Crossroads Online

April 13th, 2012

By Andrew Jenner ’04

Since the very beginning, the conviction that “there has to be a better way” has been a guiding principle for the Mennonite mental healthcare institutions that were established as a response to the experience of conscientious objectors (COs) during World War II.

Mennonite mental healthcare institutions have demonstrated ingenuity and leadership in the face of changing circumstances within the field. Examples over the years include the development of programs to assist in patients’ reentry to the working world, long-term independent living facilities, rehabilitation programs for people with drug or alcohol addictions, and the repeated adoption of new medicines and therapeutic techniques across all programs.

“There’s a much broader emphasis now on additional supports that are needed to help a person live within the community,” said John Goshow ’69, a retired social worker who was CEO of the Penn Foundation from 2000 to 2010.

One recent example of innovation at the Penn Foundation has been the development of  “community treatment” teams made up of a psychiatrist, nurse, social worker and other support staff to provide coordinated care to patients living in their own homes.

“We’re trying to take services to where people are, rather than trying to make them come to some centralized place,” said Vernon Kratz ’57, the former medical director of the Penn Foundation who now sits on its board of directors. “It keeps people in their communities, it keeps people in their families.”

Another example of an unprecedented initiative: Amish leaders approached former Philhaven CEO LaVern Yutzy ’70 and others in that Mennonite mental healthcare institution near Lancaster, Pennsylvania, to discuss the development of a treatment program for members of their community. Their collaboration led to the 2005 opening of a new 15-bed inpatient facility on Philhaven’s main campus for patients from the Amish and other “Plain” groups (referring to their “plain” clothing). To date, it has served hundreds of people from 12 states.

In Goshen, Indiana, Oaklawn opened the nation’s first residential unit to serve adolescents from Amish or conservative Mennonite communities in February 2010. Maria Martin Shisler ’04 is a case manager there.

Impact of “Managed Care”

Changing conditions within the industry have forced all mental healthcare providers to adapt, sometimes in ways that challenge the survival of non-profit institutions seeking to provide compassionate care for all who need it. The advent of “managed care” in the 1980s and 1990s – through which insurers used new reimbursement models to encourage providers to treat more patients through outpatient programs and reduce the length of inpatient hospitalizations – had a mixed impact.

In 1993, soon after Yutzy was appointed CEO of Philhaven, 82 percent of the organization’s revenues came from inpatient programs. By his retirement in 2008, overall revenues had doubled but the share of inpatient revenue had dropped to just 32 percent. That drastic shift over a relatively short period of time, he says, threatened to sink the institution. A positive outcome, he acknowledges, was that more patients were being treated earlier and with less disruption to their lives.

Insurance reimbursements present a huge and ongoing problem for many of the providers interviewed for this issue of Crossroads. Gerald Ressler ’79, executive director of the Samaritan Counseling Center in Lancaster, Pennsylvania, said that many insurers have reimbursed mental health providers at the same rate for the past 15 years, causing providers to see their real income fall dramatically (on the average, $20 worth of goods in 1996 cost over $28 in 2011). Some insurance companies are even cutting their reimbursement rates. Ressler said that the Samaritan Counseling Center’s largest insurer informed the center in 2011 that it will decrease reimbursement rates by 35 percent in 2012 – a decision that will have a huge impact on the center’s balance sheet.

“Outpatient mental healthcare is as close to being at the bottom of the [insurers’] priority list as it gets,” said Ressler, a licensed clinical social worker who spent 30 years on the staff at Philhaven before moving to his current job.

Additionally, when it comes to public insurance programs like Medicaid, reimbursement rates are simply not high enough to allow practitioners to stay in business if they only see patients on those programs, said Tom Martin ’78, who works as a clinical psychologist in addition to teaching psychology at Susquehanna University. Some practices, including the one in Selinsgrove, Pennsylvania, where Martin now works, have stopped seeing Medicaid patients entirely for this very reason. It’s a reality, Martin says, that points to a key shortcoming in our healthcare system: only employed people have a chance at having decent medical insurance policies. Yet people with serious, untreated mental illnesses tend to have difficulty keeping good, steady jobs with health insurance coverage.

“If you’re affected by a mental condition that prevents you from working, then you will not have ready or consistent access to the best mental healthcare,” Martin said.

Falling in the Cracks

People with serious mental illnesses who need care the most are often left to seek treatment at crowded, publicly funded clinics that often, thanks to the constraints of resources and excesses of demand, struggle to provide quality care. And if, for whatever reason, that care isn’t quite enough, or a patient’s illness hampers his or her ability to apply for and receive public assistance, that person is at high risk of falling through the cracks, where the statistics paint a particularly grim picture of the state of mental healthcare in the United States today:

• Twenty-four percent of inmates in state prisons across the country had a recent history of mental illness, while up to 49 percent of these inmates showed symptoms of mental illness. ¹
• Three times more people with serious mental illness are in jail than in hospitals. ²
• In January, 2010, 26.2 percent of homeless Americans staying in shelters had a severe mental illness, ³ as illustrated by the article on the work of Nate Hoffer ’03.
• The life expectancy of a person with a serious mental illness is 25 years shorter than the national average of Americans.⁴
• After earning a doctoral degree, a clinical psychologist at a psychiatric hospital or substance abuse facility earns a mean annual wage of $69,830, despite the demanding nature of their work and years of study.⁵ With reimbursement dropping, incentives for well-qualified mental health providers are largely internal.

“So many people are just not getting the care that they need,” said Tim Derstine ’88, a psychiatrist and the medical director of Behavioral Health Services at Mount Nittany Medical Center in State College, Pennsylvania.

Tammy Eberly ’80 Bos, a child and adolescent psychiatrist in Grand Rapids, Michigan, noted that a specific recent challenge within the field has been increasing pressure on psychiatrists to quickly prescribe medication to a patient and move on to the next one with little, if any, time for individual therapy. Adding to the pressure, there is a shortage of psychiatrists, making it hard for people – particularly ones without good insurance policies – to receive prompt attention and treatment for mental illness.

This often means that programs, strained by high demand and limited resources, focus on crisis response rather than providing preventive care to patients with mental illness. “We do a lot of cleaning up after things have gone awry for a long time,” Derstine said.

Shortage of Providers

The shortage of treatment providers is more acute in rural areas of the country, and can be partially attributed to the fact that psychiatry is a relatively non-glamorous, lower-earning medical specialty that doesn’t attract as many ambitious young doctors as other fields of practice. (According to the Bureau of Labor Statistics, psychiatrists earned a mean annual salary of $167,610 in 2010, slightly below the average salary for a family doctor and significantly less than surgeons’ annual average salary of $225,390.)

Derstine, who specializes in treating substance addictions, said that the perception that psychiatry is a less serious specialty persists to some degree even within the medical field, and that he spends significant energy working to counter the notion that addicts simply lack willpower or self-control, rather than suffering from an illness as real as diabetes or heart disease.

Among the goals of the Penn Foundation from its inception was public education to put mental illness on par with other medical problems and eliminate the stigma surrounding mental illness. While much progress has been made toward that goal, stigmatization of mental illness remains a challenge for patients and providers.

Progress Has Been Made

“It’s not as bad as it used to be,” said psychiatrist Vernon Kratz, class of ’57, former CEO and medical director of the Penn Foundation, who is familiar with the appalling way patients were treated during WWII (see pages 2-11). “It’s kind of like racism. We’ve made a lot of progress, but there’s a long way to go.”

Society has become more accepting of seeking professional help for mild depression, grief, troubled relationships and other problems, noted Ressler. Most of the clients at his Samaritan Counseling Center are in relatively good mental health and thus encounter little stigma. More severe forms of mental illness, he said, tend to be more disparaged and feared, as indicated by frequent (and far disproportionate) connections drawn between violence and mental illness in the popular media.

Counselors who see clients from conservative religious backgrounds often encounter the common misconception that mental illness is linked to spiritual or personal shortcomings, explains Lois Shank Gerber ’66, who primarily sees Amish and other Plain clients at Upward Call Counseling in Lititz, Pennsylvania.

Yet another testimony to lingering stigma is a tendency for clients to pay Phil Weber ’77 out of their own pockets when they come for a session. Weber, a psychologist with a home practice in West Chester, Pennsylvania, mainly sees successful, white-collar clients, nearly all of whom have good medical insurance policies. Yet frequently they don’t want records to exist of their mental health treatment, so they don’t file insurance claims. They simply pay him directly. “They don’t want people to know they’re coming to see me,” Weber said.

More Humane, Compassionate

Depending on one’s perspective, someone could reasonably draw wildly different conclusions about the country’s ability to treat people suffering from mental illness. Taking the long view, there’s the fact that, within living memory, mentally ill people were treated like animals in filthy, dangerous and overcrowded state institutions – a situation that shocked the country’s sensibilities once it became widely known. Thanks to the resulting reform movement, both within the Mennonite church and larger society, this model of treatment has been replaced with something far more humane and compassionate.

At the same time, it can be a bleak exercise to focus on the current challenges facing the mentally ill and those who treat them.

Which view is the more accurate?

“The answer is, both of the above,” said Tom Martin ’78 of Susquehanna University.

He concurs with Ressler that today people with less severe mental disorders, like mild or moderate forms of depression, face less stigma and can receive very effective treatment close to home. At the same time, people suffering from severe, chronic conditions – particularly if their illness prevents them from working – face enormous, and even growing, challenges.

Vernon Kratz, on the Penn Foundation’s board of directors, noted that a significant and positive development in the field over the course of his career is that the word “recovery” is in common usage, even for people with serious illnesses.

“There used to be a feeling of despair and hopelessness when [serious] diagnoses … were made,” Kratz said. “I think today there’s much more hope that these can be treated.”

State and federal agencies are seeking to cut expenses, raising concerns about reduced access to care for the most vulnerable people in our society. Yet this is not the first time that the Penn Foundation, Philhaven, and others working in the field have needed to advocate for those who need more supporters. And they know they are standing on the shoulders of earlier advocates for compassionate care for all humans.

“There are a lot of good stories, as well as some really painful ones,” Kratz continued. “[But] overall, I feel fairly positive.”

Able to Survive Challenges

John Goshow, the recently retired CEO of the Penn Foundation, noted that financial uncertainty has long faced mental healthcare providers.

“We’ve been able to survive many different challenges over the years,” Goshow said, adding that church and community support has played an essential role in allowing the Mennonite psychiatric institutions to continue their tradition of innovation and leadership. “If it weren’t for the support of the community, it would be very difficult for the Penn Foundation to stay on the cutting edge.”

At the Samaritan Counseling Center in Lancaster, Gerald Ressler also remains confident that, despite the increasing challenge of dealing with stagnant or dropping insurance reimbursements, his staff will continue to fulfill its mission of offering counseling to anyone and everyone who comes in the door. “We’ll have to be more and more creative to figure out how to provide services, [but] I think we’ll figure out how to make that happen,” he said.

As EMU alumni search for ways to carry on the tradition of Mennonite leadership within mental healthcare, Carl Rutt ’66,⁶ medical director at Oaklawn in Goshen, Indiana, from 1982 to 2003, sees a continuing role for the church-affiliated institutions founded after World War II.

“We convey hope,” Rutt said. “We try to plant mustard seeds until the state agrees, ‘Yes, let’s do this. It’s the right way to treat people’ … I still believe there is a role for the Mennonite institutions.”

And beyond these words, there are also now deeds demonstrating this commitment to continued relevance and engagement. Beside the Penn Foundation’s headquarters north of Philadelphia grows the steel skeleton of a $9.2-million, 32,000-square-foot expansion that will provide much-needed new space for its various treatment programs that long ago outgrew the original building.

“This is a sign of our belief that we will be treating people in our community into future,” Goshow said. And when he says “community,” he means everybody –not just Mennonites, or Christians, or people who can afford the care, or people who look and act a certain way. Everybody, whether they drive a buggy, a BMW, or hobble in on pained feet.

1. Loren E. Glaze, & Doris James, Mental Health Problems of Prison and Jail Inmates (Washington DC: Department of Justice, Bureau of Justice Statistics, Special Report NCJ 213600, 2006), 1.
2. E. Fuller Torrey, et a.l. , More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States (Arlington, VA: Treatment Advocacy Center & Alexandria, VA: National Sheriffs’ Association, 2010), 1.
3. Kristen Paquette, Individuals Experiencing Homelessness, Homelessness Resource Center Fact Sheet (Newton Centre, Massachusetts: Homelessness Resource Center, 2010), Feb. 1, 2012, http://www.homeless.samhsa.gov/Resource/View.aspx?id=48800.
4. Ron Manderscheid, Benjamin Druss and Elsie Freeman., “Data to Manage the Mortality Crisis,” International Journal of Mental Health (2008), 37(2), 49-68.
5. Bureau of Labor Statistics Division of Occupational Employment Statistics. Occupational employment and wages, May 2010. Feb. 1, 2012, http://www.bls.gov/oes/current/oes193031.htm.
6. Though semi-retired Carl Rutt ’66 still sees children, adolescents and adults with a wide range of mental and addictive disorders. Other alumni associated with Oaklawn are clinical psychologist Paul J Yoder ’77, clinical social worker Jeannie Brunk ’83, and psychiatric aide Ryan Graber ’02.