Working Inside a Collapsing Mental Health System
After the passage of the Affordable Care Act, tens of thousands of people suddenly had access to health insurance. Here’s how it affected my job.
In December 2013, I changed positions in the nonprofit community mental health agency I had worked at for about three years. I left the stress and constant pressure of the front desk and got a desk in a different, quiet office where I became the asshole who asks nosy questions about your symptoms and drug use when you’re interested in scheduling a first-time appointment. For about two weeks, the job was a dream. I could stream music, the office had a couch, and I could walk away from my desk without everything getting out of control. Then, two weeks later, tens of thousands of more people suddenly had health insurance, maybe for the first time in their life, and they all wanted appointments.
The effects of the Affordable Care Act shouldn’t have come as a surprise to anyone who was part of an organization that dealt with Medicaid, and this is the sole funder for the outpatient mental health program. Somehow, though, no material changes to the programs were made. The community mental health system is known to be brutal to the people who work inside it, and unforgiving to people who use its services, and the introduction of thousands of people seeking services was an unprecedented new strain.
If you live in Multnomah County and use Medicaid, there’s a good chance I’ve talked to you on the phone. The agency I work for is the largest by a pretty big margin, and there’s only three people who answer the phones. If you call and you’re in crisis, I’ll tell you to call the county crisis line. If you’re lucky, you’ll get to talk with a clinician on the phone there, but waiting on hold isn’t unheard of. I’ll probably also tell you that there’s a walk-in clinic you can use that’s open most of the day, and if you come in you’ll have to wait an hour to see a therapist. But if it’s really busy – and it gets really busy – you might have to wait much longer.
If you want to get enrolled to see a therapist, I’ll check your insurance. The problems with people trying to sign up for insurance under the ACA are well documented, and Oregon was no exception. If you were lucky enough to get insurance, we’ll keep talking, but if you weren’t, I have to tell you I can’t schedule you. You might have worked really hard to make this phone call, and this moment sucks. I dated someone with pretty severe depression for a long time, and there were months and months of talking about making phone calls to see a professional. It might seem like a small thing to someone who lives without feelings of dread and anxiety, who doesn’t walk around in a fuzzy and sometimes dark cloud, who hasn’t gone through days and days in a row of numbness and derealization, leaving bed only to pee or to eat something. But, someone for whom that’s the reality, phone calls are fucking dreadful.
There are places where you can get some free counseling, although not many, and there are places where you can go and pay on a sliding scale, but not everyone has the money to do that. There are some other options I can suggest too: Multnomah County has funding for some people without any insurance at all. I don’t know how hard it was for you to make this phone call, but I don’t imagine this is the outcome you were hoping for.
When people pass the insurance test, I try and get the bad news out of the way first. When the call volume exploded, it seemed like the strategy in dealing with it was nothing more thoughtful than “let’s wait and see”. Our wait times for first appointments peaked at three months, and have fluctuated since. Right now, I can usually schedule you in six weeks, a few months ago it was eight weeks. Looking forward, I don’t feel confident in saying that those wait times are going to come down in any predictable way.
At some of our clinics – there are four – the wait time dipped to just one month pretty recently. When you’ve been telling people over and over six weeks, eight weeks, three months, saying one month feels better. A clinician at the walk-in clinic asked us to schedule a walk-in client for an appointment, and there was no mistaking the frustration she was having. A manager happened to be in the room and tried some authoritarian positivity spin.
“One month isn’t that long”, she said.
“When you’ve just spent an hour in a room talking with someone who can’t stop crying and has told you how much they want to kill themselves, telling them to wait a month for help is embarrassing.” She was being very polite. ‘Embarrassing’ is short of the truth. It’s irresponsible.
The manager took it personally, but at least that ended the apologism, which I believe is one of the tasks that takes up most of the time in a manager’s day.
If that same client had called on the phone, I would have told them the wait time myself. Maybe they would have told me how bad it was going for them – people do this sometimes – maybe they would have just said “never mind” and hung up on me. I don’t know what people do after that. Some people sigh and say “that’s fine” or “I guess I don’t have a choice” or just stay silent.
I spoke with someone on the phone who used to come to the clinic where I worked at the front desk. I remember him being exceedingly nice. He called to re-enroll in services after having stopped coming to appointments for a little while. When I told him the wait time, he yelled. He had been enrolled for a couple years, stopped coming in, and was now looking to see a therapist again because his symptoms were escalating. I scheduled him for a new intake appointment two months out. I also know that he had a lot of memory problems and had trouble remembering appointments a week out. I left that call with a lot of frustration, and I don’t blame him for yelling. He’s right – waiting two months to see someone when you try and reach out for help is crushing.
When you go through this with people twenty or thirty times a day, you either get good at dissociating, or you get an empathic overload and start taking it with you when you go home. I’ve done both. I really try and be as supportive as I can to people on the phone, but I think internalizing the guilt of the whole malfunctioning system in unproductive. Sometimes I wonder about culpability by participation, but if someone told me they were having those kinds of feelings, I would discourage them from treating them as valid.
After talking about how far out first time-time appointments are, I ask a lot of nosy questions. I’m sometimes surprised by how casual some people can be when they talk about their symptoms. I started using shorthand for “depression” and “anxiety” as I take notes because these are words almost everyone who calls uses to describe what they are dealing with. Sometimes I schedule people who have kept it inside for so long that they get really upset just naming their symptoms out loud.
I ask if they have suicidal thoughts in the same tone as I would use if I asked what they had for lunch, and make a note to give them information about crisis services if they do. I ask if they struggle with any drug use, because therapists will want to know. I ask if they are on parole or probation, because sometimes people who are have restrictions that prevent them from enrolling. I ask if they are going anywhere else for mental health services, because only one agency can bill at a time. I ask what race they identify as, because the state mandates that we do for tracking purposes. If someone’s name is different from their legal name, I tell them that our software is kind of fucked up and requires they use their legal name for billing purposes – a not-so-subtle brutality for many trans clients.
If you are someone who considers yourself stable in your situation, and are just looking to meet with someone to get a prescription for the medication that helps you stay this way, I have no options for you. Every community agency in this county is counseling-first, medication-later. If you want to go through with counseling you know you don’t need in order to get that referral for prescription services, you will have to wait about three months, because that is how long that process takes. If your previous prescriber won’t write you a new script, all I can do is offer you crisis services. If that medication is a benzodiazepine or an amphetamine salt of one kind or another, no one is going to write you that script.
The first appointment includes a mental health assessment – a much more in-depth set of questions, done by a clinician. A person will leave this appointment with a diagnosis and a grade that will determine what kind of services will be available to them. A diagnosis means that someone can be treated for something, and this means the agency can bill insurance. The level that someone is graded on will determine how many services we can bill for. The levels are “A”, “B”, and “C”, sometimes with a few other qualifiers, but otherwise they are pretty clear in the ideology they are projecting onto human bodies. “A”s have been assessed to have the lowest level of needs, and will be able to access the fewest services, “B”s have higher needs. Level “D” and higher would mean someone needed inpatient services.
Following a first appointment, a client will be assigned to a clinician based on their grade. For lower-graded clients, they might only be able to see their therapist once a month. They have the option to split this into two half-hour sessions every other week. (The only people who have been able to talk about this “option” without rolling their eyes are apologist managers.)
If someone reports any drug use in the past three months – even if they only had a single drink on someone’s birthday three weeks ago – they’ll be scheduled for an alcohol and drug screening. For example: someone who is seeking help with their symptoms of bipolar disorder, knows they would benefit from a counselor, shares that sometimes they need a drink when they feel manic. They then are directed to do another interview with another person about their drug use. There is a lot of skepticism from clinicians about this, in no small part because assessments bill for more money than regular appointments. In the nonprofit world, “profit” is just replaced by “revenue”. The rest remains pretty similar, with no excuses for low wages.
Once you are enrolled, the clinician you are assigned to, in a current best-case scenario, will have about 80 people on their caseload. In worse cases, they may have 120. That means that if you do have a crisis, or a sudden exceptional need, you will be competing with 119 other people for your case worker’s limited and underpaid time. In some cases your caseworker may only be getting paid in school credit. Nonprofit mental health agencies rely on a tremendous amounts of unpaid work, performed by interns.
A few months ago the agency had a staff “retreat”. Before an uncomfortable speech about stepping out of our “silos” and into “synergy”, the clinical director walked us through some new clinical tracking software that the agency had paid who knows how much for. Apparently every relevant consideration in a client’s “recovery” can be plotted on an axis and graphed on a scattergram. They were beautiful charts – great colors, lots of numbers – and perfectly representative of how the system understands the people who the agency seeks to serve.