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Choice Not There

November 16, 1986

Re Donald Woolson's commentary in the editorial section of The Times of Nov. 2 ("Policy Makes Short Shrift of Mentally Ill"):

Although I am a public mental health employee, I am speaking as a private citizen, but with knowledge of the issue to which he writes.

Mr. Woolson's impassioned pleas are misdirected. For years (it seems forever), the chronic mentally ill have been "second-class" patients within the mental health system, shunned by the private sector in most instances because of limited funding, and mainly due to the nature of their problems (in and out of hospitals, on the streets, in jails) and the seemingly no end for constant treatment with medications (talk therapy is rarely effective without the medications), and because there is no cure for the chronic illness. The public sector provided what it could to the chronic cases, but also gave them a lower priority because there was no point in expending large amounts of time and money on patients whose expected recovery was never!

On the other hand, the private sector always attracted the "couple on the verge of divorce, the man who exposes himself to young girls, the woman unable to hold a job because of her anxiety, the rebellious teen-ager flunking out of school," etc. These are behavioral, life crises cases which can be worked with in talk therapy, and in most instances, can be effectively and conclusively treated, i.e., cured. The only barrier was of a financial nature . . . if they had third-party insurance or personal finances, they were most desirable cases.

The low-income group of behavioral cases were allowed into the public sector during a period of fiscal wealth within the public sector because it was theorized that by treating these cases quickly, they would leave the mental health system forever. But good intentions or not, it failed to happen. Many psychotherapists do not like a great turnover in their caseloads. These behavioral life crises cases are good to work with, they respond to talk therapy, but they also stay with the therapist perhaps too long after the therapy is effective. And while the behavioral cases remained in caseloads, the chronic mentally ill population in the communities around the country greatly increased due to a number of reasons: better medications therapy allowing them to be treated in the community rather than in a locked ward, fiscal restraints within the public sector, and so on. And now, the culmination is that the two types of cases cannot be treated by the same public sector . . . there just isn't the resources available for both.

Mr. Woolson is pitting one type of case against the other, one being more deserving than the other. Rather, let him direct his plea to the real problem: not enough resources for either type of case!

In the current atmosphere of fiscal conservatism in government, let the chronic mentally ill continue to be treated with a high priority simply because they do not have any alternatives. For the behavioral cases who are low income, they do have a possible alternative: let private practitioners and groups open up their caseloads to accept 20% Medi-Cal or lower rates and alleviate the strain on the public sector.

And let both the private and public sector lobby for the higher Medi-Cal rates to cover the realistic cost of treatment.


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