Just Like Any Other Illness

For a while this had been the paradigm for our society. Mental illness is just like physical illness, and ‘deserves’ the same treatment.

I remember early in my career, when I was on the national board of IAPSRS (the International Association of Psychosocial Rehabilitation Services, predecessor to the current Psychiatric Rehabilitation Association) in the early days of psychiatric rehabilitation, in the late seventies (I think). I was talking with then-Executive Director Ruth Hughes about the exciting possibility that Medicaid funding would be available to spread psych rehab services into all the states that lacked anything like it. Unlike many states, Massachusetts was using savings from closing state hospitals to build a community support system. Being something of a rehab prig/purist, I raised the concern that medically-oriented funding might not be the right path, and might end up compromising the services we cared so much about. I was, quite literally, shouted down by Ruth and a board leader, the Executive Director of a provider agency. I backed off.

That experience has stayed with me. Expansion of services that in some ways at least I would recognize as psych rehab did happen in most states through use of the Medicaid Rehab Option, but it didn’t have much effect on Massachusetts. Here we used funds that used to fund the closed institutions to fund our services through contracts rather than fee-for-service schemes, and I always felt we were better off for it. After a while, our state government came up with a rather unique scheme to capture Medicaid funds by billing for state-run Case Management services under the rehab option. Those funds didn’t come back directly to mental health, but rather were returned to the state general fund, but I’m sure they helped support mental health spending. Unfortunately, they also violated federal regulations, and the state finally realized they were an audit away from having to return hundreds of millions of dollars to the Feds, and they changed direction.

The result was Community Based Flexible Supports (CBFS), which privatized most case management functions and provided much more rigorous (and cripplingly expensive) paperwork support to the Medicaid billing under the Rehab Option. IMHO, we got to a point of punishingly picky state audits of provider record-keeping for two reasons: first, to avoid federal audit of our Medicaid billing at all costs; and second, as a backlash by former DMH Case Managers who, after CBFS privatized them out of the jobs they signed up to do, watched their friends and colleagues lose their jobs and got stuck with the shitty job of paperwork auditor. There is a third reason, which has to do with the dynamics of being a reviewer of other people’s work. Like any critic, you tend to the picky and negative: it seems to be human nature.

As a result, CBFS direct-care staff, when I left the business very early in 2013, were spending approximately half their time on paperwork. Worse, the requirements of the paperwork infected their work with the individuals they were paid to support, interfering with the development of a partner relationship and resulting in weirdly tense and unproductive interactions. The intent of the Rehab Option regulations were poorly understood by the auditors, and enforced in such a strained and adversarial manor that rehabilitation became resented by all involved and goals became a vehicle of oppression.

We are left with a system that is still dependent on medical interventions in the form of medication, social control in the form of guardianship, and a crippled and distorted form of “rehabilitation” that is unrecognizable to any of us who fought for it in the early days. Only the recovery movement, with its small but growing insurgent army of peer specialists, has been able to counteract the tyranny of the medical model and its rehabilitation option offshoot in any meaningful way.