Won’t Ask, Won’t Tell

Last month I went to a suicide prevention seminar designed for therapists. In the first training video, a man who had jumped off the Golden Gate Bridge talked about his experience. For hours he was out in the wind trying to decide what to do. He told himself that if someone, anyone, asked him if he was OK, he wouldn’t jump. Eventually someone did stop to talk. But only to ask him to take her picture. He took this as his final sign.

The moment he cleared the railing he regretted his choice.

For chunks of the training I was dissociating. Words stopped penetrating. I felt floaty, detached. Dissociation is a natural process that kicks in when we’re overwhelmed. My body was shutting itself off from more input while my mind dealt with what was already on my plate. The same thing, dissociation, had happened to me only two times before — on the two occasions when I learned that a Kaiser client of mine had killed himself.

You might think it would be disturbing to dissociate in the middle of a training. But I knew what was happening. I knew I was safe, just overwhelmed by memories. Dissociation was a marker that I was in the right place addressing these issues. It proved that the suicides at Kaiser still bothered me years later, as one would expect, even hope. It motivated me to learn proven strategies to protect my current and future clients. I never again want to get news like that about someone under my care. Not if I can help it.

One of the stated goals of the training was to foster a willingness in therapists to conduct thorough suicide assessments. The need to foster willingness presumes that there are times when therapists are unwilling to ask about suicidal thoughts. Maybe the reason therapists avoid asking these difficult questions is that we don’t know what to do if our client says, “Yes, I am thinking of suicide. Yes, I do have a plan. Yes, tonight.”

To foster willingness, the seminar demonstrated that people with suicidal thoughts often respond to very basic interventions. Anyone can intervene just by opening up the conversation and focusing on safety planning. Consider the man on the bridge…. If a stranger had said, “How’s it going? Are you OK?” he would have said, “No. Actually I’m not OK.” And if the stranger had said, “Then let’s get off this damn bridge and talk for a little bit,” he would have gone with the stranger and talked. Someone who self-presents to a therapist, not a stranger, is even more likely to talk things through, to allow the therapist to make friends with the part of the client that wants to live, and to work collaboratively toward the client’s survival.

This training message worked for me. The very next day I started asking my clients at the health center where I now work, “When you get really down, how bad does it get? Do you think of suicide? Do you have a plan? Have you been having any of those thoughts recently?” I thank my clients for their honesty. I let them know that if suicidal thoughts emerge I want to know about them. There’s no need for anyone to sit alone with such loneliness.

I got into some very bad habits in my years at Kaiser. Perhaps the worst is that I learned not to ask too deeply about suicidal thoughts. I didn’t have time to manage a yes. To rationalize my avoidance I relied, as I’m sure my colleagues did and still do, on the questionnaire clients filled out every clinic visit. The questionnaire asks: “Over the last 2 weeks, how often have you been bothered by…thoughts you would be better off dead or of hurting yourself?” When clients responded with anything other than a “not at all,” I pursued. If they circled “not at all,” I left it alone. But, of course, there are many reasons why someone might not put in writing that they have suicidal thoughts. And only two reasons a therapist who cares about people would avoid repeating the question in person. The first was addressed by the training: not knowing what to do with a yes.

The second reason is not having enough time to manage a yes, even if you know what to do with one. At Kaiser, when I had only an hour to conduct an assessment of mental illness and develop a plan for follow-up, I was not going to open up a can as wormy as the one containing suicidal thoughts. Not if I could avoid it by rationalizing.

I’m just now undoing the far-reaching effects of working for seven years under such extreme time scarcity. Today there’s no can too wormy to explore. Because I have time to build relationship with my clients, at the clinic and in private practice, I can ask the hard, important questions. The training was all I needed to be reassured that I can handle a yes, that any of us can as long as we have time.

Barbara Ragan, who killed herself on July 5, 2015, by jumping from a Kaiser parking structure, had been for months telling her providers that she she needed help, that she was depressed and at risk of suicide. No one had the time to listen or to develop a plan for her safety. There are thousands of Kaiser patients every day who keep private their suicidal thoughts, hoping, like the man on the bridge, that their providers will ask, “How are you really doing?”

Kaiser therapists have announced their intent to launch a statewide open-ended strike. Soon they will leave their jobs and refuse to return until they are guaranteed adequate one-on-one time with their clients.Their message is the message of this post. If we have the time to listen, the man on the bridge will talk. He’ll even let us help him choose life.

But we have to have the time.

Not Enough Therapists? In California?

In an August 13, 2015 article by KHN’s Jenny Gold, the director of the Department of Managed Health Care, Shirley Rouillard, was quoted as saying: “There just aren’t enough therapists to see everyone who needs help. It isn’t just a plan problem; it’s a societal problem. And that is really the crux of the matter.”

Not enough therapists? Where is this assertion coming from? And why is it coming now, in this edgy interlude between the DMHC’s second report about Kaiser’s misbehavior and the announcement of remedy from the DMHC’s Office of Enforcement?

In a September 16, 2015 press release Kaiser’s public relations people claimed that: “Kaiser Permanente’s significant hiring of mental health therapists comes during an overall shortage of these professionals in the U.S. According to an April 2015 report by the National Alliance on Mental Illness (NAMI), patients nationwide face difficulties in finding a mental health treatment provider because of the increasing demand for, and shortage of, mental health professionals available.” I read the NAMI report in its entirety and did not find anything to suggest that urban areas in California have a shortage of therapists.

I find it alarming that the head of the agency responsible for holding Kaiser accountable to State mental health parity laws might be considering legitimate Kaiser’s cry of therapist shortages. Perhaps the distribution of therapists is not uniform across the United States. But there are more than enough therapists to meet the need in the urban areas where Kaiser primarily operates. A cursory search on the Psychology Today website in the California cities where Kaiser sees most of its patients reveals hundreds of licensed therapists in Oakland, San Francisco, Los Angeles, San Diego… to name a few of the cities where the DMHC has identified deficits in Kaiser’s care.

There are two main reasons why Kaiser continues failing to meet basic community standards of care. Neither has anything to do with a scarcity of therapists.

The first is that most therapists do not wish to work for an organization that makes it impossible to practice psychotherapy.  A friend at Kaiser’s Psychiatry Department in Santa Rosa confirmed that in the past year new hires, even though they’re being well paid right off the bat, are quitting their jobs quicker than their managers can replace them. Why? Because therapists want to help people. If we can’t see them, we can’t help them. Therapists will continue to quit or refuse new opportunities to work at Kaiser until Kaiser puts in place a credible plan to fix the problems now on the table.

A credible plan would include a statement of intent to improve and a time frame to make the improvements. For example, “By 2018, 95% of Kaiser members with mental health parity diagnoses will be receiving the level of care deemed appropriate by the therapists evaluating their needs.” A credible plan would include steps to achieve its goals, with visible measures for each step. But instead of a credible plan, with goals and strategies to achieve these goals, Kaiser claims they are diligently hiring more staff and that this single strategy will take care of the problems.

The second reason that Kaiser is failing to meet community standards for individual therapy is that they are not paying their subcontracted therapists enough. For the past year or so Kaiser has been subcontracting with a group called ValueOptions to manage their overflow. In Sonoma County (my home county) a Licensed Clinical Social Worker is offered $65 an hour to see a Kaiser patient through ValueOptions. By comparison Medicaid (MediCal in California) is paying LCSWs $103 an hour. Not surprisingly, the numbers of private practice therapists signing on to accept MediCal is growing geometrically whereas the numbers accepting ValueOptions/Kaiser remains low and the growth is flat.

If Kaiser wants to attract and retain new hires, they will need to present a realistic plan to transform the current structure into one that works for therapists and their clients. If they want to attract therapists in the community to participate as subcontractors in the care of Kaiser patients, ValueOptions will need to match Medicaid’s reimbursement rate.

Attention, DMHC: there is no shortage of therapists willing to take care of Kaiser patients with mental illness. Instead of accepting their clever excuses, this is the time to leverage Kaiser into making the real (and really expensive) changes they’re doing their darndest to avoid.