We want counselors, therapists & peers to be authentic. But what does that really mean in the context of systems of care? Authenticity is commonly defined as true to own’s own beliefs or without pretensions. My question is how can someone be authentic in a system that pushes it values, ethics, and prescribed regulations for your treatment? How can a consumer of services ever hope to treated without bias or judgement in a system that categorizes, assesses & diagnoses you with prescribed manuals? I am now suggesting that if there are authentic therapists or peers, than the empathy and connection made with you during your treatment in the system is really a negotiated form of the word. It doesn’t meet the platonic, pure definition of authentic, and , I would hazard to say, been commoditized for reimbursement from insurance companies & non-profit (but really, for profit) agencies.
On the level of common Article 31 clinic regulations for practices operated by the New York State Office of Mental Health, and other states with state regulatory commissions for mental health treatment, there are rules for participation in treatment. Wait a minute, I’ve never heard of rules in an authentic relationship. The relationship, if it espouses authentic values, will inherently take its course given the input and energy invested in connection. Well, this is not how treatment plays out in the modern clinic. It is prescribed, very much based on funding streams & “anchors of care” which denote which practices take privilege over others & which interventions are “in” and which are “out”.
When you enter the first enter the clinic and come under its gaze, immediately, you, the consumer, are assessed for risk of immediate harm & safety, and given a diagnosis which supposedly helps practitioners map out a pathway and strategy for your treatment. Hold on, that doesn’t sound very authentic! Why are consumers of mental health treatment assessed, marked, and essentially ticketed for retail value for reimbursement by insurance companies?
This is because, if we are to be completely honest here, when you are given a diagnosis for insurance purposes the clinic is basically forwarding your projected cost given the “medical necessity” of your diagnostic label. This means, if you are given a diagnosis of acute anxiety, most managed care insurance companies will want to know your progress towards your “goals” or readiness for discharge. On the other hand, if you are lucky enough to be given a diagnosis of chronic schizophrenia you are eligible for Medicaid and other catastrophic coverages which pay for long-term care, because, that is your value & worth in systems of care.
So, where in all of this is the authentic relationships? I would hazard to say it rests in the negotiated “back-and-forth” dialogue between you the consumer & your practitioners willingness to drive treatment forward and justify your continuing care at the clinic. This means, depending on various factors, such as: 1) weighing out your needs as a consumer, 2) the cost to keep you in treatment, 3) pressures of a rising caseload, 4) risk of harm as a level-of-care issue, 5) participation in treatment; you, the consumer can rest comfortably that your care cannot be terminated without a complex & systematic formula justifying your discharge.
There is no space for authenticity when the system determines your medical value, but, is does hold space in the consumers active participation. In order to keep driving moving forward, you the consumer will need to participate to justify your ongoing treatmen by your willingness to be active in your care. The rules for Article 31 clinics are clear as day. State regulatory bodies want to know if you are involved and vested in your treatment or you the consumer are simply not worth the cost of your state and insurance psychiatric rehabilitation.
Unless you are a freelance, privately contracted peer, or consultant, you are apart of a larger system of care. Understanding the peer’s authentic value to the consumer is even more problematic in this context. But it is a value. I am suggesting that the peer, too, in the wake of systems of care justifying peer work; the peer as been assigned a rate for their services & an identified need has been filled with the addition of peer services to the consumers treatment in the system. The integrity of peers aside, consumers of services are duped into thinking their voice is heard by their peer advocate and whatever problem they are having moving through the system and recovery process will be righted by the peer.
This is fallacious thinking and should be addressed by peers working in all systems of care. In my blog entry titled: Addendum to the House Negro & Peer Professional: Not all Allegories are Created Equal, I suggest that peers too are traded among agencies like commodities & packaged under the disguise of mutual support. This is extremely problematic for consumers that are truly disorganized in their thinking & actively delusional or psychotic. In most of these cases, the voice of the peer is silenced and the legal system goes to work. This means, if you are so sick that you cannot differentiate “right” from “wrong” and become an acute risk of harm it isn’t your peer’s voice that will be heard by the treatment team when you are unhappy with your care. Instead, it will the lawyer’s voice, above all, that either justifies your continuing care on a voluntary basis or conversely, the consumers committment to forced treatment & change of legal status to involuntary.
I have not been a peer forever. I did not rise through the ranks of the movement. However, I’ve done my research & don’t know of too many courtroom peers challenging judges to convert a consumer’s legal status to voluntary. So why aren’t peers advocates in the courtroom? To find the reason peers havent made it to the level of law in mental health treatment just follow the money. Peer work, as a commodity to be traded for essentially peer support, has no trade value in the legal system when it intersects a consumer’s treatment within systems of care. This means, essentially, it is the voice of the lawyer, psychiatrist, & perhaps therapist that has primacy over the peer because its legal worth can be justified on a level that satisfied the court’s concern over risk & harm to others.
I am not suggesting that peers should be assessing for risk or making legal decisions regarding their clients. I am also not saying clinicians should fly by the seat of their pants and forgo prescribed treatment practices because on a philosophical level it doesn’t satisfy the definition of authentic treatment. Instead, I am trying to signal to the mental health community that we have a long way to go before consumers will begin to percieve their therapists advice as truly empathetic and the peers voice as their equal in systems of care. With this said, we can continue to evaluate funding streams and question the reimbursement practices of insurance companies that assign consumers of care treatment that is based more on money and worth than our society’s drive to end disparities in treatment practices.