is the perfect example. The most proximate goal of substance-abuse treatment is to reduce, or preferably eliminate use of a substance or substances. Detoxification, and short-course therapy, is usually covered under an insurance plan. However, substance-abuse is, by definition, a chronic relapsing disease. If people didn't use a substance in spite of negative consequences, substance-abuse would not be a concern. In fact, people would get better on their own, as the negative consequences of use, abuse and dependence mounted.

Substance-abuse is also simply the most overt symptom of a constellation of related psychological, social and other issues. Underneath it are issues of self-esteem, stress, family and other relationships, social and cultural mores, etc. Unless these are also addressed, a problem which takes time and effort, there is likely to be an eventual relapse or some other flaring into different symptoms.

That is with insurance, and to have health insurance, someone in the (legally-defined) family needs either an employer who can provide it or the financial resources to pay for insurance. Without insurance, an individual is left with state-run plans. In this case, poverty is a requirement. This means folks who do not have a full-time job including benefits - folks who work multiple part-time jobs, for example - must make so little money that the government is willing to pay for them. In such situations, it actually pays not to have a job in order to have medical, including mental health, coverage. Given the increasing reliance of companies upon part-time employees, so as to avoid the rising cost of providing health insurance (again, not because any given company is evil per se, but because that company is legally-obligated to seek the highest return to investment for its shareholders; or, in the case of small businesses, simply because the business cannot afford to cover the benefits that accrue with full-time employment), this is an increasing problem as well.

So if you have an illness - mental or not - it is better not to work in order to receive government benefits. One of the ongoing questions of my clients during my tenure has been: is finding a job worth it? What impact will work have on my benefits? Will I still be able to collect social security payments, access food-stamps, utilize housing programs, retain Medicaid health insurance? Given that my clients are 99%, poor, uneducated (high school or below), and unskilled, the answer is almost always a resounding "No."

Reagan, long ago, spoke about so-called "Welfare Queens." What he did not actually understand is that in my clients' situation, the rational economic consideration is to remain unemployed, as the resources to move out of poverty disappear beyond a certain point. There is poor, and then there is working poor, and then there is the very bottom rung of what you and I would call 'middle class'; rationally, for any given individual, it is better to remain poor until and unless one can jump to lower middle class than to become part of the working poor.

In fact, the only reason why clients such as those I have had should seek employment is to fulfill non-rational goals, such as an increased sense of self-esteem and self-efficacy. My clients have almost universally described employment as a goal for these reasons. Something we working people often forget until we are out of work is the array of non-rational and emotional securities that working provides. As I, myself, have become burnt-out from this job, I too forgot this. I feel shameful for doing so. Many, many people would be happy to have the job which I have, especially given current economic conditions, while I have spoken only ill of the job. Actually, I've been lucky to have it.

Of course, poverty does not decrease the desire for financial well-being, and social services provided by the government cannot, do not, and are not intended to fill that need. When you cannot become employed (or you lose your benefits), and the social welfare benefits you receive do not fulfill your needs, to what can you turn? Essentially, three options:

One can beg, or 'panhandle.' This is intensely degrading, and does not offer much financial return.

One can work 'under the table', for cash. Such opportunities do, sometimes, exist; though in areas of concentrated poverty (i.e., Hartford, Connecticut), it is usually more difficult to find someone with money who can offer such employment.

Or there is crime. One can steal, which carries a specific risk, but - for the morally conscious - is also degrading to one's sense of self. Or one can get involved in the production, distribution and sale of illicit substances: drugs. This is less degrading to one's sense of self. In fact, it is simply a black-market business carrying both increased risks (prison, murder by a rival outfit, etc) as well as increased reward. There is plenty of money to be made in the drug business for those with the right sort of business acumen suited to such an industry.

Given all of these circumstances, it is no wonder that any individual would seek to continue receiving welfare and turn to a life of crime, most especially drugs. The cruel circumstances of poverty, and the lack of supports as one transitions out of poverty, make the rational individual choose such a life.

Now add mental illness to the mix.

In 1963, the Federal government passed the Community Mental Health Act. The idea: get the mentally ill out of state-run psychiatric facilities - places straight out of One Flew Over the Cuckoo's Nest - and into the community, and treat them there. Let psychiatrists in the community provide psychiatric services; let social workers in the community help them to find stable housing, employment, etc and connect individuals with other social supports; let counselors and therapists provide ongoing treatments; let patients reconnect with their families, perhaps even live with them; let patients adapt to society and - not mentioned at the time - societies adapt to the mentally ill. Let newly-created Local Mental Health Authorities (LMHAs) provide all of these services through Community Mental Health Centers (CMHCs).

A wonderfully well-intentioned idea that went horribly wrong. Now sanctioned to shut down expensive state-run hospitals and trim their budgets accordingly, states did precisely this without getting community mental health centers up to speed. Patients left the hospitals without adequate supports for living in the community, and communities were left without preparation to handle such a sudden influx of individuals with chronic mental problems and everything that went with them. Families suddenly had to care for sick individuals who sometimes needed 'round-the-clock care on top of the increased financial burden of an additional member of the household who, perhaps because of the severity of their illness (or the nature of their medication -- see below) could not add to the household income.

Mental illness is tricky; it is not something fixed by anodyne bromides. Talk to an individual who has successfully recovered from mental illness, and they are likely to talk about a variety of conditions and responsibilities which allow them to live with their conditions: medication, talk therapy, proper diet, exercise and sleep, a positive social milieu, etc. The constellation of factors which create success is often built up over a long period of experimentation, with frequent 'relapse' (or 'decompensation') a prevailing characteristic of this learning period. Each of these factors is different for different individuals; there is no single solution.

Most medication for severe mental illness comes with a long list of side-effects and contraindications. Thorazine and Haloperidol, for example, are notorious for reducing individuals to near catatonia. Thought and movement are slowed down so much that the experience is a living hell. Some medications cause tardive dyskinesia, a series of physical tics that appear like Parkinson's and are just as non-reversible. Akathesia - the inability to stay still - is another problem, as individuals are simply unable to remain in one place. Obesity is nearly always a concern, as most medications cause significant weight gain; and along with obesity come diabetes and cardio-vascular diseases. One medication, clozapine, carries the danger of agranulocytosis, which is potentially fatal.

Given the severity of these side-effects - as well as the fact that in many cases, the medications do not work, or only reduce symptoms to some degree without alleviating them entirely - is it any wonder that the mentally ill do not want to take them?

Many people - including several clients - watch a movie like A Beautiful Mind, and wonder about dealing with mental illness without medications. While I would applaud John Nash for his recovery, as well as raising questions about antipsychotic medications, I have seen this as a danger for many clients. Delusions are a priori fixed, false beliefs. You know something is a certain way before you look at any evidence. One client I had believed the NSA were tracking him with sattelites; no amount of rational argument or evidence could convince him otherwise; just as with all conspiracy theories, evidence that the theory is wrong is proof that the conspiracy is covering up the truth. Given this, it is hard for a delusional person not to act or react to their delusion. It is, after all, more real to them than what you and I call reality. Medications, can (and I stress 'can', and not 'do') help to reduce the potency of delusions. So in deciding with a doctor whether or not to take a medication, I think it's important to weigh the side-effects of the medication versus the benefit of not having to wear tinfoil to stop Major League Baseball tracking you through dental implants.

So I find it no large surprise that mentally ill individuals would not want to take medications. The side effects are too painful and the benefits too minimal for the drugs to seem in any way useful. At the same time, lacking the (minimal) anchor that the drugs might provide, a mentally ill individual is likely to forget to pay bills, go to work, make appointments, clean his or her home, shower, etc. The illness becomes all consuming.

And illicit substances become appealing. I could not tell you why illicit substances, many of which exacerbate symptoms of mental illness, should be so appealing to those with mental illness. In the case of marijuana, there is some evidence that the chemical cannabidiol acts as an anti-psychotic (it's mechanism of action still unknown); however, the active ingredient, tetrahydrocannabinol (THC) is known to produce psychotic symptomology itself. Mentally ill individuals may smoke pot because the cannabidiol helps to alleviate symptoms of mental illness, but the varying ratio of cannabidiol to THC makes any single joint a crap-shoot.

As for cocaine, especially in the form of crack, the substance can only exacerbate mental illness to a large degree; however, since the drug overloads the brain's reward circuitry to such a high degree, any given individual is likely to feel compelled to use more whether they like it or not. As for alcohol, we still barely understand how it affects the brain of those without mental illness.

The only drug, actually, which I have seen reduce symptoms of mental illness is nicotine, perhaps the most deadly and addictive drug in existence. ALL clients that I have worked with have been smokers, usually heavy smokers if not chain-smokers. In one case, I could visually see a client with severe mental illness calm down and become more settled as he smoked.

All of these things create the image of the crazy homeless man which has become an accepted part of the urban landscape, a trope of it if you will. Unclean, raving about sattelites following him, probably smelling of alcohol or the peculiar "burnt plastic" smell of crack cocaine, begging for change. Or the crack-whore, an unattractive woman in hideous clothing too small for her body, bitter, nasty, reminding you in some not-so-small way of a rabid rodent in human form...

These were my clients.

I do not mean to deride them by my description. I am not entirely willing to accept that their fate is the outcome of their decisions, just as I am not entirely willing to blame the rest of us for creating them. Since I am not the severely mentally-ill, I cannot speak to their willingness or responsibility to effect a recovery and 'join society'; I can, however, speak to the various obstacles we put in their way.

The mental health system, to put it bluntly, is overwhelmed, underfunded, undertrained, and designed seemingly to obfuscate. It is not designed to move people from illness to health, but simply to move people. Perhaps the clearest example I can give of this is that of an obese diabetic alcoholic with some variety of schizophrenia. Through the program for which I worked, she was able to stabilize symptoms of her mental illness, develop social skills necessary for leading a good and decent life, navigate the medical and mental health systems with some competence, and to obtain a few precious months of sobriety.

The local CMHC, using state-funding, moved her into a third-floor apartment above a liquor-store that could be reached only by stairs. This was not a move designed to place her in housing that supported her continued recovery; this was a move designed to add a tic-mark in the agency's "success" column. Numbers do lie: just because her level-of-care dropped does not mean that she is on the road to no-level-of-care. Given those circumstances, it is a matter of time before she is once again utilizing more and more supports - and the state's resources, and more of the taxpayer's money.

Politics - and therefore government - is about the short-term, however. Lower taxes for my term in office, and let the next guy worry about the budget deficit I create. Democratic governments, as a rule, do not invest in long-term projects without being able to present some evidence to their electorate of benefit, the more immediate the benefit the better. Given that the poor and disenfranchised are less likely to donate to your campaign - and that the working poor, saddled with multiple jobs and responsibilities, are even less likely to donate or even vote - government is not likely to address issues important to such communities. When you're mentally ill and poor, forget about it.

The government and its agencies are therefore likely to look for programs that provide immediate 'results' that can be shown to an electorate that is, after all, not entirely selfish: we want to do something for poor people, even if we put our own needs first. Those programs must not only be 'effective' on paper, but should be as low-cost as possible, else the electorate shall accuse the government of wasteful spending.

The criminal justice system is a good example. It is easier to warehouse criminals in prisons than to provide rehabilitation and the necessary community development to reduce recidivism. The electorate responds well to the idea of locking up prisoners and throwing away the key; it is easier to politically justify the expense of building more prisons than finding ways to make productive members of society out of criminals. Mental health works in a similar fashion.

For a state, the most cost-effective way to deal with the problem of mental health for poor individuals is Medicaid. Medicaid is a program whereby the federal government provides matching funds to the states to provide medical care for poor individuals. The Fed pays half, the state pays half, and poor individuals are provided with a (very) minimal level of medical attention.

Given the constellation of additional issues that go along with mental health, however, and the fact that the Fed only pays out for certain treatments (usually those that have known courses of treatment with known outcomes, just as insurance companies are only like to pay for such), states are in a bit of a bind when it comes to illnesses of a chronic relapsing nature, such as mental illness and substance-abuse, or those which require an indeterminate amount of time to treat, such as mental illness and substance-abuse.

Tucked away in the Medicaid legislation is something known as 'Medicaid Rehabilitation Option', or MRO. MRO allows the states to receiving matching funds from the Fed for certain courses of treatment, such as a group-home for people with mental illness and substance-abuse problems to receive housing, food, and some treatment services. This is the piece of legislation that allows for the group-home in which I worked.

Of course, the state is still under pressure to keep costs to a minimum. The Fed may foot half the bill, but the state is responsible for the other half, and both governments want things to run as cheaply as possible.

The solution: contract out to local agencies to provide these services. Find the agency able to provide the best service at the cheapest cost. Use the strength of market capitalism, in other words, which is to find the best product at the cheapest cost. The types of agencies which usually provide such services may be non-profit agencies; never-the-less, they are looking to utilize the money they earn to provide additional services through additional programs. A non-profit, though less driven by the profit motive, is never-the-less driven by profit motive. The program in which I worked, for instance, loses money routinely; the deficit is made up by other programs of the agency, while the program in which I worked provides a service to the state and the community and allows the agency to demonstrate competence in handling such an assignment.

Keeping costs down is never-the-less incredibly important; that means the physical plant - the 'house' part of the group-home - needs to be cheap. Cheap, in Hartford, means "in a bad neighborhood." The group home is situated in an area of Hartford that - while not absolutely horrible - is known for drug activity, petty theft, and rape. For all of the clients, recovering as they are from substance-abuse, the drug activity constitutes the most prevalent environmental concern, while for female clients the rape is a strong concern as well. Various clients have commented on the difficulty of recovering from drug abuse when it is possible to walk across the street (literally) and score crack.

It also means that employee salaries must be sufficiently low. Although I would be grateful to have had a higher salary, it is the side-effects of low pay on services that concerns me more. Low pay, for example, means a higher turnover rate of employees. If there is an opportunity to earn more, an individual is more likely to consider it. This was a part of my own decision to leave: I could seek further education in order to earn a higher salary, as well as pursue advancement of my career, for which a graduate degree is necessary. A higher turnover is problematic when dealing with mental illnesses, as stability and structure are usually necessary components of recovery, and relationships with counselors have a high turnover as well - one is always starting new relationships with people, and never able to benefit from more long-term continuity of care with a single person.

It also means that people with little to no interest in mental health and/or substance abuse are likely to take the job. It is, for them, simply a way to pay the bills, and they have no personal investment in job-performance or their clients. I left a training early yesterday, when individuals with which I was partnered chose to ignore the exercise we were given in favor of making sarcastic and nasty comments about their clients. They did not want to be there; they did not want to know how they might perform their jobs better; they just needed a paycheck.

Low-pay comes with something else, and that is low education and training. Most individuals working in my program are in school, but in unrelated fields. They lack practical or even theoretical background in severe mental illness or substance abuse (unless they have dealt with such issues in their personal lives; however, such experience is very much different from formal training). Though the agency for which I work seeks to educate its employees as much as possible - for example, through the training I received yesterday - it nevertheless runs up against the fact that it can only provide brief trainings; and such training means nothing to someone who simply doesn't care.

This means that the interventions we as counselors provide to our clients is suboptimal. Though we provide, in the eyes of the state mental health agency, some of the best services throughout the state, I cannot help but observe that our work falls far below the current standards in the field. That isn't because we, as staff, are not driven, inventive, compassionate hard-workers; it is simply because we don't have the training and tools to perform the job well.

Low pay also makes us expendable. We can be replaced. That factor makes organizing for better pay, better training, better anything, much less likely. I mentioned that I suffer right now from burn-out as a result of this job; I believe, actually, that all of my co-workers suffer from some degree of burn-out as well. I have felt that an enormous burden has been placed upon me not by the clients with which I have worked, but by the agency and the state. I am required, for example, to obtain a certain minimal number of contact-hours with a client over a given month, or the agency is not payed for services rendered. However, in some cases - many cases, actually - clients have not wanted to meet with me, or indeed any other individual on the staff. I cannot force a person to talk with me about their substance-abuse problem; yet if I do not achieve that minimal number of hours, I receive official reprimand. I am punished for someone else's decisions: what better way to create a feeling of impotence, and thus burn-out?

Burn-out, I know, is best treated by time off, allowing an individual to regain perspective, composure, optimism and compassion. When you work with mental illness and the people who suffer from it, it is necessary to have the time and resources to maintain your own mental health. But when you are a mental health paraprofessional, such as I was, time and resources are scarce, and because you have no organized recourse to demanding better pay or more time off, the chances of burn-out increase. Add to that the fact that my own position was shift-work, and you can add problems of getting adequate sleep some nights, and a general disconnect with the rest of the world working the 9-5, Monday through Friday schedule. You become further disconnected with your family and friends simply because of the hours you work, and these supports for your own mental well-being lose some of their strength.

Burn-out, seems to me, is pretty much par for the course in mental health. My clients' clinicians usually seem to have some degree of burn-out too, often to a worse degree than I have experienced myself. I've heard Mobile Crisis workers, individuals trained to provide over-the-phone counseling to folks with mental illness, yell at the people they were supposed to help (and no, yelling is not an effective form of therapy, especially to those in crisis). Psychiatrists, too, seem to prescribe medications without consulting their patients, often telling their patients to deal with the side-effects rather than attempt to work with them to find the optimal medication(s) at the optimal dosage. Everyone seems to be working in their own crisis mode, in a panic, at a frantic, unsettled and unsettling pace. The result is a deep, pervading bitterness and cynicism that provides an unattractive backdrop to the field. There are often a few individuals, full of enthusiasm and optimism, who appear to the rest of us incredibly naive: there is no hope. We watch and wait for their cheer to die an agonizing death with obvious schadenfreude.

Worst of all, however, and the largest problem with which I have grappled over the course of the past year and a half in this job, has been the utter hopelessness of my clients. They seem to have no hope for the future, no interest in recovery, no desire to do what they can to improve their lives. I don't blame them: in their shoes, I would feel the same way. There is no point in finishing their education, seeking employment, addressing their symptoms... none seem like objectives which would significantly alter their lot in life. They have become 'institutionalized', used to saying whatever people in authority think they should say in order simply to get those people off their backs, whether they be police, judges, social workers, doctors, therapists, counselors, or any other social-service provider, and then doing exactly as they want to do.

This, perhaps more than anything, is the reason I leave the field: I simply do not have the constitution to hold out hope for these people when they cannot do so themselves, and the reason that I cannot hold out hope for them is that I know they are hopelessly outnumbered in any such struggle. I feel as they do: powerless, the play-thing of forces larger than me. The people who work in this field and manage to avoid burn-out have my respect.

Though, this job has been beneficial in that it has shown me something of the nature of poverty and disenfranchisement, things which I did not understand much before (and about which I very obviously have a great deal to learn). I'm leaving the job in order to go to school to receive the training I need to work at a more systemic level. Recovery is about creating an environment in which natural health is able to take root and flower. Create the environment, and it will happen in its own good time. In order to create that environment, though, the 'System' needs to change, and that requires a certain shift of perspective.

Government's role needs to adjust to a more long-term perspective. We need to be willing to invest in our future, and I believe that we the electorate know this, though we would prefer to ignore it. In the long-run, the costs of ongoing treatment of the symptoms of the mental health problem exceed the cost of changing treatment to the underlying pathology. Investment, now, in better treatment, now, means less treatment - and therefore less cost - in the future.

For one, we could require mental-health paraprofessionals to have minimal certification for the job. Certification means that we have an established baseline level of training amongst those working in the field. It helps to weed out individuals who aren't looking to do the job as part of a larger career, people who don't care and are just working for the money. Why invest in training and passing a certification exam if you're not going to use it down the road?

It also creates the incentive for workers to organize, as they cannot be as easily replaced, and to demand better pay and/or benefits - such as enough time-off to be able to cope with burn-out. Better pay necessitates more professionalism: workers have to demonstrate that they are worth the better pay. And professionalism means better interventions provided to clients, who then have a better chance of effecting recovery.

That means additional costs to the government, federal as well as state. It will not be popular with the electorate. But it does mean that over the long-term, hopefully, there are less crazy homeless drug-addicts on the street, reduced crime, and reduced use of other social services. The benefit is distributed in a systemic way, so that no politician can point to the change and point to the benefits; and yet society will be better. That, of course, requires a courageous politician: a politician who works for the benefit of the community, and not the aggrandizement of his or her own ego. In itself, that's a tall order.

Of course, it is only a part of the problem. Also needing to be addressed is the way in which our society helps people out of poverty - provide incentives to people to transition into work, rather than remain in poverty because of the benefits of the social safety net that classification provides. And other issues.

Until these are addressed, though, I will not be the last mental-health worker to quit in frustration at not being able to help his clients to recover from their illnesses.

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