Tuesday, January 03, 2012

Tear down the wall: Broken models of mental health service delivery

I have a longstanding interest in Systems and their impact on our ability to care for people. In 2005 (I can't believe I have been blogging that long) I wrote a blog entry about foster care policy and its impact on occupational therapy.

I try not to get outraged on a daily basis because it makes it a little challenging to maintain focus. If you think about foster care too much though it is hard not to get a little upset.

These Systems are populated by well intentioned and kind people who have to do yeoman's work to make the System run. The problem is not with the well intentioned and kind people who work within these Systems - the problem is with the System creators who have set up a structure that in my opinion fails to meet the needs of the people being served.

That's not so good.

Mental health care Systems are notoriously poorly designed; we have systemic problems like homelessness and poor care coordination and uneven access to care. The Systems are so poor that the American Academy of Pediatrics recommended a model of school-based mental health service delivery. I like the concept, but I am noticing more and more that school systems are ill-equipped to handle mental health needs of children.

The primary point of difficulty that schools have with this kind of service delivery is in the MODEL that is used for defining problems. As an example, an Intake History that I read recently started off describing all of the problem behaviors of a child including lying, cheating, stealing, profanity, attention difficulties, poor ADL compliance, and aggression. Somewhere in the middle of the second page of the Intake was a section with diagnostic information, and it was left blank because the information was not available at the time the Intake was completed. Digging through the educational file, I eventually learned the following:

1. Diagnosis of Dysthymic Disorder, early onset
2. Parental abandonment
3. Possible sexual abuse
4. Multiple foster home placements

This child's story is sordid and would bring most people to tears.

I am stuck because I am trying to understand how we have created a System where the well intentioned people have no MODEL for understanding the nature of the problem. They are just educators, or perhaps people with a B.S. in psychology or a generic human services degree - and they start off with defining the problem as lying, cheating, stealing, etc. etc.

How does that happen?

The System is populated with clinical social workers and an occasional consulting psychiatrist and even an occasional occupational therapist - but the NON-CLINICAL MODEL that is perpetuated causes people to start identifying the problem as the presenting behavior, or by how the child is functioning in the context of the school. Somewhere along the line we have forgotten that this is a child whose parents have abandoned her who has been to multiple foster home placements and repeatedly raped.

If these facts are true, how horrible is it that we have created a System that places the PROBLEM on the middle of the second page (where it was unceremoniously left blank) and only ambitious people who dig through old records are able to find a psychiatric report that lists the REAL PROBLEM??!

To make matters worse we then relegate the care of these abused children to people who do not have enough input and guidance from mental health clinicians. I really don't know where all the mental health clinicians are. I can speak for my field of occupational therapy - only 2% of OT practitioners even work in mental health settings. Occupational therapy has abandoned mental health and moved on to other pastures. Only now is our professional association starting to make some much needed moves to re-insert the profession back into the mental health care Systems.

I suspect that this issue of abandonment of mental health is not unique to OT. Every professional who still has involvement in these Systems has a unique opportunity to educate the Systems on the value of using a more clinical model for the purpose of FRAMING PROBLEMS.

Eventually these Systems need to be absolutely torn down and replaced. They are broken and we need to stop pouring money and misplaced effort on propping up failure.

Unless we are intent on continuing to fail.

1 comment:

TherExtras said...

I relate to your frustration, Chris. Systems also move in slow motion - so truly helpful intervention likely does not arrive in time. Those recommendations from the AAP are from 2004 - seven years ago.

I wrote about this a while back, too. I did not provide a solution either. Barbara

http://www.therextras.com/therextras/2010/07/school-responsibility-for-child-mental-health.html