The video is based on my experience, thoughts and opinions. Which are open to change.
Brief Overview History
Community MH Act
Transition from State Hospitals into Community
Direct Billing the State for services provided.
State Financial Liabilities
Managed Contracts to limit financial and legal liabilities.
The breaking of the bonds… State to community to client
Move to privatization via corporations… both non-profit and profit.
1940-1960’s The Farm
1960-70’s the behavioral, humanism, rational cognitive
1980’s Clinical to Corporate and the rise of MBA, JD and IT; scientific, imagining, psycho-pharmacology. Research for specialized high ticket interventions. Public MH is left scurrying for crumbs and captured in a maze of regulations.
1990’s from Client to Contracts and rise of insurance and regulation are inserted between the patient and provider
2000-2010 From services to regulation
2010-2020 The implosion?
Shift from humanism, sanctuary to clinical, to regulatory
CYA avoiding liabilities via the cover of regulation, contract/audits and slap on the wrists.
With contracts, regulations, audits… less attention and services to the client
Under the cover or Black Box of HIPPA, confidentiality and games
Games of laws, administrative codes, regulations, contracts, bureaucratic obfuscation
Drift away from clinical to the research academic
Losing clinical expertise, lack of mentors, loss of value to the client which is
Replaced by the appearance of services… but of little value to the client.
Instead of service, a client gets brokered to a spin bin of services…
And on the provider clinical side there is a high, small and costly window for education and trainning.
A noble vocation yet the pay is negligible for the demands and regulatory requirements.
Currently Hitting The Fan…
High need, lack of qualified and experienced staff.
Many seasoned, experienced staff have left or barely hanging on.
The marginalized, the homeless have given up hope, and only eek out a day to day and hour to hour existence. Devoid of dreams; stumbling to the next fix, the next meal, the next place to sleep.
An over run community systems that can no longer handle the load let alone be responsive. It is the political “HOT potato.” This is because it is a not a clean issue (without political liabilities) and it costs money. It has become a “shell game” of where’s the peanut and hiding the true costs. In the totality of MH costs, there are cost to the client, client’s family, community with hospital, law enforcement, medics, fire department, clean-up of encampments, public health, civil and criminal courts, drug enforcement and treatment and jail/incarceration costs… before there is an accounting of actual treatment costs provided by the local MH agencies. At one level, it spreads out and hides the political, financial cost and liabilities amongst the community parties. Often what is noted is the treatment cost because it plays better to the community. However, when the total actual costs are noted, a $10 million MH grant in a small to mid-sized community is just a drop or two in the bucket. Granted politically, there are much bigger fish to fry… or money to be massaged with transportation, utilities, housing and public schools. I imagine that the cost to benefit ratio is quite high when compared to a group of MH consumers to the public. It conscripts the homeless mentally ill to a political and financial issue. I wonder with the increased visibility of the MH homeless on the streets, sleeping in the doorways of businesses and piles of trash; will this become an existential crisis flash point for the political folks because of the demand of their community voters?
The academic thoughts: Has the social contract between the community, providers and individual been abrogated to a maze of laws, contracts and regulations?
A matter of family and parenting
Education and opportunity
A matter of social, economic, class issues
A matter of community economics and taxation
A matter of the community mental health system
Is there a remedy? Where to start?
Presuming that we are social creatures, perhaps a place to start is “what is the human condition relative to their community. The foundation of the modern care, a person who cannot care for themselves is the concept of “parens patriae.” Which is the king or state is regarded as the legal protector of citizens unable to protect themselves. Currently there are challenges to this concept. Whether there are issues of an abrogation of responsibility or duty, a balance of an individual civil rights versus community safety/protection or how are assurances of care and protection of individuals ensured via contracts with non-governmental/private corporations. It’s a complex multi-layered situation. Parens patriae is a simple concept but is a sledge hammer… vague and costly.
What can a person do, at what level. What are the mechanisms for assessment and evaluation? To what specificity and who is the evaluator and for what purpose. Yet this only addresses a time limited or temporary evaluation and to what specific circumstances of health and safety.
Homelessness is not a crime or civil violation nor is an illness. Whatever the associated behaviors might be, even though a person is yelling and acting bizarrely does not necessary constitute forced containment, medications or treatment. Admittedly the bar is high and access to treatment is near impossible for both the MH consumer and clinical staff.
Recognizing and understanding the issue or condition is one thing. The analysis and resulting treatment is another. And lastly the engagement of all parties is like herding feral cats.
Do or Not DO… It Depends?
Because a person has MH, drug or homeless issues/conditions, the presumption is that they are soiled, unfit or unworthy. And therefore, the blanket conclusion is they are not capable, nor able and need to be taken care of; it depends. It depends on the premise of the paradigm. There are many paradigms such as the religious sinner that needs saving. The savage or ignorant beast that requires education. The industrial, scientific standards of measurements and uniform tolerance of widgets. The humanism that each human is a unique and thus requires special treatment or compensations. On one hand, is it off the rack or shelf where one-size fits all. Or a matter of uniformity/standards and tolerances and is really a matter of the economics of production. Or some folks just special and requires custom, boutique, high-end service. Of course, the answer to all is “yes!”. Underlying the premise level of understanding is the “problem and solution” paradigm and the selling of the solution. It’s easy to see that it depends whether or not “to do or not do” is based on the subscribed paradigm and who prescribes the solution, their intention, investment and costs. It’s about “the sell’… the sizzle and the relationship. This is where we start and depends on if you are the seller or buyer of last resort. This interaction often starts with the statement of “I want or need.” Or “I have and can give”… It is a conversation, negotiation or dialogue of what and how to collaborate. It’s old fashion bartering between the buyer and seller. But in our modern civil society there is a multitude of costly intermediaries that are inserted into this simple relationship. It could be banks, insurance, regulatory, escrow, standards and measurement (surveyors, CMS, FDA, FTC, EPA, etc.) These intermediaries are the friction or cost of the interaction which are the evident or hidden administrative fees in the transaction.
Hierarchy of Needs
Before we continue, we need to venture down the simple path of Maslow’s “hierarchy of needs.”
- Physiological Needs. Food, water, clothing, sleep, and shelter are the bare necessities for anyone’s survival. …
- Safety and Security. The want of order and predictability sets in.
- Love and belonging… relationship with their community, family, tribe.
- Esteem… feelings of self worth, self respect.
- Self-Actualization… feeling empowered with meaning and purpose.
A discussion of needs and wants is challenging. But quickly becomes complex when motivation, knowledge, skills, strategy and execution or the “how to” of making something happen for both the buyer and seller parties. Duh, nothing new.
I’ve often thought about the individuals’ needs versus the community’s needs surrounding the issues of homeless with MH, drugs, violence, etc. And found myself in the center of the hurricane at 2am conducting crisis evaluations under the guise of involuntary mental health and drug commitments.
The Disconect… Relationship
While not having any solutions or remedies, I see a clear disconnect. The disconnect is between an individual’s need and the community’s ability to serve those needs. Duh, again nothing new.
But here’s a starting point. Communities often presume that they know the need and what to do about it (the problem/solutional model). But rarely does the community, i.e., stakeholders directly establish a relationship with individuals. Of course, there are a host of intermediaries that have direct contact, such as law enforcement, emergency departments, criminal courts and corrections, a few MH professionals and churches or social organizations, etc. The problem is the community intermediaries start the dialogue as “here is what we can do. We can take you to jail, to the ER, get you a crisis bed, here’s a sandwich, a blanket, some shoes, shower, a medication appointment, etc.” Which is needed but is only at Maslow’s basic “physiological needs level.”
Basic physiological needs are relatively minimal, straight forward and easy to provide. Globally most of the world’s population exist on very little. Walking around my small and relatively wealthy community, frankly I am in awe and humbled by the homeless. They survive on very little…and there are small groups and larger encampments that form to address the needs of their ad hoc communities of lost individuals.
They, the homeless form communities. They have relationships with others in their self-selected and often hapless manner. Agreed they don’t have all the administrative intermediaries. But there is a tribal recognition and organization based on leaders, followers, healers and functionaries. A while back, I was out walking the dog and returning to the car. There was a couple (man and woman) of homeless outreach workers in their mid-20’s to early 30’s on the trail, who stopped and ask if I had seen the homeless encampment. I noted we had not walked the trail that far back into the woods, but that the encampment was there. A short while later, the outreach folks returned to their car. Because of the timing, I am sure that they did not go the encampment. But I wondered their purpose of going to the encampment and why they did not make contact? Perhaps a wise decision on their part. Even though having many years of crisis MH experience, countless outreaches into the community and on the streets. I have minimal fear of homeless folks and a tolerance for high-stress situations; but it is an gained skill set. I highly doubted that these two outreach folks had sufficient experience.
Before I get to the main point, I’ve had several experiences of amorphous communities. These communities came together rather organically. These individuals were self-selective and self-organizing. That individuals for whatever reason wanted to take part in the community. As part of their participation in the community, they contributed interest, skills and services/labor. Also, the community did not exclude nor prescribe an individual’s contribution. They accepted all contributions without regard to contemporary/standard valuations. Individuals were free to come and go as they pleased.
Another experience of note was being a grad advisor for a peer health program at a university. The concept is based on engaging the “natural helpers” of a community. The focus of the program was to engage the “go to” individuals or natural helpers in the university’s residential and Panhellenic (fraternity and sorority) programs. The short story was the engagement of the natural helpers was an exceptional success. Because the natural helpers were the informal connectors that provided the relationship and avenue into their respective communities. They were the link and validation between their community, individual in need and the larger university’s community and resources.
Throughout my mental health career, I have met outstanding individuals frequently homeless, drug history and victims of violence. The point is, just because a person is homeless, mentally ill, a former victim of abuse, et cetera does not mean that they are helpless, dumb nor worthwhile. And just because a person is a politician, bureaucrat, or concerned community member does not mean that they are dis-interested, incapable nor compassionate.
First, I wonder if the “natural helpers” concept could be effective in establishing relationships with local homeless community. Second Is I wonder if community homeless programs are aiming too low. Meaning that the physiological level needs are relatively easy to provide. But if we focus on the higher needs of an individual’s meaning, purpose and roles in their community, would this be a more effective strategy towards helping an already self-selected and self-organizing homeless communities to better leverage the larger community’s intents and resources? Resulting in a collaborative relationship towards a win-win engagement.
I have often wondered, what if we can focus on what we can we do instead of what we cannot do? How can we help a marginalized community establish a sense of safety and security for their community… not just individuals. How can we encourage folks and their communities to become meaningful and purposeful in their relationships? Both as a part of their self-selected community and to the larger community. I wonder if this leads to an individual discovering their self-worth and their self-actualization within the self-selected community. Can we help each other move from dis-affected, disenfranchised and disempowered to becoming empowered, engaged and connected? And in that we all find opportunities to discover our meaning and purpose in our community.
I wonder if we can find empathy to support establishing a sanctuary for folks in need? However, not to do it to them or for them; but a space so that they grow themselves and their community. Folks don’t want a handout, but a safe and secure sanctuary with opportunities to discover safety and belonging. To experience self-esteem/worth and take part toward actualizing themselves. A garden for them to discover their meaning, purpose and contribute to everyone’s survival… their community. Here’s the thing most folks want to feel like they contribute something of value to their existence. Essentially it is about connections and relationships.
P.S. Ideas off the top of my head in which homeless could be offered opportunities to contribute.
There is always work to do, the issue is how much do you want to get paid. Being homeless there is very little overhead or living expenses. What about local “work project administration“ (WPA) style projects? Things like cleaning up beaches, making trails, filling in potholes, etc. Things styled like “work release” crews for public parks, public buildings and university/school grounds. Or instituting a $0.10-0.25 deposit/refund on cans, bottles and plastic bottles so that homeless can feed themselves.