Psychotherapy and the System of Care

systemic uncaring?


I have been working in what is commonly referred to as “the system of care” for the past 26 years. This system includes a breadth of social support programs and apparatus that include the foster care system, medi-cal, state county and federal mental health systems, in-kind support programs, housing programs, programs for transitional age youth, etc. The list is exhaustive and exhausting.

What ties the existence of all these programs together is that they are all focused on providing services, resources, and support for people that cannot purchase them on their own, and who have been identified due to their caste, addictions, and various other signifiers that  they are “the other” needing outside assistance. I stress outside, as the services we speak of, while often offered in the community, are often not imbedded in the community. Social workers and therapists perform guerrilla raids of human kindness and charity, and then retreat back to the edges of suburbia quite often, to replenish their weaponry for more limited assaults on seemingly insurmountable problems.

I am not saying that these programs and indeed much of the administrative apparatus that support them should not exist. It is a mark of an enlightened culture to provide for those at risk, even if the motivation is in the end pragmatic and self-serving. The alternative to not having any sort of safety net is untenable, as it is certain that such a move would prove to swell the already obscene ranks of the penal monstrosity, which is fodder for another topic.

The key problem in the implementation of these programs, the functioning of this “system” is that it has grown into a self-perpetuating monolith that feeds upon itself, providing a great number of jobs for many middle class citizens, and has become overtly self-conscious and self-serving, to the detriment of the populations that it endeavors to serve. The IT management of the medi-cal system costs literally billions of dollars, and provides for the paychecks of hordes of private consultants that make in excess of 100,000 per year. These are not manager or director level staff, these are implementers, workers. It is not unusual for a County Department of Social Services to have 1/3 or more of their salaried employees in non case-carrying positions, while the caseloads of those that do carry cases are pointedly unmanageable. Much of the concrete work in the community is performed by Community Based non-profit organizations that are largely staffed with intern-level employees that are at the beginning of the curve of learning their trade, often poorly trained, over-burdened, and tasked with monumental responsibility.

I assert that the resource issue is not so much a problem of available dollars, but of mindful allocation and application of these dollars. It is time for nothing less than a total re-imagining of this system of care that is truly geared towards improving the quality of life in some of this country’s most challenged communities. To do so  will involve a new commitment to community imbedded services as well as a  commitment to proper training of professionals, trimming the administrative fat from social services agencies, and eliminating unnecessary fiscal oversight concerning potential fraud and exploitation( which arguably may cost more that savings from those efforts). An excellent example of a community imbedded organization that is realizing phenomenal outcomes is Geoffrey Canada’s Harlem Children’s Zone. I will not elaborate here, but encourage the reading of Paul Tough’s examination of the project called Whatever it Takes.

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