Thursday, September 27, 2007

In The Little City That Couldn't

In my city of employment---which I like to call "The Little City That Couldn't"---child poverty and infant mortality run rampant, as do drug abuse, violence, domestic violence, and crime. When measured against other small and medium-sized American cities, our little fiefdom is almost always ranked on the wrong end of the scale. Social service agencies abound, but is this little society truly being served?

Take mental health, for example. For our Medicaid patients, there is a small handful of behavioral health agencies which accept new patients. Most of these agencies have long waiting lists, and our patients in crisis often go without mental health services at the time that they truly need them. Due to the backlog of needy individuals, the local psychiatric emergency service is reknowned for turning away even the most blatantly suicidal patients. In a broken system, broken clients are served by broken clinicians employed by broken agencies which limp along on poor funding and frequent mismanagement. Sometimes, the streets seem to be teeming with the Walking Wounded, and we well-meaning clinicians who truly want to make a difference wring our hands in desperate impotence.

One of my patients desperately needs mental health treatment. This person would like to undergo treatment with Interferon and Ribavarin for chronic Hepatitis C, but the Interferon can cause debilitating depression and suicidality, thus, before beginning Interferon, the client must establish a relationship with a mental health professional. Unfortunately, there is at least a three-month wait for a mental health intake appointment. Following the intake, it could be another month or two before the client finally sits down with a new therapist. When it comes to seeing a psychiatrist or Clinical Nurse Specialist who can prescribe psychotropic medications, it may be another four months for that appointment. Sadly, due to our patients' frequently chaotic lives, missed appointments are all to common. If one too many appointments is missed, the client is put back on a waiting list and left to their own (often suboptimal) devices.

A broken city simply cannot provide a strong enough safety net for its neediest citizens, and our little city often falls flat on its face vis-a-vis this ultimate responsibility. Be it mental health, environmental safety, public safety, transportation, substance abuse treatment or housing, many American cities fall far short of what they should be able to provide. With billions spent to support a seemingly pointless (and endless) War on Terror, where even returning veterans with PTSD are left out in the cold, our cities struggle to meet even the most minimal of their responsibilities.

Here in the trenches of human service, we cling to whatever lifeboats we can find, as do our clients. At times, we succeed in saving those in our care. At other times, we watch as our unfortunate charges slip away on the currents of social problems too large for us to tackle alone. Occasionally, the vicious undertoe will obliterate a client, and we face our failures alone on the shore. In this Little City That Couldn't, each day is another opportunity for success or failure, and we simply accept that both potential outcomes are part and parcel of the day to day struggle.
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