August 10,2019

I try to write on themes that will have “legs,” that will, after a few years, still be relevant to the practice of clinical supervision, will age well.  I risk abandoning that standard for today’s blog, but can hazard a guess that some of my thoughts will have a bearing on clinical supervision a few years hence.

One thought is that the last state level project, permitted by the federal Centers for Medicaid and Medicare (CMS) as a “1915(b)(c) waiver,” and entitled  “Mental Health Reform” (implemented on or around October 2001) was marked by many problems including the following:

There were significant criticisms of state’s shift to privatization, including:

• Many highly trained mental health care workers – especially psychiatrists and C-suite managers -left the field as private providers took control of service delivery, reducing the professional public sector workforce.
• The fragmented system created through privatization had a tremendous negative impact on the quality of services provided to clients. Many times, important mental health services were no longer even available to clients.
• Private providers engaged in “cherry picking,” offering only the most profitable services, such as “community support” services. These services include basic assistance and mentoring, and such tasks as running errands for a client or helping with a child’s homework. They could be performed by low-paid, unlicensed personnel. Many providers focused on these highly profitable community support services and left seriously ill clients without the more costly care they needed.
• Initial reports of cost overruns estimated that the state wasted at least $400 million in community support services offered by private providers that were unnecessary for the client or not even performed. As a result of the treatment offered by the private providers, the number of North Carolinians with mental illness who ended up in emergency rooms or jails significantly increased.

I would balance this by noting the following:

• Many individuals who, under the previous system, would probably not enter the field, did enter the field.
• This included people of color as both owners of agencies and as licensed and certified line staff.
• The expansion of the schools of social work in North Carolina from a few to more than a dozen; and the expansion of substance abuse certification programs at the masters degree level.  How closely tied this is to the opportunity vs. the need is not clear, but since several of those new masters degree level social work programs are at Historically Black institutions and another is situated at Pembroke, a locus for the Lumbee Tribe, one can infer that there is a correlation if not causation.
• And, as a first tentative step towards addressing “Social Determinants of Health:”
• Modes of treatment such as Assertive Community Treatment began to flourish.
• Community Support changed into a professional service with both therapy and case management.

As far as clinical supervision, the result has been a mixed bag:

Some of the then prevalent, at times inappropriate psychodynamic passivity and 12 Step oriented passivity on part of clinicians began to wane, and more active and at times appropriate models emerged.  And please understand, I support those two models and regret that there now seems to be a lack of both in situations where those formulations and interventions would be appropriate (if applied by trained clinicians); but I am pleased that other tools are in our toolbox.

Those would be, on the short list (in alphabetical order): Cognitive Behavioral models for various specific disorders; Dialectical Behavior Therapy; EMDR; Motivational Interviewing; and Solution Focused therapy.

I’d like to remind and encourage those of you who live within driving distance of the Triangle that there are numerous opportunities to get advanced training:

• NC Society of Clinical Hypnosis & Wellness Consultants International
• UNC Satir Program (Virginia Satir Model Family Therapy)
• North Carolina Group Psychotherapy Association
• Psychoanalytic Center of the Carolinas
• Southeast Institute for Group and Family Therapy

I mention these post-masters level associations, programs and institutes for many reasons, but I will leave you with this thought:

Advanced training makes it easier and more enjoyable to do the work of therapy, whether you are working in the public sector (and its oncoming transformation) or the private sector; and if you want to work in the private sector, advanced training (specialization) is a key to referrals.