Managing Madness in the Community: The Challenge of Contemporary Mental Health Care

1. Introduction

1 Jabar Jones was pretty content with life at Suburban, a multiservice mental health care organization outside a midwestern US city. With an official diagnosis of schizoaffective disorder, he had spent the previous three decades involved with the mental health system in one form or another, including more than twenty hospitalizations. Had he been born a couple of decades earlier, Jabar could easily have spent those decades in a state hospital. Instead, coming of age and becoming ill in the era of deinstitutionalization, he fell into the all-­ too-­ familiar pattern of contemporary community care for people diagnosed with severe mental illness: residential and psychiatric instability. Having attended Suburban’s day program while living at a nursing facility for a few years, Jabar made the move to Suburban’s group home a few years prior to our meeting. Compared to the alternatives he had experienced in the mental health system , living at Suburban had many advantages. All the residential programs he had been involved in had met his basic needs—­ food, a roof over his head, basic medical and psychiatric care—­ but he was given a lot more autonomy at Suburban. Two areas in particular stood out for Jabar. First, he had much more control over his money at Suburban than at the nursing facility where he had previously lived. The nursing facility was for-­ profit, as most are, and kept all his income except for a $30 per month allowance, which remained the same regardless of whether he supplemented his Social Security income through work or not. At Suburban, however, it was different: “Here, everything over my rent, I keep. I work . . . I get to keep all my money,” he said. Jabar also liked having more control over when and how much he ate than he had in previous Introduction Chapter 1 2 Managing Madness in the Community placements. However, not everything was positive for him or for the staff that provided him with care. Staff members at Suburban were concerned about Jabar. He had once attended the day program and had obtained a job at a cafeteria, but he had been fired from the job and no longer regularly attended the day program. Staff claimed that since his firing, his motivation had waned. One group home staff member said, “He just lays around, eats, sleeps, and smokes cigarettes” (interview ). Further, Jabar spent his money in ways that caused problems for him and for Suburban. He was months behind in paying rent. Other residents of the group home pointed out a double standard with Jabar, arguing that he was permitted to not meet his obligations while they were not allowed to do the same. On the other hand, Jabar made claims of a reverse double standard, saying staff members were holding him to a higher standard than another resident in the house who had schizophrenia. Because Jabar was a client at a mental health services organization and had an official diagnosis of severe mental illness, one might find his problematic behaviors no big surprise. This picture of Jabar as a severely mentally ill individual was the one depicted in his clinical file, which described him as at times experiencing unspecified delusions and disordered thought processes. He was prescribed a host of medications, including antipsychotics. However, in numerous staff discussions regarding Jabar that I observed, his behavior was not described in this setting as resulting from mental illness. Rather, his disruptions were referred to as willful acts. Hence, it was a challenge to determine exactly what staff thought of Jabar’s mental state. Jabar himself did not connect his current behaviors with mental illness; he discussed them as based in rational decisions. He felt the day program no longer interested him, saying, “They can’t teach me nothing new” (interview). He did, however, participate in illness management and recovery, an “evidence-­ based practice” involving his setting goals and working with a staff member and a curriculum to achieve those goals. Among the top goals he set were losing weight and catching up on his back rent—­ two problems that were directly tied to the freedoms Suburban had brought him. It became clear that staff felt pulled in a number of directions. Suburban ’s delivery of services (and the outcomes of those services), and their use of the resources their funders provided, was increasingly tracked and audited. This made “evidence-­ based” services such as illness management and recovery increasingly attractive. Impending changes in the state’s Medicaid mental health financing were...