What state do you practice in?

Every night when I get ready for bed, I say my prayers and one of them is to express three things I am grateful for that happened to me that day. One thing I am always grateful for is that I live and practice Psychiatric Social Work in New York State, one of the states with the best social policies in the nation in supporting a high quality of life.

I have often thought about what it is like to practice in a state with repressive and regressive social policies? I wonder, being more blessed than others, how I can help my colleagues? 

As you probably are already aware, the social indicators of quality of life are quite different between the red and the blue states. I don’t intend this comment to be political but sociological. I often wonder what it would be like to practice in a red state where social policies are often out of line with Social Work values and human rights?

What state do you practice in and how does it make a difference?

Should community based psychiatric services be publicly funded?

Should community based psychiatric services be publicly funded?

08/07/26

Should mental health services be publicly funded as they have historically been with the old State Hospital System? In the 60s deinstitutionalization of services for people with psychiatric disorders occurred moving the required services to Community Mental Health Centers.

States promised that the money saved from closing their psychiatric hospitals would be reinvested in community based services and then reneged on their promise and used the saved money for other purposes. The costs of psychiatric services were shifted to health insurance.

Health insurance, though, said they would only reimburse for services that were “medically necessary.” Health insurance would not pay for what came to be called “wrap around services,: which many people with psychiatric disabilities need. Case management services were not “medically necessary” and so people with psychiatric problems were left to navigate an increasingly complex service system on their own and there was a rise in the criminalization of people’s behavior and homelessness.

A return to State Hospitals is not the answer, but state legislators keeping their original promise to fund community based services not covered by health insurance is.

Does availability of mental health services make a difference?

I asked myself  last week what I had to show for my work after 57 years as a Psychiatric Social Worker in New York State. I decided to investigate further and here is part of what I found. New York is ranked as #1 in mental health and well being among all the US states according to Mental Health America in 2025. There are seventeen indicators that are measured to determine these rankings one of which, is “thoughts of suicide in the past year.” New York is ranked third lowest suicide rate in the nation after District of Columbia and New Jersey. 

In my career I have estimated I have done over 15,000 suicide/homicide evaluations most of them in large urban emergency rooms after an attempt was made or the person was bought in with a mental hygiene arrest. How many lives working as part of a mental health system team have been saved? Compared to other states, very many.

The national average suicide rate stands at 13.7 deaths per 100,000 people. However, individual state rates vary dramatically—ranging from a low of 5.7 to a high of 29.7.

In general, the highest rates are concentrated in the Mountain West and Alaska, while the lowest rates are primarily found in the Northeast and California. The rate in New York is 8.3 far below the national average. 

If mental health professionals were to build a mental health system that prevented deaths from suicide what elements in that system would be beneficial to that goal?

The glaring discrepancy in suicide rates is rarely recognized and acknowledged let alone addressed. For example the suicide rates in the worst states: Alaska 29.7, Wyoming 27.8, Montana 26.8, Oregon 20,0 and the best states: New Jersey 6.7, New York 8.1, Massachusetts 8.3, and Rhode Island 8.9 is very significant with the rates in the worst states being three times higher than the best states.

One of the biggest factors in suicide rates is the quality of the infrastructure that supports personal functioning. In other words, does a person have a place to turn when they are down and out? Is there help available? 

Mr. Rogers said that his mother told him, “Freddie, if you are in trouble look for the helpers.” Mental health professionals are a type of helper. The concern is that they are available  to meet needs of ultimate desperation. In some states that are more available than in others. The public health data of suicide rates is one way of measuring the difference their availability makes in the health and life of a population,

What happened to continuity of care in mental health?

 As has long been observed (e.g., Henry, Sims & Spray, 1972; Holt, 1971; Orlinsky, 2009) there is no single, inclusive and comprehensive profession of psychotherapy. 2 This differs markedly from other established professions such as medicine and law, engineering and accounting, nursing and ministry, and so on. Instead, psychotherapy is practiced as a sub-specialty within several different professions, each of which itself follows no single pattern of practice guided by a generally accepted theoretical framework.

Orlinsky, David E.. How Psychotherapists Live (p. 14). Taylor and Francis. Kindle Edition. 

Psychotherapy is a subspeciality of several professions such as Psychiatry, Psychology, Social Work, Counseling, Nursing, Art Therapy, Music Therapy, Marriage and Family Therapy, Substance Abuse counseling, Occupational therapy, Acupuncture, Naturopathic medicine, etc.

This use of psychotherapy in many mental health professions is called “role diffusion.” Each mental health profession also bring different knowledge bases and skills which is called “role differentiation”. In agencies and health care organizations, mental health services are often provided by a “team.” A mental health team is composed of individuals from different professional disciplines.

In agencies and health care organizations where teams are used to provide services there often is a “primary therapist” assigned who oversees the comprehensive treatment plan and assures continuity of care. In the last few decades with the increasing reliance on revenue from health insurance to pay members of a mental health treatment team, the emphasis by administrators is on the provision of reimbursable procedures rather than patient care and this management system has fractured treatment teams and corrupted the continuity of care leading to poor patient care and demoralization of staff.