ISSUES IN PSYCHOTHERAPY WITH CLIENTS AT OR BELOW THE “SAFETY NET”: Challenges, Observations and Dilemma’s
By Mickey Skidmore, ACSW

With mental health reform fast becoming a harsh reality, I have been thinking a lot lately about the vast number of people who need or will need mental health services in the future who are at or below the poverty level. This growing cohort of the population has been identified as one of the primary reasons that Medicaid expenses continue to rise at both the state and federal levels. North Carolina has decided to address this by focusing almost exclusively on providing some sort of a “safety net” for children. In the not too distant future, if you happen to be an impoverished adult without children, you will be out of luck.

Beyond the issues of reform however, is the juxtaposition of “safety net” services, monies, etc. and how well this fits with the goals and purposes of psychotherapy. As a clinical social worker, I strive to impart the fundamental values of empowerment, self-determination and independence in the therapy we embark on together. Yet, as a therapist I am increasingly confronted with clients who have become dependent upon the “safety net” to the point that there is little incentive for them to seek true independence.

Therapists who see clients at what was once the Community Mental Health Center are seeing a steady rise in an interesting sub-group of clients. These clients present with a range of vague (but legitimate) medical issues, such as fibromyalgia, chronic fatigue syndrome or chronic pain conditions which the medical establishment has been ineffective or failed miserably at treating. They feel that as a result of these conditions they are no longer able to work, which in turn results in further financial burdens (remember these folks are already at or near the poverty level). Needless to say these types of circumstances would contribute to the development of depressive symptoms in almost anyone.

If in fact there is a legitimate disability issue, it is not (or at least it was not when the issue originated) resulting from underlying psychiatric pathology (mental illness). Yet, lawyers shuffle these clients through the mental health system as part of their strategy to win disability cases. So, such clients present to therapists with the goal of seeking disability benefits rather than for genuine treatment.

This disconnect is further magnified by those clients who actually succeed in getting disability or other “safety net” benefits. I have several clients who receive a wide range of benefits, including: food stamps; Section 8 housing; Medicaid health insurance; First Work Program (which includes educational funding and day care resources for children); and transportation services. Totaling up these services and benefits in real dollars in many cases is far more than many professionals make in today’s economy.

While I do not begrudge clients who receive such benefits, my efforts to persuade them towards a path of independence, self-sufficiency and pride tend to fall on deaf ears. Why should they buy what I’m trying to sell them, when they already have more? And not only do they actually have more sometimes in real dollars, they do not have to deal with the issue of responsibility at all. Many of these types of clients wind up using the mental health system to seeking a label which reinforces the legitimacy of their plight, and ultimately an ongoing dependence on the “safety net.” For such clients, these are difficult dilemmas which are often counterproductive to the therapy process.

Such observations simply confirm a fundamental Social Work value: many problems of living are societal and systemic rather than personal or interpersonal. By learning more effective strategies, people can effect changes in various aspects and dimensions of living. The purpose of psychotherapy was never intended to address the increasing array of societal and social ills. Yet, it seems that any further thoughtful consideration as to how to better address where the efforts of the “safety net” and therapy intersect is still far in the distance somewhere.

I submit that a primary focus which has been lacking lies in the arena of responsibility. As Social Workers consider the wide range of challenges and dilemma’s they encounter daily, I offer the following thoughts about some of the core values of the profession:

* Ideally, people should have access to the resources they need to meet life’s challenges and difficulties, as well as access to opportunities to realize their potential throughout their lives. I submit it is a disservice when “access” and “opportunities” become dependence and a sense of “entitlement” without a developing sense of responsibility to utilize access and opportunity as a spring board to realize their own potential.

* Every person is unique and has inherent worth; therefore, interactions with people as they pursue and utilize resources should strive to enhance their dignity and individuality. I submit there is little dignity, uniqueness, individuality or inherent worth for those who’s sole subsistence comes from the “safety net.”

* People have a right to freedom insofar as they do not infringe on the rights of others; therefore, interactions with people in the course of seeking and utilizing resources should also strive to enhance their independence and self-determination. I submit therefore, when individuals become dependent on the “safety net”, they have not been afforded true freedom. Who was it that said, “A hungry man is never truly free”?

* Realization of the above values should be the mutual responsibility of both individuals and society. Society should endeavor to foster conditions and provide opportunities for individuals to participate in the democratic process. I believe our society should bear the responsibility to foster conditions and provide opportunities for individuals to participate successfully in our society. Yet, I also believe it is the responsibility of individuals to realize their full potential as a contributing citizenry, and not exploit the “safety net” simply because it seems to be a free ride. Although controlled to some extent by their environment, I submit people are capable of making their own choices and decisions — able to direct their lives far more than they sometimes realize. Thus, they always have both the freedom and responsibility to exercise the shaping of their lives.

I am sometimes criticized for addressing these issues in therapy. Yet in the long run, I maintain that by not doing so, I am only perpetuating a dysfunctional arrangement that has yet to figure out a way to bridge these realities. My fear is that mental health reform will only widen the gap further, or worse still, put these issues even further on the back burner..