By Mickey Skidmore, ACSW

I’m not sure how I lost sight of this simple truth, but I was recently reminded what a tough business providing mental health services is these days. And the truth be told, it is only getting tougher. It is difficult to deny that managed care continues to be a dominate influence in determining what the mental health delivery “system” will allow for. And while this too changes at a fast and furious pace, both providers and consumers alike can clearly see the direction of these changes. And while there are some significant realities which demand our attention in regard to managed care, there are some disturbing trends unfolding at a societal level which is slowly redefining our national psyche – at least as it relates to mental health care.


The two most identifiable populations caught in the middle of our national cognitive dissonance regarding mental health care delivery are children and the elderly.

Services for children are diminishing in North Carolina at an alarming rate. The systems currently in place to provide existing services are understaffed at the front lines. So too, they are disorganized and mismanaged at the State level. As a result, State and Federal funding mechanisms are endangered. Departments of Social Service (DSS) and Area Mental Health Programs routinely engage in “turf” disputes which compromises effective and meaningful interventions for children and families who have often already been traumatized. The infusion of private organizations with market driven strategies in some cases has resulted in creative collaborations, while in others it has only served to inflame the feelings of mistrust harbored by all parties.

Services for the elderly continues to be a struggle for our nation. Skilled Nursing Facilities (SNF’s) which is a level of care licensed and regulated to provide 24 hour nursing care is providing less and less “skilled nursing care.” Intermediate level of care beds in SNF’s are virtually disappearing. Unfortunately, SNF’s have developed the perception from the public that they will hire as few CNA’s at the lowest pay rate they can find to care for the most amount of total care patients. These employees will also have the least amount of training, knowledge, or understanding of the developmental aspects of the elderly or of dementia, a predominant affliction suffered by many in such facilities. When dementia-related behaviors present themselves, SNF’s move quickly to have these “residents” admitted to acute care psychiatric facilities as “patients” to treat their “behaviors.” This becomes problematic on two fronts:

From a psychiatric perspective, there are few effective treatments available to address dementia-related behaviors. Given this, many insurance and managed care companies are reluctant to reimburse (and in some cases will not) for a condition (dementia) in which a patient will likely not improve. In effect, the environmental change itself and a higher staff to patient ratio than typically found in SNF’s usually result in relatively quick and successful stabilization.

From a nursing home perspective, SNF’s are increasingly taking the position that they cannot care for elderly patients with “psychiatric” conditions. When confronted by patients with dementia-related behaviors they seek to “place” the patient in a psychiatric facility, not always aware that the current system does not allow for acute care psychiatric facilities to take anyone for any purpose other than stabilization. When the patient is stabilized in a matter of days and the psychiatric facility attempts to discharge the patient back to the SNF – they refuse. This creates a disposition problem for both agencies, hardship for families, and uncertainty of how the patient will have his/her needs met.

Both of these scenarios have resulted in a trend which is at best unsettling, and at worse, the breeding ground for corrupt contracts.

On the children’s front, the trend has been to establish Residential Group Homes for “high risk” youth. At face value this appears to be a reasonable and innovative response to a clear need. However, given the current threats to Medicaid and HRI funding sources in North Carolina, coupled with confusion, mismanagement, and insufficient staff, there is tremendous pressure from the area programs to have children who meet the criteria for acute psychiatric care to be served at a the lower level of Residential care.

On the geriatric front, a similar trend has emerged in the form of “Assisted Living” centers. This level of care grew out of a need to care for the elderly that needed assistance with activities of daily living, but did not yet require 24 hour “skilled nursing.” What is beginning to happen is that Assisted Living centers are also being pressured to take residents who in effect meet the criteria/need for a higher level of care normally provided in a SNF placement.

Whenever we say we are providing one level of care, and we accept clients, patients, or residents who clearly meet the criteria for and require a different level of care, and we charge a fee for this scenario we have participated in a corrupt contract – written or not. (If I purchased a first class airline ticket, but was told I had to sit in the coach section when I went to board my flight — and my fee was not adjusted, would that be an ethical business practice?). No matter how politicians or administrators hope to reframe it or sugar coat it – if you call it one thing, yet provide another, and a professional fee is involved, it is nothing short of misrepresentation at best, and fraudulent at worst.


I can think of no other topic in the mental health field in which we as a culture, a society, a people, and a nation are more schizophrenic about than the issue of substance abuse. Statistics of overwhelming sorts reflect a pervasive presence of drug use, abuse, and dependence in our society. Furthermore, these same statistics reveal that no social class or ethnic group is immune to this influence. Nonetheless, we have all witnessed the gradual eradication of substance abuse treatment by insurance and managed care companies. Medical detox is the only acute care substance abuse condition third party payers will reimburse for. (Yet, it has come to be “accepted” that there are no medical protocols for cocaine detox). The 28 and 21 day programs we used to consider substance abuse treatment is no longer considered “acute care” – but rather “rehabilitation,” a level of care fewer and fewer insurance and managed care companies are willing to pay for – even on an outpatient basis.

We see that drugs are introduced to schools as early as the second or third grades, and we preach the need to “educate” our youth about the perils of drugs. We acknowledge the enormous financial impact that substance abuse has on the daily work force of America. We shamefully minimize that there are more black men in prisons today than in colleges across our country – many on drug-related charges. We see consistently that more than 50% of all auto accidents in this country are alcohol and/or drug related. And despite lack of consensus within our own field regarding treatment approaches, there is compelling research to support the notion that treatment on demand is what is most successful. Despite patients pleading for help with substance abuse conditions, it appears we have reverted back to the affluent being the only ones with access to substance abuse treatment. By default then, our society is sending the shameful message that it has opted to address a public health issue with the solution of incarceration.

On the surface this appears to be a corrupt contract by virtue of omission. Yet further exploration will reveal similar parallels to the earlier examples. Drug abuse as a public health problem is one level of care (an issue of treatment). Prison, for those who have violated the law is another level of care (an issue of incarceration). Our tax dollars are the professional fees being paid. I admit there are times when substance abusers violate the law. The question might be however, would they have violated these laws had treatment been made available to them? Each reader must decide for himself or herself. Do you think it is an ethical practice to spend increasing amounts of money for jails to house substance abusers? Given all that we know, (including much more not presented here) it is simply unconscionable that our political leaders would allow this national tragedy to unfold any further.


It is clear that providing mental health services these days is a tough business, and is only getting tougher. One of the reasons for this truth is that cognitive dissonance is rampant in the macro level systems which led to increasing prevalence of corrupt contracts (either overtly or covertly). At the societal level this reveals our cavalier disregard for the potential for young lives and our denial about the erosion of the institution of the family. It also exposes how poorly we as a nation and culture have decided how we will care for our elderly and the place they hold in our society. And finally, as we allow insurance and managed care companies to say “no” more and more to mental health treatments, in the next breath we are also saying that society has decided that substance abusers and the mental ill will ultimately be incarcerated as our primary method for addressing such concerns.

Until such time, Social Workers and other professionals in the midst of this are confronted increasing with being a pawn of such corrupt contracts. At a micro level, professionals struggle daily with the ethical dilemmas which are encountered in such tangled service webs. To rationalize that “the system is the way it is – and it’s far bigger than me anyway” may not be sufficient or adequate when dealing with the lives entrusted to us by our clients.

At the risk of sounding negative, some of you may think me far too ominous or cynical. Still others may suggest that I simply chill out. I suggest however, that a challenge we face daily in our work as Social Workers or mental health practitioners is to “touch one.” This simple yet profound act helps to center us ethically in these storms of corrupt contracts. Perhaps the larger challenge we face is treating the system from within, as we strive to treat our clients. When enough professionals find the appropriate way to express their concern, contempt, and discontent for being pressured to work within systems which are flawed, we can create new and better systems which truly focus on the quality patient care rather than a false “bottom line.”