Dear Senator Alexander… the biggest issue facing the mental health system

Dear Senator Alexander,

My name is Larry Drain and I live in Knoxville, Tennessee.   This is my third letter to you about mental health reform and the bill before the Senate.   I really appreciate you taking the time to consider the points that I am making.  As I  said in previous letters I  am grateful for your attempt to provide leadership in such an important area.

I want to briefly discuss what I think in the end may be the biggest challenge facing the mental health system and one that must be addressed if we have any chance of making changes in the mental health system that really matter.

In the end I think health care reform may unintentionally be the biggest challenge facing the mental health system and failure to meet that challenge will make it hard for other changes to matter.

Let me use Tennessee as an example to show what I  mean.

The mental health system in Tennessee has fought for years to try and maintain their level of funding in each state budget, not to increase services, but just to maintain them on a current level. Over the last two years they have been largely successful in doing that. But there is a major challenge on the near horizon.

This coming legislative session the leadership in the House will propose a bill with bipartisan support to expand insurance in the state of Tennessee to cover those without insurance. Their approach is a two step approach with the first step being to provide insurance to those with mental health diagnoses.

They believe they are talking about 114,000 people. About 35,000 people currently receive services in the state behavioral health safety net so you are potentially talking at least 80,000 people being added into the system. 80,000 people being added to a system that has not had an appreciable increase in services in many years.

I don’t think Tennessee is alone in facing this kind of challenge. Systems all over the country are fighting not just to improve but to not lose ground in face of the challenges ahead of them.

Much of the rhetoric around the Murphy Bill is misplaced and simplistic. What is facing us is far more than something more hospital beds are likely to solve. It is something far more than trying to build in more coercive mechanisms to force people into treatment. It is a fundamental challenge to being able to provide anything close to adequate treatment for thousands of people. It is not just a challenge to provide better services, but a challenge to even maintain what we do now.

One area of possible resources that is woefully underused is the use of peer support, people with lived experience who have been there and learned about how hard it is to find and build a better life, people who are trained and who can be used to provide a whole array of services to people needing them.

It became somewhat fashionable in some quarters during the debates about reform to dismiss peer support as less than important and less than professional. Let me say clearly that is a pointless and irrelevant debate. We are in a new reality that requires new thinking, new ideas and new approaches. With the exploding demand fed by health care reform unless you plan to plant and harvest them whole there are not enough psychiatrists, psychologists, master level counselors, or social workers to begin to meet the needs ahead. Ask any mental health center in Tennessee about wait times for psychiatric appointments or therapy appointments. Ask them if they have enough case managers to go around. Then ask them what 80,000 more people will do.

An increased reliance on peer support is inevitable. The key is in developing the programs, defining the roles, and providing the training to make it work. If we do not face the reality ahead and deal with it proactively I believe the system will crumble down around itself and 10 or 15 years from now the problems we debate having to solve will make those we currently face seem tame by comparison.

There is a provision in the House Bill which would provide $10,000,000 for training and education for peer support specialists over the next 5 years. While it is gratifying to see the issue of peer support realized this approach is inadequate. I would suggest instead that money be made available to States, not just for training but for the actual development and operation of peer support programs.

There is not nearly the widespread knowledge and support of the potential power of the peer support role to improve and actually be part of needed reform in the mental health system. Again let me use Tennessee as an example, not because they are necessarily far ahead of other states, but because I know more about what they are doing.

The state of Tennessee has invested $425,000 in a program using peer support to drastically change the outcomes of people who end up in the state psychiatric hospital program.   In contract with the Tennessee Mental Health Consumers Association they have developed a program with immense implications for the future of how Tennessee does mental health. 

I  quote some of the program description from the TMHCA website to describe the program.   All the services provided are provided by peer support specialists. 

The Peer Intensive Care Program has both clinical and environmental goals. The main clinical goal is to reduce the need for repeat psychiatric hospitalizations by providing immediate assistance following discharge from the hospital for patients who voluntarily enroll in the program. A program specialist will make initial contact 24 hours after a person’s discharge from a hospital.  They will coordinate, schedule or attend (with) patient’s first appointment; assist with intake and recovery planning within fourteen days of discharge; and make weekly contact for ninety days after discharge. Environmental goals are considered equally important. A patient will be provided necessary community resources prior to and during discharge and offered education and support to help patients make successful transitions back into their communities.

This has been a long letter and I apologize for that.   My message throughout all the letters has been,  I  think the same. Real issues face the mental health system that will affect the lives of millions of Americans.   The House bill,  though all intended,  is an inadequate response to many core issues.   I wish you luck and you have my support in passing the Senate bill as written and hope you will consider some of the points I have made as you go into the conference with the House to come up with a final bill to present to the president. 

Thank you again 

Larry Drain 


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