America’s Mental Health: Budget Cuts, Poor Training and Stephanie Moulton

Anybody who’s been an administrator in a community mental health system in America in the past three decades knows the drill. During bust times, state governments actually come close to doing a good job with members of society who are at their most vulnerable. Services are — while never fully-funded — well-funded, and for the most part, there’s enough staff to cover the huge need in communities for mental health care for the poor.

But when budgets tighten, the first place governors look to cut are social services. High on the list of social services to be cut are mental health services, because they are often people intensive. Nevermind that most of those people are poorly trained “aides” or others who often have little direct education or experience with people with mental illness.

Governors and state legislatures do this because they know few people complain when government has to cut services to the poor. Sure, a few advocates and agencies may get up in arms about the cuts, but they quickly get drowned out by the fact that nobody wants their taxes to go up and cuts have to be made somewhere.

So as Massachusetts considers more cuts to mental health services, the New York Times yesterday took a look at a tragic case that occurred earlier this year, when someone who was suffering from schizophrenia allegedly brutally beat and murdered his group home counselor and aide, Stephanie Moulton.

Tragedies are not always preventable. But in this case, it seems clear that a lot more could’ve been done to help ensure that the dangerous circumstances Ms. Moulton found herself in didn’t occur.

Because of budget cuts and the focus on de-institutionalization — moving even people with severe mental illness out of state hospitals into group homes and other care settings — the state is outsourcing a great deal of their services to private providers. These private companies and organizations set their own rules for safety and care, often with very little external or government oversight:

Over the last two years, the department has increased its reliance on private community providers who say they are underfinanced and struggling to stay afloat. It has closed one state hospital and a small inpatient psychiatric center. It has whittled its client list by almost a thousand. And it has laid off a quarter of its case managers, severing important relationships for thousands of people with serious mental illness and transferring them to younger, lower-paid workers in the private sector.

In the cuts being debated now, [the governor of Massachusetts] proposes to eliminate roughly a quarter of the 626 long-term care beds left in the state’s psychiatric hospital system. This unnerves many mental health professionals. Not only do they believe that there are already far too few beds for new cases — “It’s harder to get into a state hospital than into Harvard Medical School,” Dr. Duckworth said — but they also worry about discharging long-institutionalized patients into communities whose resources are clearly strained.

The North Suffolk Mental Health Association runs the house where Stephanie Moulton was allegedly beat and stabbed to death by Deshawn James Chappell. Chappell still had the soundness of mind, I should note, to allegedly try and dispose of the body by driving it away in Ms. Moulton’s car, parking it away from the house, and then stealing clothes to replace his bloody ones. Chappell has had a long history of violence and arrests for violence.

The Right to Refuse Treatment

But most frustrating to me in reading this article is that people who knew Chappell knew he was stable and non-violent while on his medications. He had stopped taking his medication when transferred to the new house where Ms. Moulton was working, and the staff knew that:

He got antipsychotic injections every other week from a nurse at a clinic until he apparently stopped going.

Ms. Moore, the chief executive of North Suffolk, would not discuss Mr. Chappell’s case. Asked what her employees did if residents became noncompliant with their medication, she said: “I don’t like to use the word ‘compliant.’ That implies you can force people to take medication, which you can’t.”

Still, she said, “Our staff is trained to observe and document, to note and report any changes, any symptomology. We would not ignore it.”

People have a right to take or refuse treatment as they wish. But what if their refusal is putting your staff at increased risk of violence with an individual with a known history of violence?

It appears Ms. Moore is claiming that a patient’s right to refuse treatment trumps her own staff’s safety.

Staff Training Suffers

The North Suffolk Mental Health Association, according to the Times article, has a $43 million annual budget. Of that budget, $28.5 million is spent directly on personnel and associated costs (an 8 percent increase from 2009’s budget figure of $26.3 million).

North Suffolk cut their training budget 10% in the past year. — training that could’ve helped Stephanie Moulton.

Of that amount, $56,535 was spent on staff training — a nearly 10 percent decline from 2009 when nearly $62,000 was spent. Staff training is important, especially to the lowest paid mental health aides and workers. With little experience or education in mental illness, staff training is often the only time to teach the basics of how to work with people with severe mental illness. It would also not seem unreasonable that for staff in a group home environment to teach basic self-defense skills as well — especially if those workers might be left alone with patients who have a history of violence. (To be clear, mental illness is not correlated with an increased risk of violence; but substance abuse or a record of violence is — both of which were apparently present in Chappell’s history.) In comparison, North Suffolk paid more money in their 2010 budget year for staff to attend conferences and subscribe to professional journals than to train their often inexperienced but well-meaning staff.

To be a mental health aide — which pages $12 – $14/hour — in a group home like Ms. Moulton requires no specific training or education; many don’t have college degrees. The Times article notes, “At North Suffolk, workers in group homes get at least a week’s training, as Ms. Moulton most likely did before starting her job at a residence in Chelsea.”

Jackie Moore, the chief executive of North Suffolk, noted in the article the training consists of an orientation, education about mental illness, and among other things, how to “de-escalate a situation.”

When you’re increasing your personnel costs but cutting your staff training budget, it looks like that training may not be sufficient. It’s also not clear what emergency contingencies North Suffolk have in place when an aide like Ms. Moulton needs immediate assistance. 911?

Now, North Suffolk is not operating in some vacuum, nor alone in blame. According to its own financial statements, 59 percent of its revenues and support come directly from contracts with the Commonwealth of Massachusetts. That means the state has the responsibility to ensure that North Suffolk is operating in a way consistent with its own intentions for the healthy de-institutionalization of its in-need citizens. And that appropriate protections are in place for the staff who help these people.

Ms. Moulton’s case is a tragedy. But it appears it’s one that could have been averted if people had been more proactive with regards to Chappell’s treatment, or, barring that, at least ensured that nobody was left alone with Chappell given his extensive violent criminal history.

Have we gone too far with cutting the budgets of mental health services to the poor and in-need? While the answer may be obvious to some of us, what is less obvious is how we stop such cuts from occurring during rough economic times. And if we can’t, how we can at least ensure patients like Chappell don’t fall through the cracks of the system — a slip that resulted in a young woman’s death.

Read the full story: A Schizophrenic, a Slain Worker, Troubling Questions