I received an e-mail two days ago from the current President of the Minnesota Psychiatric Society on the formation of a Governor's Task Force On Mental Health. That e-mail commented that no psychiatrists were considered for the Task Force, but that psychiatrists could apply as concerned citizens and were encouraged to do so. I have done this in the past and been ignored so I was not eager to repeat that again.
The public mental health system in Minnesota has been seriously mismanaged and ignored for the past 30 years or about as long as I have been a psychiatrist in this state. During that time, I have witnessed a long string of bureaucrats with no specific experience trying to manage a state hospital system or more likely trying to shut it down. Those efforts were seriously compromised by some of the same legislators who decided to develop a system of civil commitment for sex offenders because they thought it would be easier to detain them on a dangerousness standard than the usual legal criteria. Let's forget about the commitment standard that suggests the person should have a treatable illness. The efforts to shut down the state hospital system were also compromised by the fact that the system really started to backfire when the number of available beds in Minnesota dropped to the lowest number in the US. At that point there was always a large pool of unstable patients circulating between the emergency department, brief inpatient stays where not much happened, and the street. During that time significant housing resources for both adults and children with significant psychiatric problems was shut down.
The icing on the cake from the State Legislature was their myopic approach to the problem of the mentally ill being incarcerated. They "solved" the problem by coming up with a rule that any county jail inmate could be transferred to Anoka Metro Regional Treatment Center (AMRTC) within 48 hours. AMRTC was supposed to the the remaining flagship public psychiatric hospital for patients with no forensic problems, that is they had not committed a violent crime due to mental illness. This was a predictable double whammy, sending violent inmates to a hospital setting and short circuiting long waiting lists of patients waiting to get to AMRTC as a result of commitments at community hospitals. This has led to a record number of assaults on staff working at AMRTC, at a time when nurse manager staff critical in managing aggression had been downsized.
Community mental health centers (CMHCS) have certainly not fared any better. At some point the decision was made that they could be treated like managed care clinics. In other words they would be funded by staff "productivity" and practice medication rather than psychotherapy focused services. Even then, reimbursement from traditional funding sources was so poor or so entangled in unnecessary paperwork that the funding was inadequate to keep the doors open. Some CMHCs have just gone out of business and advised their patients to see primary care physicians or distant mental health clinics. People generally do not drive long distances to be seen, at least not for very long. It is hard enough to drive across town, much less several hours for an appointment.
Looking at the goals of the Mental Health Task force and who the Governor wants on it - it is clear that this is a serious committee with a serious mandate to develop a continuum of care and the supporting infrastructure with funding sources. The political and managerial members of the Task Force are carefully specified. Why then would representatives of the same failed agencies from the past be appointed to serve on it? Why are there no psychiatrists or psychiatric nurses - linchpins of what can be loosely described as this system of care? Why are there no psychiatric social workers - the people with the most experience in dealing with the glaring lack of resources? These are the people who know what the problems are, how they can be solved, and what they have to put up with every time a state politician or bureaucrat makes another bad decision. And yet none of these groups are specified Task Force members.
The implicit question is how many times these state government driven processes need to fail before there is a rational process? One of the associated questions I dealt with as the President of the Minnesota Psychiatric Society is why professional organizations in the state always seem to fall silent about these processes every time they occur. There are psychiatrists employed in these systems that may not want to hear any criticism from their professional organization about the overall processes, and that is something I have never really understood. There are certainly plenty of professionals who avoid contact with these systems entirely. It is one thing to have to try to function very day at work in an environment where doing the work is impossible due to financial and bureaucratic constraints. It should be fairly obvious that is not a personal criticism of any employee in that system. It is well past the time when the professional organizations represented in these systems get involved and tell whatever Task Force coming down the pike what is necessary to provide quality care to people with severe mental illnesses.
Until that time comes, I encourage every psychiatrist in the state to use my standard answer about why the mentally ill in this state get rationed and inadequate treatment:
"This decisions in this state are made by people who know considerably less about it than I do."
That is just the way we do business in the USA right now. At some point the American people were sold the idea that managers with no particular skill other than declaring themselves to be managers were what we needed to solve problems. Being a politician or a manager seems to trump just about every technical skill, but in this case the resulting problems have been more than a little glaring. Knowing how to treat the severe mental illnesses that are seen in state hospitals and CMHCs requires more than an MBA or JD. You have to be well trained and know what you are doing.
This Task Force seems to be a collection of what has come to be called stakeholders and it is more than a little ironic that this group never seems to include the people who show up each day to do the work.
George Dawson, MD, DLFAPA
Here is the original Executive Order - dated April 27, 2016.
A rich source of political rhetoric that is frequently used against professionals by managers is: "Let's see you come up with a solution." They never really step aside and let the professionals manage. They are just trying to shut them up. Well here are a few ideas for starters that I will put up right now against any Task Force product. And I am the only stakeholder writing this blog:
Minnesota State Hospitals Need To Be Managed to Minimize Aggression - link
Minnesota's Mental Health Crisis - The Logical Conclusion of 30 Years Of Rationing - link
Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression - link
Public Sector Mental Health Continues to Be Squeezed Out Of Business - link