THERE'S A BRAVE new world coming to treatment of the mentally ill as states begin to experiment with commissioning private, for-profit companies to treat conditions that continue to baffle and frighten people even in this sophisticated medical era.
A recent article in The Wall Street Journal noted that companies such as the Atlanta-based Magellan Health Services are seeking increased business as states— who now have greater responsibility as a result of the new federalism revolution in Washington—seek ways to deliver care to the mentally ill.
It is still a neophyte movement, but private firms have already made inroads in states such as Tennessee. State and corporate officials argue that such cooperation can result in better care at lower cost.
But Catholic mental health advocates, wary of previous reforms, which included the large-scale elimination of institutions that were never adequately replaced by community residences, are looking at the effort with jaundiced eyes.
“We, as Church, should not put profit before the dignity of the individual. When you're in a business, it is evaluated for the most part on the profit margin,” said Mary Jane Owen, director of the Washington-based National Catholic Office for Persons with Disabilities, and a former psychiatric nurse. She expressed fear that a concern for the bottom line in mental health care—a field where results are often painstakingly slow and expensive— will contribute to homelessness as programs put unhealthy people out on the streets.
One such privatization effort in Washington, D.C., resulted in company officials “buying Cadillacs and fur coats, and the people were absolutely forgotten,” said Owen. That scandal could be chalked-up to the problems encountered by the D.C. government on a wide range of concerns. Still, the potential for privatization abuse bothers advocates.
Tom Lambert, a deacon of the Archdiocese of Chicago and vice president for the Illinois Chapter of the National Alliance for the Mentally Ill, said that the new trend could be a boon or a bust. The federal government is currently moving funds to the states to run their own programs for the mentally ill. Many are expected to contract with HMO-type organizations to administer treatment. “It all depends on the HMO they have and the way they administer the services,” Lambert said, adding that states like Illinois are currently doing a poor job of caring for the mentally ill.
Thirty years after the massive trend of deinstitutionalization—when huge hospitals, which were accused of being little more than human warehouses, were emptied—follow-up community care is practically non-existent. The result: Many of the mentally ill wander the streets of Chicago and other large American cities, endangering, to some extent, the general public but, most of all, themselves, said Lambert.
“The fear is that with HMOs we will wind up with the same problems,” he said. And, with horror stories of drive-through mastectomies and other more-defined illnesses administered by HMOs already garnering criticism, there is little optimism that the new approach will be effective in dealing with the more complex treatment of mental illness.
Lambert noted that some advocacy groups have become involved in writing contracts for large HMOs contracting with state governments to assure that treatment standards will be upheld, “so that accounting is on the outcome, not on the cost process.”
Bills currently being discussed in Congress and in state legislatures would create parity between the insurance reimbursement for treatment of mental illness and other ailments. In many insurance contracts, noted Lambert, caps are placed on the reimbursement of mental illness treatment that are far lower than those established for such afflictions as cancer and heart disease.
Advocates for the mentally ill note that treat-ment—whether through drugs or psychotherapy—is a long process. It's generally, they note, a costly condition to treat.
Jennifer Shifrin, director of Pathways to Promise, a St. Louis-based group that promotes Christian and Jewish involvement with the mentally ill, warned that an increased emphasis on the financial bottom-line will threaten the invaluable role of chaplains. She noted that in Georgia, for example, chaplains have been eliminated from institutions operated by the state in a cost-cutting move.
“If a person has a mental health problem and needs spiritual resources, doctors can't do very much,” said Shifrin. Even in the best treatment schemes, she added, “people who have spiritual distress, unless it's worked out, will relapse quickly. It's unlikely that private companies will see the need for spiritual support for mental patients.”
She emphasized that mental illness doesn't fit easily into managed care concepts. “Each person is struck differently,” she said. “We all have different personalities. There is no test that can tell you specifically. You can't take a blood test and say ‘Yes, this person has schizophrenia.’”
Diagnosis of ailments such as depression is even more difficult. What can be perceived as a case of the everyday blues can gradually mushroom into full blown depression. “The definition is the inability to perform. That's pretty subjective,” said Shifrin, who noted that insurance companies and HMOs prefer to deal with more objectively-defined illness.
Whatever the finance mechanism that will evolve for treatment, the Churches should continue to play a role, advocates agree. But it should be a well-defined and limited one, argued Shifrin. The Churches, she said, should not have to shoulder the burden of the mentally ill while the government is freed of all accountability. The resources for such an effort are just not there.
“The government would like that because they could abdicate their responsibility completely,” Shifrin said. Yet Churches, she added, can serve the mentally ill by becoming advocates for people who don't have the strength to get through the system to get what they need. A simple service such as making sure that patients get to their doctors for treatment can be helpful. And, as treatment progresses, patients often need someone who can look at their situation objectively and compassionately.
A successful Church model for helping the mentally ill and their families takes place each week at St. Ignatius Retreat Mouse in Manhasset, N.Y. It is not very complex or costly; it involves simply the gathering together of the mentally ill and their families each Thursday morning for breakfast, Mass, Rosary and discussion.
“I am a great believer in groups,” Jesuit Father Bernard Shannon, the chaplain of the Thursday morning gathering, said. Father Shannon has struggled with mental illness himself. He joined the Jesuits in 1947; six years later he suffered a complete mental breakdown. He spent time in mental hospitals but never let go of his dream of becoming a priest. After already 33 years with the Jesuits, he was ordained in 1980.
Shannon recovered through his involvement with Recovery, Inc., a self-help group for the mentally ill. He believes that self-help organizations, modeled on Alcoholics Anonymous, can be a great support for the mentally ill and their families. In such groups, he said, ‘’miracles take place. When people come together I see great healing.”
For Owen, perhaps the most positive role for the Church is to educate people on mental illness. A recent Harris Poll indicated that the disability that generates the highest fear in the public mind is mental illness. Across the country, efforts to establish community residences for the mentally ill in middle-class neighborhoods have been defeated by zoning restrictions and community pressure. The result is that many such residences are clustered in poorer neighborhoods, where crime is high and residents live in fearful circumstances. “This is a justice issue. And we as a Church have not addressed it,” said Lambert who noted that one in four families is affected by mental illness.
Lambert, a member of a commission for the Archdiocese of Chicago on mental illness issues, suggested that the U.S. bishops write a pastoral letter—much as they did on economic justice and the arms race during the Cold War—that would alert Catholics to the need to care for the mentally ill.
While non-profit Church groups should be encouraged to compete for programs to serve the mentally ill, Owen suggested that the specter of for-profit care is a dangerous one. “We as Church should not put profit before the dignity of the individual,” she said. “We as Church must realize that if we put the bottom line before our objective to serve, God is not going to be happy with us.”
Peter Feuerherd is based in New York.