Evidence Based Practice in Community Mental Health: Part Two

Looking further at evidence based practice, I want to use professional experience to look at how putting-the-cart-first treatment translates into wasted public dollars and second class services. In this article, I take myself out of the State Hospital, and insert myself thirteen years later in the ranks of the mental health workers.  Not only are we perhaps wrongly trained in the universality of counseling theories (as part 1 on this series suggests,) but additionally we are the rank and file that get hired into local systems that use fidelity measures to promote proven recovery practices.

Much like with economics, it can seem to be widely presumed among administrators that recovery services can only transform via academic trickle down guided by research. I contend that this reductionist view is self-serving to the power structure not taking into consideration the nuances of local culture and recovery itself. In this article—part two, coming at you from my work in Shy Town, Illinois, I am here to reflect opinions of the sometimes underestimated rank and file. While administrators depend on evidence that a practice will work, the potential for doing damage and being wasteful rises exponentially.

I have seen evidence based practices in community mental health perpetuate myths, stigma, unstable relationships, and limit healing.  They may be used to fuel programs that are chasing money and more concerned about silos and statistics than the community.

I, like many in the rank and file, have a hard time counting on a person with a highly reputable background come in from out of town who says, this is the best way to do it. I now look at their culture and wonder what they in fact know about the systemic history of their subjects. I wonder how much money they are going to take and waste. I could do this and that alone could easily prevent a researched recovery principle from materializing.  Evidence based practices as I’ve seen them play out presume that there is no such thing as class, race and gender biases or local distinctions that are going to get in the way of implementation.

They need to.

A Social Experiment: Three Competing EBPs

Four years ago I left my job in a community I love and have since returned to, to join an effort to jumpstart recovery via importing three evidence based practices. In 2008, Cook County imported the Housing First best practice; the IPS employment model; and the best practice of Peer Support by a leading out-of-state company.  Clients were given all three practices at the same time and expected to transform into work and end their dependence on Social Security.  Teams were set up with representatives of all three of these best practices and these teams were led by case managers from seven local case management teams.

I came on board during the second year of operation as the back-up administrator of peer support.  I completed a comprehensive and experiential peer-employment training with a new team of workers and my first task was to attend all the team meetings and represent the peer workers.  Sure enough, I would find many of our peer workers, just out of the system and battling external and internal stigma, being bullied into silence at the meetings.

After I made the rounds, on a day when the top administrator and our boss were present, a worker who seemed most effective, and on-the-ground respected came into my office before meetings commenced.  He shook my hand and told me I was walking into a bee hive.  As soon as he was gone and the door closed, I found out that the top administrator had a file on this worker, who was a racial minority; he was on track for being fired along with another minority worker, who was axed that day.

Sure enough, the man of a minority race was trying to provide for his family on wages that barely cut it according to the local standard of living. The things he had done, in my mind, demonstrated his economic need. Memories of my own sense of financial hopelessness were triggered. Indeed, the more I took inventory, I quickly became alarmed about what I considered to be racial and class in-sensitivities: workers who had harder inner-city backgrounds seemed to me to be more heavily scrutinized. I felt that the best thing to do was to send an email expressing my concerns to the boss.

Meanwhile, as I was feeling quite bullied and insulted at the tables, I quickly got feedback from my own company that I didn’t know how to present as a professional; however, the feedback from the program evaluation came back that I was well received in the eyes of the local workers.

Time passed and the worker who warned me about the bee hive was fired. Likewise, a minority director who I had forged a relationship with was replaced.  I continued to observe the other male minorities to be not treated well from my perspective. The new director formed a close relationship with my domain boss, who, though rarely around seemed to be very offended by my email.

The bullying at the table overseen by the county’s new director was now escalated. I was told my actions weren’t intelligent when I was at the center of a table attack.  One time, I was likened to Stuart Smalley. On another occasion, I was ambushed with several domain leaders present and accused of influencing and enabling “psychotic” clients to be against medication.  When I explained that I myself believe in and take medication, a worker from another domain who supported me was written up for not being a team player. I experienced no sense of an apology. I was accused of being paranoid by my domain leadership when I complained. Shortly thereafter, I was vanquished from the meetings.

Meanwhile, back on the company’s ranch, the top administrator was out on disability. I hoped that the fact that our domain’s productivity numbers were steadily growing with me as the temporary leader, and that our specific company boss was replaced with someone who seemed to respect me might mean job security. I was not looking for control of the program I was fine with being number two. I was most interested in being in a position to advocate for better wages for the workers. From my perspective, this was key to promoting quality services making a permanent stay in the county. Then after two years, I got the word that at the call of the county’s program director, I be demoted and put in charge of the charts.

My powers were totally stripped.  When a worker was sick I was not allowed to release them.  They had to work until my rarely responded to emails gave me the approval. There were many examples suffering that occurred from unanswered emails. Meanwhile the productivity sank. At the same time I was micromanaged. Company people were brought in who publicly sabotaged my credibility in front of the team.

It occurred to me as the bosses hired the wife of the lead author of the collaborative program that letting productivity tank could justify my demotion. I was told that I was disorganized which is true, but never had been brought to me as a concern. All details of the job that I was responsible for were factitiously done on time because, I worked sixty hour weeks. I never realized that disorganized people who have a history of success conducting therapy, were only gifted when it comes to taking care of charts.

I made a rapid exit to a part-time gig at my old place and opened up a private practice for Medi-Cal clients. My application to be a Medi-Cal provider mysteriously stalled at the county’s highest level for reason that did not make sense.  I pinched pennies, worried about mortgage payments, and eventually got back to full time back in the community I love.

Looking Beyond my own Scars:

I learned a lot about community dysfunction caused by EBPs from this experience. I believe it’s possible that this kind of experience has happened before in history as streams of funding and innovation have come in. Training changes and as our nation gets impacted more by trauma and poverty and we struggle to know what to turn to.

Ultimately, the county closed this expensive collaborative program and the out-of-state company I worked for lost its contract.

It was true that the company I worked for had some pretty awesome training and that they have successfully expanded. Much of what they have to convey about mental health, I continue to agree with. I wouldn’t even be so brazen as to conclude from what I experienced that they unilaterally discriminate against racial minorities.  But I do contend that they did not know the ethos of the community they were operating in. Though not their fault that local people were insulted that they got the contract and attacked, the unhealthy attack back mode made a few heads roll, mine being one of them. In the process, the strong local consumer base was denied the opportunity to run the peer support.

I believe what happened in Cook County is likely when a practice uses research to proclaim that their fidelity measures are going to work anywhere. It’s a false sales pitch. It presumes there is no such thing as politics. It presumes that an academic elite is needed to train the masses of people who may well have walked a different path. It releases all or nothing funding streams without taking into account the fact that there are cultural factors at play, personalities, egos, cliques and competing financial incentives.

In the bee hive that I was hired into, competing fidelity measures didn’t match up.   Local case managers and the employment IPS domain were highly critical of the peer domain in part for survival purposes: if peers could do what they could, jobs might be lost, or pay cut.

In sum, with a high need for collaboration and an enormous amount of political infighting recovery was not promoted. Perhaps some will say it’s the clients’ faults. That was certainly the pervading ethos of some of the more disenfranchised workers.

I contend that recovery cannot be replicated in a uniform manner. I’d argue that what is more important is a healthy family mental health system that is in a cultural state of learning in order to meet people where they are. In this Illinois experiment, it seemed like the companies who own the best practices came and scooped up the money and the rest of us suffered and were more likely to walk away hurt and burned out.

In spite of all this, though, I saw the pilot program did transform some lives on the ground in ways that weren’t measurable. I like the other workers also learned a lot about a number of different EBPs that I will take with me.  But clearly what is most memorable is the dysfunction.

Yet, my intial question stands: did all the money for all the promises of the evidence based practices trickle down into the lives of the people served? Would the county not have been better off going to its strong consumer base, taking the ideas from these evidence based practices and co-constructing locally sensitive recovery? Was imposing change in top-down ways based on the notion of a superior intelligentsia cost effective?

This entails, much as my part-one article did, that Theorists need to first define themselves culturally and then assert themselves locally. They need to interact with their local consumer base and not gear themselves up to sell their experience on a global market. When it comes to practice of mental health a theorist and a therapist need to constantly define the limits of themselves and not focus on growth so as to impose their values and experience in universal terms on others. It is time administrators understand this and ease up on the evidence based demands.