This question might seem disingenuous, or simply rhetorical, to anyone who is employed in the behavioral healthcare or social services fields. I posit it is anything but.
My agency is one of many that serves individuals with mental illness, substance use disorders and other special needs, and our workforce is comprised of paraprofessionals who possess training and experience in the provision of rehabilitative services to our clients. They do not hold professional licenses (excepting those in supervisory capacities) nor do they deliver or receive reimbursement for behavioral health “treatment.” In fact, they are continually reminded of this and advised to redirect any treatment-related issues to properly qualified personnel within our local clinics, hospitals, Assertive Community Treatment (ACT) programs and other “professional” settings. In other words, ours is simply a community-based organization that does not provide treatment per se. Treatment occurs in the rarefied presence of professionals who have received specialized training and the requisite licensure and experience necessary to address our clients’ presenting symptoms or other manifestations of their disorders.
Some would argue this approach follows an antiquated medical model and is antithetical to principles of person-centered and recovery-oriented care. It is anything but holistic insofar as it regards individuals not as individuals but as constellations of symptoms, issues and concerns for which each element of the behavioral healthcare system bears a separate and discrete responsibility.
Nowhere is this destructive “division of labor” more apparent than in the Balkanization of mental health and substance use treatment. Mental healthcare providers generally operate under the regulatory auspices of the Office of Mental Health (OMH), whereas substance use treatment providers are beholden to the Office of Alcoholism and Substance Abuse Services (OASAS) for their licensure and operating guidelines. Moreover, these regulatory bodies and the entities subject to their oversight possess unique histories, philosophies, standards, evidence bases, financial constraints and a host of other defining characteristics that influence their approaches to the vulnerable individuals entrusted to their care.
Imagine, for a moment, if you were struggling with a mental health condition such as schizophrenia for which you received treatment that includes various psychotropic medications, psychotherapy and rehabilitative services. Imagine if you were also dependent on alcohol and marijuana to ease some of the pain and discomfort of your symptoms. You might have been told the use of alcohol or illicit substances is unhealthy but you cannot resist the immediate relief they provide. Now imagine if you received treatment within an OMH-licensed facility that espouses an “abstinence only” approach to substance use treatment. That is, it suggests recovery from a mental health condition cannot proceed in the presence of active substance use and you must forsake any and all substances in order to remain in treatment in this facility. Alternatively, this facility suggests it cannot treat your substance use issues and refers you to another facility or organization with real or presumed expertise in this realm (i.e., an OASAS-licensed provider). You must then enroll in two programs, establish relationships with two (or more) clinicians to whom you must disclose your needs, receive (likely conflicting) guidance on the most appropriate courses of treatment and so on. You must continue to tell your story in all its intimate and traumatic details to a succession of professionals who apply their expertise to a portion of your experience but disavow the rest of it.
You get the picture.
Such “treatment” doesn’t seem so appealing does it?
This scenario is quite common, and as much as we pay collective lip service to the imperative to integrate substance use and mental health services our silos persist. Individuals with co-occurring or complex conditions are shuffled among providers and frequently discouraged, if not altogether alienated, in the process. Mental healthcare providers operate under the assumption they cannot treat substance use issues. Substance use treatment providers maintain the same assumption with respect to mental health conditions. Our society’s most vulnerable individuals get lost in the process.
I am pleased our agency has joined many others throughout our region in a collective effort to eliminate this longstanding schism. Counties in the Hudson Valley Region have formed Co-Occurring System of Care Committees (COSOCCs) through which healthcare providers, social service agencies and a host of other stakeholders of all stripes have come together to identify and to incorporate best practices in integrated care in their respective organizations. This work rests on several key assumptions, foremost of which is an acknowledgment that clinical complexity and co-occurring disorders are an expectation (and not an exception) within our practices. Its corollary assumption is that all individuals, including those with co-occurring conditions, must be welcomed into our practices and provided with the tools and resources necessary to advance their recovery in accordance with their unique needs, capacities and readiness for change. It is no longer acceptable (not that it ever should have been) for us to shun elements of our clients’ experiences because we are “not qualified” or “ill equipped” to address them. There can be no wrong door for individuals in need. If there is, that is, if we close our doors to people who present issues that challenge our skills or cause us to question our competence we may lose them forever.
I am not suggesting there is not a time and place for referrals. There are surely limits to our expertise and we must remain attuned to our clients’ needs and recognize when additional resources must be brought to bear. But this should follow, and not precede, the difficult work of engagement and relationship building. When we earn others’ trust by accepting the totality of their experience they are more inclined to consider our counsel, even if it entails a referral or redirection to another service provider. Conversely, if we lead with a referral or usher our clients to the door at the earliest opportunity we run the risk of alienating them…not just from ourselves but from other sources of support. This could be nothing less than life threatening for those in the throes of serious illness or substance dependence.
So what, exactly, is behavioral health treatment and who is equipped to provide it and under what circumstances? Each of us is equipped to support and engage the vulnerable individuals to whom we have dedicated our mission and to ease their suffering in the process. If that’s not treatment then I don’t know what is.