Child Welfare and MH Specialized

CHILD WELFARE AND MENTAL HEALTH: Cross-training and Team Process

Day 3

December 3, 2003

Green Lake, Wisconsin

SPECIALIZED SERVICES

Jon S. Matthew

1. Mental health practitioner as specialist

The term specialist is a complex construct. The meaning of specialist is developed, rather than given, so we must consider the various aspects of this development to be able to understand what we are talking about when we say that mental health practice is a specialty.

The mental health practitioner has training and experience in diagnosing and treating people with mental health problems. This training and experience provides the mental health professional with a set of skills that others do not have for addressing the needs of the population with mental health problems (see material from Day 2).

These skills qualify the mental health professional to do the following:

a. Work in a clinical setting

b. Charge mental health customers

c. Have a legal right to be paid for their services

d. Identify the source of the person’s mental health problems

e. Focus activities to get at the source of the problem

f. Stimulate movement toward the desired outcome

As stated above the mental health professional concentrates on diagnosis and treatment of mental health problems. How does this make mental health professionals specialists? To be a specialist you have to focus on a branch of a larger field of study. So then, is mental health a branch of something larger?

Mental health may be considered a branch of healthcare. That focus is certainly one of the primary ways that other healthcare providers, and the mental health clients, view the qualifications of the mental health provider. However, mental health may also be viewed as a branch of social services; that is, as a way of eliminating or managing needs that result in social problems. Take the need for children to be protected from abuse and neglect, for instance. Many people see protection as the primary role of mental health professionals; protection of the individual with mental health problems and protection of the community. Mental health may also be viewed as a branch of education, at least in the broad sense of teaching people skills in coping. Another closely related way to view mental health practice is that it focuses on improving the quality of a person’s life; mental health focuses on individual growth and development in helping people realize their potential to live full and productive lives. Thus, mental health professionals specialize in treating mental health problems, in remedying social problems, in training people to function at a higher level. These functions of the mental health professional roughly correspond to the rehabilitative roles, the social protection roles, and the habilitative roles that have long been the focus of mental health practitioners. One may look at this picture this way: mental health is a branch of healthcare, a branch of social services, or a branch of the self-improvement industry. Take your pick.

Actually, these separate aspects of mental health practice cannot be separated. However, the emphasis may be on one or another of these aspects depending on the demands of the situation, including the expectations that customers have. There is tension between these different views of the mental health practitioner as specialist; special interests focus on shaping mental health practice in one direction or another.

Consider the interests of the healthcare industry. Their focus is primarily to remedy problems that create impairment in the individual’s functioning, and to accomplish that goal directly and quickly. The healthcare industry focuses on fixing people who are broken, putting them back together, and sending them on their way. This is the rehabilitation function of healthcare. To determine whether or not the services of a mental health professional is needed for a specific patient, the practitioners apply the criteria of medical necessity. By applying the criteria of medical necessity, we assume that we have determined that the service will restore the individual to a previous level of functioning, or close to it. The healthcare industry, using criteria of medical necessity, is dubious about fixing social problems, or about individual self-improvement activities. Often, such activities are denied as benefits within healthcare insurance policies. Such restrictions within healthcare insurance policies have significant impacts on mental health practice. Many people believe that the rehabilitative role used in healthcare practice is far too narrow a point of view to address the needs of the individual who seeks care. After all, social problems and factors that influence the individual’s development as a person also affect whether or not the individual will exhibit a diagnosable mental health problem.

Now let’s consider the interests of people who are concerned with keeping our communities safe and secure. Safety and security is the responsibility of the police, the court, and social service agencies, among others. Healthcare interests and those focused on safety and security frequently diverge, especially if the healthcare industry is asked to pay for treatment approaches that segregate the person from the community. Although, segregation, or lock-up, may temporarily improve community safety, the high cost of such placements are contested constantly. The healthcare industry looks for loopholes

to pass these costs to governmental authorities, or the reimbursement is insufficient to pay the full cost. Social service agencies also want people in their system to have access to services from mental health professionals to reduce risks of future problems that relate to safety or security. Their thinking seems to be that the risk people pose is enough reason for them to see a mental health professional. Social service agencies want this access to be direct and immediate, and are often not very interested in diagnosis or matching treatment with needs, to meet some rehabilitation objective. Also, social service agencies often use the Court process to gain access to services. Within the court process the issue of medical necessity is often ignored, sometimes inappropriately so, making it more difficult for the client, rather than helping. Another way that the perspectives are different is that the formal aspects of mental health services that are valued by the healthcare system, such as the credentialing and licensing of professionals, is far less valued by the social service system, if valued at all. This difference in perspectives can increase the potential for misunderstanding and conflict due to having different aims.

In the arena of skill development for purposes of self-improvement, mental health professionals can provide a significant benefit in the role of coach, consultant, or trainer to their customers. The individual customer is the one who usually wants the mental health professional to assume these roles. As a consultant the mental health professional can assist the client improve relationships, productivity in work settings, and in realizing some hidden or undeveloped potential. These pursuits may be only tangentially related to a diagnosable mental health condition, but are nonetheless very important to the quality of the individual’s life and the level of satisfaction on a long-term basis. The healthcare industry may not be willing to pay for activities that are considered elective. Also, the customer may not want to be labeled as having a problem. The social service industry is more interested in doing those things that reduce risks, so endeavors that support skill development are promoted only so far as these have "face-value" as skills that will increase safety or security.

These different ways that mental health professionals serve as specialists to their customers contain inherent conflicts. All three roles are important; sometimes all three roles are important to the same customer.

`2. Specialties within mental health practice

Considering mental health professionals as specialists in mental health is one way of looking at the issue of specialization. Another way of looking at specialization is to consider the issue of specialization within the field of mental health; that is, some practitioners consider themselves specialists in some part of mental health practice. These practitioners may advertise their services as being superior due to special training and experience, as compared to those services provided by general practitioners in mental health. Some examples of these claims include those who specialize in "sex-abuse counseling", or those who specialize in "anger management counseling", or those who claim to be experts in attention deficit disorder, or other specific problem areas. Supposedly, because these services are delivered by a "specialist" many people assume that the services will be more relevant and more effective.

It is true that the healthcare system is made up of specialists. If you have a serious problem you see the specialist for that problem, such as the cardiac specialist for a heart attack. In effect, the body is divided up into parts with a specialist available for each part that can malfunction. This specialization has some serious consequences for patient care, as the patient is compartmentalized, the doctors have difficulty communicating with each other, and the treatment may not be properly coordinated. Witness the problems that senior citizens have in understanding who they are seeing and for what reasons.

Specialization implies that the treatment will be more effective because it is more focused and precise. Greater focus may not be desirable if the problem being addressed is actually quite broad or plastic. An example of this occurs in agriculture with broad-band vs narrow-band fungicides. The broad-band fungicide has an adverse impact on a variety of fungi in a variety of weather and other local conditions. A narrow-band fungicide affects only a few fungi, or one type, only under stringent conditions. Also, the fungi that are the target adapt quickly to narrow-band fungicides so the fungicide quickly loses its impact in retarding the growth of fungi; the fungi become resistant. The same kinds of problems may occur in narrow-band mental health treatment, such as what is commonly referred to as "intensive one-on-one" mental health counseling, or "anger management counseling", or "sex abuse counseling". Also, narrow spectrum medications that are supposed to be focused on one kind of problem have not been very effective in the long-run, possibly because the behavior, like a living thing, develops a "resistance" to the treatment, or is only useful under certain conditions. Thus, specialization may not be particularly effective, such as when the focus is on the child, but the conditions supporting the behavior lie outside of the child, in the child’s social environment.

Specialist providers in mental health are probably more valued in social services than in the healthcare system. Those professing to work with one type of problem or another, or certain kinds of clients, do not appear to make their point very well within the healthcare system. However, the differences in credentialing and licensing are taken quite seriously by other healthcare providers, such as the differences between psychiatrists and psychologists. Healthcare providers are more concerned about practical issues such as whether or not the person can prescribe medications, or whether the service is inpatient or outpatient. These broader distinctions are more meaningful to healthcare providers then purported expertise in dealing with one type of patient or another. More refined distinctions in expertise are generally not well recognized within the healthcare system. Part of the reason for this low recognition of claims to special expertise is probably that subspecialties in mental health have no formal credentialing process for establishing that a provider is an expert with particular subgroup of mental health patients. The mental health provider may not get affirmation for having special expertise because their claim is made personally rather than being endorsed through a public credentialing process.

Formal mental health training and the clinical settings people work in greatly influence the perception of expertise. Credentialing and licensing is also a big factor in establishing expertise of mental health professionals. Personal claims to expertise generally have a low impact.

Most mental health providers have formal training in psychotherapy. However, psychotherapy can be differentiated by different types such as play therapy, individual therapy, couples therapy, or family therapy. These distinctions are probably less important to providers in general healthcare than they are to social service workers or to mental health professionals. Mental health professionals may claim that they specialize in one type of psychotherapy or another, as the formats for providing psychotherapy differ somewhat depending on who is present in the meeting. Often clients request a specific format. Sometimes clients feel very strongly about who should be present in the meetings, which can have implications for whether or not proper assessments can be completed, etc. Conflicts may result between the professional and the client over the choice of format, and practice can be affected negatively if the format does not fit with the problem. Sometimes mental health professionals try to avoid the issue. One of the more notorious examples of avoidance, perhaps, is the situation in which the mental health professional sees the child alone, with the only involvement by the parents being that they drop the child off at the door of the clinic.

Mental health professionals may look at psychotherapy, also known as the "talking cure", as the only tool in their tool chest for addressing the needs of their clients. After all, most mental health professionals make their living doing psychotherapy. Also, mental health professionals get comfortable with the office format, and their power to affect who is present in the meetings, and their power to control contacts with collaterals. Psychotherapy is an appropriate and powerful tool for many clients having mental health problems. However, attempts to apply psychotherapy to all kinds of clients with all kinds of problems is not always appropriate. Mental health professionals do not like talking about their failures, and they do not like talking about the limitations of psychotherapy. This may give the impression to others that psychotherapy is a "cure" for all kinds of problems, when surely it is not. This aura of magical cure often also afflicts those who see psychiatrists for medications. The magical cure assumption may be prompted by the "packaging" of the "product"; that is, mental health professionals probably encourage the use of psychotherapy as a carte blanche application. This tendency to encourage the use of this modality has many aspects, but clearly omnibus application of this methodology is not appropriate. In saying this, it is important to remember that the principles of psychotherapy were developed primarily with college sophomores and with women in a Victorian age who had problems with "hysteria". Many populations of people who have significant mental health problems do not benefit much at all from psychotherapy; it wasn’t designed for them. However, if all you have is a hammer, everything starts to look like a nail, so the idea caught on that psychotherapy is supposed to be for everyone. Psychotherapy has great limitations that mental health professionals have been reluctant to admit. I have never seen a professional training on the failures of psychotherapy. We are not ready for that kind of confrontation with reality. As a result mental health professionals and others have overused this modality in circumstances in which other modalities would be more appropriate, such as intervening in the natural environment, and utilizing more informal intervention methods. Professionals from all sectors, however, worry about accusations that they are doing nothing, so they usually recommend the most vivid or "glitzy" service available.

3. Categorical services

Having so far discussed specialization practices in mental health from the standpoint of the mental health field itself being a subset, or branch, of broader fields of endeavor, to the claims made by mental health professionals that they possess special expertise with sub-populations of mental health clients, followed by a discussion of finding the illusory magic cure that is supposed to make everyone feel good, we are now at the point of discussing the use, and the misuse, of "categorical" services.

The term categorical services applies to service "packages" that are relatively self-contained; that is, the service implies that the client will get the right thing, at the right time, when it is needed. Any program, or any service modality can take on this aura of self-sufficiency and self-containment. Residential treatment, treatment foster care, psychiatric inpatient hospitalization, individual or family psychotherapy, or other services, become categorical when they can be referred to using only one or two words, or program labels. Although being handy for checklists, this approach grossly oversimplifies the linking and referring process.

The use of services categorically by professionals was one of the reasons for development of integrated services, and other collaborative, flexible, community oriented intervention programs. Categorical services did not work very well long-term for many populations of mental health patients, such as children with severe emotional disturbance. After experiencing failures and frustrations in using categorical services at the local level, many professionals developed a preference for referring these children to the most restrictive, most costly, service first. This approach was easier for the professionals at the local level, and many times the community approved these approaches that segregated the child from the community. At the time that integrated services was designed by NIMH, many children were being placed in institutions on a long-term basis. Outcomes for these children were dubious, and the costs were high, so the climate was ripe for service redesign in 1985. Integrated services was the result.

Problems with using services categorically continue today, even for children who are in integrated service programs. Social workers, teachers, and mental health professionals like to find ways to simplify their jobs, and they are often unaware of how this quest for certainty inherent in using labels and categories may miss the mark. Whenever a professional worries about a client’s behavior, there exists a significant danger that the professional will refer to someone else to address the problem, rather than adapting their own behavior to meet the need. Like shoppers in the mall they look for "package deals" that are supposed to fix the problem, while conveniently getting the problem off of their plate. It is comforting to know that someone else is available to do it, when you are unwilling or unable to do it yourself.

The problem with use of services categorically is two-fold: it oversimplifies needs, and it seeks precision that does not exist. The search for precision is born out of the hope that a specific service exists that will fit a specific need. In this quest, needs of the individual are compartmentalized; the person is divided up into parts with each part representing a separate problem that is supposed to be self-contained. Categorical services are supposedly designed to serve each category of problem. A person who is defined as having six different problems, gets six different services, one for each of the problems. Consider the following: if the model for compartmentalizing is wrong, and the model for designing the specific service is wrong, how can we hope to get good outcomes.