It hasn't been talked about much, but the District of Columbia government has decided to turn over responsibility for much of the mental health care of its citizens to independent, private contractors. It's a highly controversial action, and one I think is probably a big mistake.
Until last year, the city ran three community mental health centers as a way to reach the poor. In 1981, as a budget-cutting measure, city officials moved to consolidate services for 6,500 people into two centers, one each in Northwest and Southeast. Those same centers were to handle patients released from St. Elizabeths Hospital under a court order to deinstitutionalize. About 350 patients are involved this year alone.
With $6 million to spend on community services, the Department of Human Services decided not to expand the public services, but rather to shift towards hiring private contractors. Fully one-third of this year's expenditures for community mental health will go to private contractors.
This will mean the transfer of $2 million in D.C. revenue from the salaries and program operations of public employes, most of whom are black, to private contractors, most of whom are white and less accountable to the city.
The case for doing something about the centers in their old state was easy to make. In the nearly 20 years since they were established as a way to meet the needs of the poor, the community centers have come to be viewed as badly managed, ensnarled in red tape and filled with patients who often are desperately ill.
Part of the problem, many say, rested with the fact that the city's mental health program has been administered by a chain of weak leaders with limited funds who failed to demand accountability in the program.
Yet, instead of instituting structure and supervision and demanding accountability in the public centers, DHS has chosen to shift to private contractors.
Mental health care is a service that not only is complex and difficult to implement, but also hard to measure in effectiveness. The decision of the city's bureaucracy, in this instance, seems to be saying that the internal situation is so hopeless and chaotic that it is better to shift to the private sector than to attempt to solve it internally.
The serious question here, however, is what will be the cost to those who depend on the city when they have short-term, and in some instances, long-term mental health problems and stress-related illnesses?
Many are hard-working men and women--often at the lower end of the GS spectrum. These are the people who can't afford the services of the l,123 private psychiatrists who work here. They cannot pay out of their pockets and they do not have the insurance to cover the costs.
Moreover, there is still something of a stigma to seeking mental health services in some black and poorer communities, so many delay seeking help until they are depressingly ill. They need a system of care that is at least as good, if not better, than that provided for the more affluent.
But few of the handful of black psychiatrists here (only 30 of 1,123) believe these powerless poor people will get better services from private contractors. They worry that the white contractors have no demonstrated sensitivity in relating to the mental health problems of blacks, who make up 95 percent of those seeking service here. Poor blacks and white psychiatrists don't mix very well, partly because shared culture is a key to good treatment. This is the same belief behind the current trend toward same sex counseling.
Some black psychiatrists complain further that the contractors will be giving more "social" services, such as art therapy and psychodrama rather than the traditional psychotherapy and medicine. "It'll be a fifth-rate system of care," said one. In short, these psychiatrists say, the new system simply won't work.
"Most of the people are totally insensitive to the needs of the population," says Dr. James L. Collins, a black psychiatrist who is chairman of the department of psychiatry at the Howard University Medical School. "The city is giving the whole thing away."