Archive: Dispatch from the Trenches of Public Mental Health

Archive: Originally posted at Democratic Underground on 12/18/12

As a preface, the discussions on mental health this week have gotten me where I live. On April 20, 1999, I was working a few counties away from Columbine High School, in the juvenile division. I had several clients who were either expelled or suspended from school in the days after — not for anything they did, but for being different, under care, or just part of the geek/goth sub-culture. My clients bore the blame for the actions of others, and that blame did not help anyone — not community, not clients, not the victims. I’m seeing that exact same pattern again. We have done this, and the collateral damage endures.

These are my experiences — the stats have probably changed since my colleagues and I last compiled our numbers, but they haven’t changed much, and in many cases, not for the better. I don’t have accurate numbers for 2008-forward, but given the slashing state, county and city budgets have taken, I’m not hopeful for better.


I used to be a clinical psychologist in public mental health. Burn out is the brontosaurus in the living room. Here’s a snapshot of the trenches. The average public mental health clinician has been in the job for less than five years, and has been licensed for about the same amount of time. They’re mostly young and new. 65% leave public service for either private practice or get out of the field entirely. I was lucky — I had excellent scholarships and fellowships through grad school, but some of my peers self-financed and left grad school with debt they will be paying until they hit Social Security age. Starting salary at the county level (which is the majority of public mental health clinicians) averages less than the average first year public school teacher. (A psychologist, by the way, usually has 7 years of post-secondary education; a K-12 teacher has 5-6.) We don’t have a union. In some counties, we’re not even employees — we’re contractors, so no benefits. We don’t go into psych for the money — we’re there because we want to help others. And it kills us — we’re 3 times more likely to commit suicide than our peers. We’re 6 times more likely to be on anxiolytics than the general population.

In my last year before going back into research, 95% of my clients were court-ordered. The few who were there voluntarily were as compliant as their circumstances allowed, but a court order drops compliance by at least half. A therapist can’t help a client who doesn’t want help, and often clients work against court-ordered therapy. For the court-ordered client, the therapist is the avatar of a power structure where the client is entirely disempowered. The therapist seems to have the power to send a parolee back to prison for a beer or mouthing off, to place zir children in foster care, to force them to abandon anyone we determine to be a “bad influence” — which in a lot of cases, means most of the client’s social network. In most counties, the client is forced to pay for this. In most places, public mental health services are set up to fail comprehensively. I worked in a red county, and believe me, the county board of supervisors wanted us to fail. If we failed, they could stop paying us liberal commie bleeding hearts and just send all that human garbage to rot in prison (and that prison made a lot of the local power structure a lot of money…)

Our clients’ median household income was less than half of the local median household income. Poverty makes compliance harder.

Pop quiz:
Go to therapy or go to work — when skipping either violates parole?
Buy court-ordered meds or buy food?
Use one’s 9th grade literacy skills to write in one’s therapy journal or get an extra half-hour of sleep after a triple shift?
Pick two: rent, therapy, or kid’s root canal?

Clients have a lot of dreadful algebra every day. For a lot of my clients, poverty was both the cause and effect of their dx. Public mental health made me a socialist — fix the social safety net and half of the client load vanishes because half of the client load is situational. If every kid has enough to eat, safe and comfortable housing and an effective school, if every adult has safe shelter, valued, meaningful work and sufficient leisure, depression and anxiety plummet. It’s not a panacea, but our deficits in the safety net magnify our problems.

I spent most of my time in the trenches deeply worried about my clients — I took it home with me every night. If a client was non-compliant and I reported it, my client could have gone to prison (or gone back for parole violation), which ends any hope of effective treatment. Non-compliance can mean anything from skipping appointments to not doing the work to skipping meds to self-medicating. I was supposed to report every beer, even with clients who had no addiction problems. Do I report someone because zie blew a long-bald tire or got a chance to work extra hours so zer kids actually got new shoes, but can’t call to reschedule because zer boss doesn’t allow personal calls (or maybe doesn’t know zie’s in therapy — people still get fired for mental illness, especially in right to work states)? If I didn’t report it, that’s my license… And possibly a suicide, or domestic violence, or a relapse. Believe me, that stress eats therapists alive.

Without a license, my master’s degree won’t get me a job at a call center or flipping burgers. But pissing off a client by reporting non-compliance earned one of my colleagues a severe beating. I had my tires slashed (which were bald, but I couldn’t afford to replace them.) I was salaried, scheduled for 30 one-on-one appointments a week, plus 10 hours of group, plus 75 welfare calls (6-12 hours), plus on call for 24 hours a week. Yes, 70-80 hour weeks, for which the county paid us $27K a year plus medical and dental (but I couldn’t take the time off to actually see my doctor or dentist…) Unlike teachers, we don’t even get summers off. The year I left, the county I worked for cut 3 of the 27 positions and the county judges ordered 21% more therapy. Which meant worse service, worse outcomes, more recidivism, which gave the county board of supervisors more incentive to cut the budget.

This country doesn’t care about public mental health, either the clients or the therapists. We’re first responders — and the first rule of first response is don’t be a casualty. I was terrified I was going to kill myself, or screw up so badly that a client or someone else got hurt. I cried every night for three years. I am in research now so I have the energy and time to fight for better conditions for clients and colleagues. I still have 80 hour work weeks, but half of that time is lobbying on their behalf. It’s the only way we’ll ever change it. Public mental health is like juggling burning napalm.

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