Myra Munson was interviewed by Bill Schneider on September 7, 2010 at Elmer E. Rasmuson Library on the University of Alaska Fairbanks campus. She is an attorney with the law firm of Sonosky, Chambers, Sachse, Endreson and Perry in Juneau, Alaska. She was Commissioner of the Alaska Department of Health and Social Services (DHSS) from 1986-1990, and prior to that was Assistant Attorney General in the Alaska Department of Law primarily representing DHSS cases. In this interview, she talks about the evolution of mental health services in Alaska, the community mental health movement, the state's role in funding and delivering mental health services, and the integration between mental health and substance abuse treatments. In addition, she discusses the mental health trust lawsuit and settlement and why it was not resolved during the administration of Governor Steve Cowper.
Digital Asset Information
Project: Alaska Mental Health Trust History
Date of Interview: Sep 7, 2010
Narrator(s): Myra Munson
Interviewer(s): Bill Schneider
Transcriber: Carol McCue
After clicking play, click on a section to navigate the audio or video clip.
Section 1: Personal background and education.
Section 2: The need for and a lack of services for the mentally ill in the early days of Alaska.
Section 3: The community mental health movement, the effect of budgetary issues on development of services, and the Mental Health Trust settlement.
Section 4: Her work to change the budgetary power of the Alaska Mental Health Board and other boards related to drug abuse and developmental disabilities when she was Commissioner of Health and Social Services, and their work for addition of beneficiaries to the Mental Health Trust settlement.
Section 5: Why there was not a settlement to the Mental Health Trust lawsuit during the administration of Governor Steve Cowper.
Section 6: The factors involved in why the settlement did not happen until it did.
Section 7: The lack of mental health services in the State of Alaska in the 1970s and 1980s.
Section 8: The tensions that existed between the treatment of co-occurring mental health and substance abuse issues, and the development of community based services in Alaska.
Section 9: Problem of there being a lack of integration between treatment for substance abuse and mental health issues.
Section 10: The benefits of treating the whole person, and understanding the relationship between crises, life stages and the chance for re-occurrence and the need for supportive services.
Section 11: Reflects on changes in services and treatments in her years of work.
Section 12: Provides an assessment of the Mental Health Trust Authority in terms of delivery of mental health services.
Section 13: Delivery of mental health services and how they are affected by the insurance and Medicaid system.
Section 14: The closure of Harborview Hospital for the developmentally disabled in Valdez, Alaska.
Section 15: Lack of community-based services filling in the gaps when hospitals can not care for people, and need for continued improvement in delivery of mental health services.
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Section 1: BILL SCHNEIDER: Today is September 7th, 2010. I'm Bill Schneider, and I have the pleasure of talking today with Myra Munson. So thank you for taking the time on your trip up here to Fairbanks. And let's start a little bit on your background. You grew up here in Fairbanks? MYRA MUNSON: I did. I was born in Juneau. And when my -- I was just a few months old, my parents moved to Fairbanks and my younger sister was born here just a few months later.
And when they divorced, my parents divorced when I was two and a half, some three, something like that, my mother stayed here and homesteaded, so I grew up here. BILL SCHNEIDER: I'll be darned. MYRA MUNSON: Yeah. And then we were out of state for about three or four years. Just before I started high school, I came back here and went to high school and college, and lived here after college for a while, and then went on to graduate school.
BILL SCHNEIDER: Uh-hum. Uh-hum. So you probably went to Lathrop or West Valley? MYRA MUNSON: I did. No, I went to Lathrop. There wasn't a West Valley when I went to school here. When I was at Lathrop, it was so packed that they were holding classes in the foyer outside the library. And in -- I mean, every nook and cranny had students packed into it. There were no other high schools other than the one at Eielson, so it was jammed. You know, I can't remember the number, but it was way more than two or three times the size of the student body that it was built for. BILL SCHNEIDER: Okay. MYRA MUNSON: Yeah.
BILL SCHNEIDER: And your education, you -- after college? MYRA MUNSON: After I got a Bachelor's degree here at UAF in social -- what was then sociology and psychology, and then after working in Child Protective Services in Fairbanks for five years, I went to the University of Denver where I got a dual degree in law and social work. BILL SCHNEIDER: Oh.
MYRA MUNSON: Same three-year window, not a lot of time. My kids were a year and a half and four, without the -- I had a stipend from under Title 20, for people as old as me who might remember that, but -- but we knew it wouldn't last, so we crammed -- I crammed it all in, in three years. BILL SCHNEIDER: That sounds like a really unusual program.
MYRA MUNSON: There actually -- there -- even then, this was in -- I started in '77. Even then, there were a number of them. There was one in Denver, Washington University and Saint Louis, Syracuse up in New York, and University of Chicago all had programs. But, you know, my husband -- my ex-husband now, but my husband at the time and I were both Alaskan kids, you know, and young adults, and the thought of moving to one of those big industrial cities was a pretty -- he was a builder, it was pretty overwhelming, so Denver was kind of a perfect location.
And I knew people in Denver from working, from placing kids in Denver at some of the youth programs there. So it was -- it was a good choice. And there are actually -- I attended a few years after I was back, a couple years after I was back from school, actually a law and social work conference, and there were a whole lot of us who had law and social work degrees, there was some other lawyers and social workers in the state, in fact, although most people get their degrees at separate, at different times, typically they will get a social work degree and go back and get a law degree, and occasionally the other way around, but so many of us getting dual degrees.
Section 2: BILL SCHNEIDER: One of the things that we've been very interested in is this whole area of community services, and providing community services to people with disabilities, and what a tremendous struggle it was in the early years. Could you talk about that? MYRA MUNSON: Yeah. You know, when I -- when I worked -- well, first of all, I should say, my mother suffered from an affective disorder; she had quite serious mental health problems.
She was hospitalized occasionally for suicidal, and at the time we went Outside, it was because she was in -- in really deep weeds. Our cabin burned down and she just couldn't cope. And I don't think she ever got anything -- any -- any treatment that would be considered effective by any definition we use now.
Mental health issues are sort of prevalent in my family. My oldest sister made suicide attempts from the time she was in the early twenties, maybe her teens even, but she committed suicide when she was 35 while she was hospitalized in a psychiatric hospital. And depression is just everywhere in our family. And the -- so it's always been a subject of some interest to me.
When I started working as a social worker in Fairbanks in 1971 as an intern, and '72 I was in Child Protective Services, there was a community mental health center that was run by the state, it was a state mental health center, had a psychologist, a Ph.D., and a psychiatrist, maybe, it's like I can't remember even, probably, and some masters people who -- who were able to practice there.
And the services were really limited. I mean, that was really it. There was some -- a little bit of a private psychiatric community that developed. Irv Rothrock's clinic was active in that wind -- period. The hospital over at Fairbanks Memorial build up a unit that's designated -- what now, or at some point became designated, built up a mental health unit.
So certain services developed, but for the -- but they were always really limited. And one of the tensions that I became aware of by -- in the '70s that, you know, was really caught up in, I was in Child Protective Services is the people that I was working with, certainly some of them experienced serious mental illnesses, but lots of them had simply experienced so much trauma.
Child abuse and neglect, the issues associated with alcoholism, depression, that sort of thing. And we were desperate to get services for those children and for their families. And for the most part, you really couldn't.
Occasionally, we'd get -- sort of work out a deal with mental health center, I had a colleague there who we actually worked on some cases together where there were just sort of lots of kids and lots of family issues and we'd work on things together, but mostly just couldn't get services.
As I became more and more conscious of the issue and was working with other people in the community. Of course, it was at a time of great advocacy; I mean, the pipeline had started, there was lots of stuff going on.
And the -- this tension between what became -- you know, what people talked about is kind of the walking wounded, and the services for seriously mentally ill and seriously emotionally disturbed kids, these are all labels that are probably out of date now, but the -- became really, really clear.
And as the advocacy for people who really had been left out, and I mean, I'm not minimizing at all the disastrous lack of services and the necessary range of services, but for that population who -- who really needed services -- But the tension and the need for services for them and the advocacy from their families really became -- became really stark.
Section 3: The community mental health center movement was happening around Alaska since the state centers were becoming community mental health centers, community controlled. The institutionalization was -- you know, had swept the country with some good results and some not very good results because the community-based services hadn't evolved fast enough to back up behind them. And so there was just this real tension.
And it -- it was -- it was starting in the '70s, before I left to go to graduate school, and it was in full force in the early '80s when I got back from graduate school.
And in some respects, as is often the case in situations where there just isn't enough money and there's sort of a zero sum gain, there were -- there were huge advances being made in mental health in the availability of funds for mental health services, you know, the Mental Health Trust case helped with that a lot,
Bettye Fahrenkamp's advocacy as a senator from Fairbanks was hugely important in it, and some others who were members of the legislature, and the fact that there was some money from the '80s because the oil revenue, all of that made a huge difference.
But in the process, the services for people who didn't experience chronic mental illness or severe emotional disturbance, the kids who had been abused, their families, didn't grow to correspond. If anything, in some respects they diminished.
And then when the pressure on mental health, fast forward a decade or, I mean, less than a decade, when pressure on the budget started, then those services began to diminish even more because they didn't meet the Medicaid definitions, and as everything started to shift toward Medicaid, that fundamental notion of community mental health center started to slip.
BILL SCHNEIDER: One of the reasons why we're really interested in this is because in some of the interviews we've tried to get at the history of Morningside. MYRA MUNSON: Uh-hum. BILL SCHNEIDER: And sending people out, and the lack of services here. MYRA MUNSON: Yeah. And you know, I -- I only -- my only experience with Morningside is really just historical. I've read about it a lot.
I read -- I did a lot of reading about who had -- and who had been at Morningside, as we were -- when I was commissioner from -- see, I was appointed by Cowper in '86 -- end of '86 and served through '90, and, of course, there was all this work going on to figure out what the Mental Health Trust was going to be. Court case had been won, but getting a trust established hadn't been accomplished. BILL SCHNEIDER: Right.
MYRA MUNSON: And trying to figure out the role of all the advocacy groups and who should be entitled to services was really a huge issue during that window, and continued to be, of course. And so I -- I read it, but it's -- none of that is meaningful to me in a direct way. I mean, I don't know that I can think that I personally knew a person, anyone individually who actually had been at Morningside. I may have.
But I -- I don't -- I did, you know, know a lot about the folks who were being sent to Harborview because of the developmental disabilities, and -- and the -- and substance people who had experienced chronic mental -- chronic alcoholism, all of whom, you know, at one time or another were populations that eventually got added in to who was understood to be part of the Mental Health Trust. But not Morningside specifically. I don't have anything to add, unfortunately.
Section 4: BILL SCHNEIDER: Were you actively involved in those decisions that were made about on the trust beneficiaries? MYRA MUNSON: I think so. You know, I'm trying to remember, and I don't want to exaggerate any role, but during the window in which -- during that window on which I was commissioner, the issue of who should be served was really hot.
And we were working on -- there was a substantive, there was an alcohol drug abuse board, and there was a -- there was the developmental disability board advocacy board, both quite -- "powerful" overstates the case, but at least very -- had a real definite life. They were well acknowledged, we really sort of knew who they were. And then there was the question of what was the mental health board. You know, what...
And the -- this is a different -- this is a digression, but I think that the principal contribution I made in terms of the mental health piece of it was believing that there needed to be a board, a mental health board, advisory board of some kind, and that it needed to have the authority, statutory authority to present a budget to the legislature;
that it wasn't good enough that budgets came through the department because, you know, I trusted me. You know, I was commissioner, I trust me to play fair, but I also knew even -- even while I was commissioner, every budget eventually goes to OMB . Every budget goes to governor. Every budget is constrained by how much you're allowed to ask for.
And there -- that's the role of the administration. I mean, somebody has to play that role, it's a necessary part of government, but it shouldn't be the case that the legislature doesn't have a real picture of what the need is when they are making their decisions. That can't come from the administration in many cases because the administration has to create a budget that balances overall. And somebody has to choose how to weigh those things.
Now, I probably wouldn't agree with those choices more often than not, you know, I'd want more going to the programs I cared about, and health and social service programs than maybe transportation or something else, but somebody has to make those choices. But in the end, it seems to me that there had to be a role for the advocates to communicate real needs.
So during the course of my tenure, we did get a mental health board that had -- we got -- basically eliminated the one that had been there which had -- was extremely weak, and substituted a board that had specific authority to take a budget to the legislature.
I can't recall if we made similar changes or if they were even necessary in -- with regard to the alcohol and drug abuse board and the developmental disability boards, but I do know that before I left, we were bringing all three together to come up with a package.
And in the course of all of that, there were these discussions over that four-year window, and the timing of it fails me or eludes me, but about to what extent were people who experienced chronic mental -- chronic alcoholism or serious alcoholism or other drug abuse I suppose included to what extent were people with serious developmental disabilities covered.
It was our view they were covered. And it -- you know, it seemed to me that was the history of who had been served historically, those were the folks who should be. And eventually, that's what came to pass is that all three classes were included. Other people were working on that, as well, and played an instrumental role, but it was certainly -- we were certainly working on it and it was certainly consistent with the point of view we had about who should be served.
BILL SCHNEIDER: You were working on it as a -- MYRA MUNSON: As -- as commissioner, yeah, in the department, that was something we were working on. Yeah.
Section 5: BILL SCHNEIDER: Okay. I guess one of the big questions that I asked Steve Cowper, and I would ask you, is why wasn't there a trust settlement during that administration? MYRA MUNSON: You know, I saw Tom Koester's response to that actually, when I was browsing through -- BILL SCHNEIDER: Yeah. MYRA MUNSON: -- your pages, and I think his point is right. I think a couple things. I think Steve Cowper was -- had played such an active role that he did have to step back some from it. I think just his -- you know, he had to.
The other thing is the Exxon Valdez happened in the middle of his term, and then he decided he wasn't running again; and so the kind of attention it might have gotten from him over -- you know, if he'd served out -- if he hadn't been distracted by the Exxon Valdez and all the sequelae of that, if he had run for a second term and won, had more time, maybe it would have happened in the time.
You know, I think it didn't happen in part because I'm not sure the governor could have made it happen no matter how engaged he was. I don't think he could have made it happen. My own observation was that it took -- it took the time it took for people to get their head around it.
It was really difficult that a lot of the people who had advocated for the mental health litigation were concerned about their children who experienced serious mental illnesses, their adult children. Chronic alcoholics, chronic alcoholics, people with developmental disabilities were not on their radar screen when they filed that litigation.
The fact that it was expanding was not part of what they thought was -- there was a not-very-polite war going on about who got the benefit of this. No one knew exactly what the benefit was going to be, but whatever it was, everybody wanted in on it. And you know, there were additional lawsuits, I mean, it was evolving. It's still evolving, is my sense of things.
And I actually don't think that it could have been forced through the legislature. I think it would -- there -- there was -- there wasn't sufficient consensus in the community of advocates around what the answer should be.
I think it was my third year in office, I don't think it would -- I don't think it could have been the last year, it had to have been the third legislative year, we made a really, really serious run at trying to get something. I don't even remember what the elements of it were.
Jay Kerttula was very active, there were some other. Ron Larson, some others in the legislature were really serious about trying to make this work. Master tacticians in the legislature, this was one of those things happening right at the end of the session trying to put something together. The -- you couldn't build a con -- you couldn't build a base for something at that point. So instead, what we tried to do is get -- you know, we took sort of the next steps.
The advocates would work out their own settlement over time, it -- eventually there would have to be one from the point of view of -- of at least my administration of the department, it was make sure that all those boards, the advocates had strong voices, direct to the legislature that could bypass -- had to come to the department, too, of course, but could get to the legislature directly so that it wouldn't get stifled during periods in which there wasn't enough money, and -- and try to get more money for services.
And getting a settlement, establishing a trust, figure -- I mean, people were still struggling over how much -- how much should management of land be the focus of a board of a Mental Health Trust, and how much should it be mental health services or the -- the mix of what is described as mental health services might now be called behavioral health services more generically.
These were all things that were still -- still really being thought through, and I don't think there was any consen -- I don't think there was a basis for a consensus then. And I think it took -- well, when was it that it was finally sort of done. I mean, I don't remember the year, but it was -- it was still a ways out. BILL SCHNEIDER: But --
MYRA MUNSON: So I don't think it could have been done then. I think -- I don't think -- and had the legislature tried to do something, somebody would have challenged it. It would not have been -- there simply wasn't support.
Section 6: BILL SCHNEIDER: So your contention is that it would -- it -- the time was needed for those different beneficiary groups to work out their relationship because -- MYRA MUNSON: I think so. BILL SCHNEIDER: -- how much of the pie it was going to be -- MYRA MUNSON: Yeah. I mean, I don't think -- I don't think I understood that entirely at the time.
What I knew is that you couldn't get consensus on what color the sky was, let alone how to structure the Mental Health Trust among all the players that were interested and concerned about this issue.
And so when I look back, and when I apply the training I have, you know, my just life experience about things, some things just aren't ready 'til they are ready. This one wasn't ready. BILL SCHNEIDER: Yeah. Well, I was surprised in the interview with Steve Cowper because he said that it was the most important case he tried. MYRA MUNSON: Uh-hum.
BILL SCHNEIDER: I think those were his words. MYRA MUNSON: I'm sure it would have been. BILL SCHNEIDER: And yet, when I pressed him about the -- why there wasn't the settlement during his administration, his response was more in terms of, well, it wasn't appropriate for the governor to push too hard since I was sitting on the administrative side.
MYRA MUNSON: See, I'm -- I'm not -- I can't speak for him. You know, I learned that when I was commissioner serving under him. I didn't speak for him then, I'm not going to try to interpret what his own comments were -- BILL SCHNEIDER: Yeah.
MYRA MUNSON: -- but I think that's right in some ways, any more than it would have been. I tried really hard a couple of times to find a way, as a commissioner, to get it settled, to think of something that would settle it, but it became clear every time we put together some concept, you couldn't get three people, or you know how I mean, I'm exaggerating, but you couldn't build critical mass around it to support it.
And what that says to me is until you -- you don't have consensus until you have it. And it would have been -- if the legislature had forced something through, it would have failed in the end. It just needed time.
And I think he was right, I don't think -- I think in some respects, maybe what he -- I can't speak for him, but one -- what one might have learned from the litigation is that this was something that peculiarly needed the advocates or the -- the stakeholders to find their own solution in some senses, and that having either the court or the administration, whichever, any administration, try to craft it and force it -- force it, would have ultimately failed.
I mean, in the end it had to go through all those processes of being approved by the court and, you know, approved by the legislature and so on, but it still -- it needed first to have all that time to work it out. BILL SCHNEIDER: Uh-hum. Yeah. And I know people like Judge Greene spent years of her life -- MYRA MUNSON: Right. BILL SCHNEIDER: -- figuring out how to make it work. MYRA MUNSON: Yeah.
That's right. And in some respects, the court proceedings and the legislative process and all these boards that were meeting constantly about trying to figure out who was head of services and what kinds of services, all along with just the advocates who sort of had no -- sometimes they didn't even have a formal place, they were just there sort of constantly beating the drum, all played a role in trying to figure out the right balance.
Section 7: BILL SCHNEIDER: So using that as kind of a base, how would you describe the evolution of services over the years? And part of -- part of what our project is, is to look at what -- what is the evolution of services to folks with disabilities in the families. MYRA MUNSON: Yeah. Let's -- let me start back and I'll -- BILL SCHNEIDER: Sure. Sure. MYRA MUNSON: -- move forward. BILL SCHNEIDER: Sure.
MYRA MUNSON: As I said, you know, my mom experienced serious problems. She would have resisted any treatment. Sort of the nature of her illness, she would have resisted it. Any treatment she ever got would have been -- was the hospital care. I mean, she'd go to the hospital and be there awhile and then get discharged. I don't think there was ever much of anything else.
The state mental health center kinds of services and what -- and the services that were developing privately through the -- was it Fairbanks Psychiatric Clinic, I can't remember what Irv Rothrock's clinic was called, but his group, and you know, now that I think of it, probably not the '70s, maybe not until the '80s.
I'm sort of conflating the two time periods when I was here. I think that was not until the '80s that that was really prevalent. So in the '70s, I don't think that -- there just wasn't much. There was just a little bit of service. And there was Alaska Psychiatric Institute for people who needed that intensity of service were that much at risk.
The joke in the '70s, the joke in the '80s, before people could be evaluated and admitted at FMH was that before the troopers could get back from delivering the patient to API, the patient would be back here in Fairbanks. You know, it was a revolving door with -- and nobody perceived there to be any meaningful planning.
In the '70s, a lot of kids ended up at API, a lot of kids ended up in out-of-state treatment programs, residential, what we would now think of probably as residential psychiatric care weren't characterized that way then. Mostly because they -- they would run, and there was no place in Alaska that could contain them, so you sent them far away, and they were too scared to run away, for the most part, and so they would settle in, and some of the programs were pretty good and so they got pretty good treatment.
When I started practicing so -- when I started practicing social work, Child Protective Services in 1971 -- '2, we were still advising the parents of severely developmentally disabled babies to give them up for adoption and just terminate their contact because it was going to be too devastating for their family. That was the conventional wisdom.
That's what you did. That was the benign way to behave. That had changed; even by the time I left in '77, it was changing, meaningfully changing, but in '72, there was not much doubt about it. That's what -- you know, I started out as a -- I was 22, working as a CPS worker, that's what we were told to advise families in that situation.
And kids would go to Hope, to one of the Hope programs. And maybe they'd end up in some -- you know, in a foster home some day, maybe, but mostly not. I mean, it was just -- so the more severely disabled they were, that's what happened.
Section 8: For people who suffered from alcoholism, there were a handful of programs, you know, not very many, not very good. The split between mental health and substance abuse, which I don't perceive to be resolved, by any means, but was so powerful then and into the '80s that it was from -- from the standpoint of somebody doing Child Protective Services, so working with the kids so that that becomes your focal point, but it gives you this insight into what's going on in the family.
What we know now is that nearly all those families have co-occurring -- all those parents, people, have co-occurring conditions. They have mental health issues, they have substance abuse issues, often poly-substance abuse issues, even in the '70s, and certainly by the '80s, that was not uncommon at all.
And -- but there was a total Catch-22. You couldn't get a substance abuse program to accept them as long as they were taking any med -- any drugs, psychotropic drugs of any kind, there weren't all that many then but there were some; and they wanted their mental health issues under control before they would get substance abuse treatment because it would interfere with the substance abuse treatment if they weren't. And the mental health folks would say as long as a person is drunk, you know, don't bother sending them into us, there's nothing for us to do.
But the concept that people were whole and that you had to treat this whole person, and in fact, I think a whole family, was a long ways away in the '70s in the state. I don't have -- I don't work in Child Protective Services much. I do interact with some of the other programs some. Now in my current practice, lots of work going on to try to change that dynamic, but we're not there yet.
There's still this terrible tension. Some of it's out of what I perceive to be a political history of the way in which substance abuse services developed, from the way in which mental health services have developed, and this has been sort of a national cycle of being together, being apart, trying to be back together again, but with a better balance of who -- of control than -- than there used to be.
So then by the '80s, oil money hit, the advocates for chronically mentally ill adults and seriously emotionally disturbed children found a voice, and really powerful voice, and they were tremendous advocates. And -- and did more than advocate. Of course, they were building their own programs, they were just literally building them out of toothpicks practically to find ways to get services to their own kids.
JAMI in Juneau, which just -- people building their own program. And literally almost that in Fairbanks, too, but with a little more financial support because of Bettye Fahrenkamp's support, or at least what we hoped would be.
So -- so that services for that population began to take off, and the understanding about the whole need for a community-based system that wasn't institutionally based but -- but included all kinds of support services was dawning, and people were starting to try to fund it and build services for them. But it was coming at this tension about were mental health centers part of the solution or part of the problem.
And a -- really, a fight over who was going to control those mental health centers. And was there going to be funding for and were there going to be people whose jobs that were focused on families and the needs of people who had experienced divorce or depression or other mental health issue, you know, other -- other kinds of issues, child abuse, domestic violence, but weren't diag -- weren't seriously emotionally disturbed or chronically mentally ill.
Section 9: BILL SCHNEIDER: So it dealing with the whole person? MYRA MUNSON: Yeah. BILL SCHNEIDER: And has -- have we gotten there? MYRA MUNSON: No. No. We're not. I don't think we're even close. I mean, I think we're better.
The fact is there are treatment programs that -- in which children can come with their parents into some, there are -- the effort the department's making to -- that's been underway, my God, since I was commissioner, to consolidate mental health and substance abuse services, and to have consolidated rules and grants and, you know, all these things,
they are all -- they are sort of nominally there, but I don't have a -- I don't yet have any confidence that they wouldn't just fly apart again at the first window of opportunity that somebody wasn't saying you will stay together no matter what.
If they weren't enforcing it, I don't -- I don't have a sense that the advocates for the various groups have yet come to real common ground about how to -- how to -- how to build on the strengths and the specialized knowledge of each of the professions that contribute, each of the -- the history and the understanding of disease -- of the disease process that's in place, coming together to take advantage of the -- the -- that specialized knowledge, but still treat a whole person.
And bring it together for the person as opposed to programs focusing on their theoretical model and the -- that which they are most comfortable with. And -- and there is still such a -- my perception is -- and I'm not in this field to the same extent I used to be, but I interact a fair amount -- I think that there's still a very big gap in the perception of status and the perception of the right treatment model between folks treating substance abuse issues and folks treating mental health issues.
Much more recognition of co-occurring conditions, which is a big step forward, but not really a good integration of how to bring treatment modalities together in some integrated way that actually necessarily will work for those folks, and particularly when it requires residential care.
So I'm -- I don't think we're anywhere close to being done with that yet, but I don't think that's unique to Alaska, I think that's nationally, I don't think we're anywhere close. We -- in -- in part, I'm not sure we can be because, to a very large extent, we still -- substance abuse is still so heavily associated with criminal conduct, it's still perceived as a moral weakness, and -- and it's hard to separate.
There's certainly criminal elements to it, particularly if people are using certain drugs that are illegal, or if they are engaged in certain illegal conduct in order to get the resources for drugs, and -- and so on, but it taints -- it sort of taints everything about the process.
And in some respects, the best evidence of it is that we -- the jails are still our largest mental health provider. And as long as they are, it's the best evidence that we haven't yet found a true integration of behavioral health, and we don't -- we're not making it available early enough, long enough, consistently enough. We basically -- we treat substance abuse as -- well, as I said, I think we treat it as a moral weakness and a crime more often than a disease.
Section 10: The funding, the legislature and others are impatient for progress; they want to see that somehow you're making this work without, I think, understanding that I -- my own view is whether a person is suffering from depression, chronic depression, or they are suffering from other chronic mental illnesses, or they are suffering from substance abuse, chronic substance abuse problems, relapse is a part of the disease process.
Relapse and recovery and relapse and recovery. And I think that we -- I think folks who don't understand it, who -- who are looking for a fix, they are looking for a cure, I mean, we are, if nothing, impatient in this country about everything, we want there to be a cure.
And we understand that a diabetic will have to have treatment forever, and they will have times in which their diabetes becomes more brittle, less manageable, they'll need more intense treatment and case management, and so on, in order to be treated well, and we accept that. We don't do nearly as much about it as we could, but we at least accept the premise and don't view it as a personal failing.
We do not do that with behavioral health issues. We don't do it with mental health illness, we don't do with substance abuse. We do it with developmental disabilities to a large extent because it's something that's tangible, you can sort of see the disability, at least in the more extreme versions.
I'm not sure that we do with people who experience developmental disabilities that are less immediately recognizable. Fetal alcohol syndrome, for instance, and the milder forms, or the fetal alcohol spectrum disorders, I guess, now, at the lower end of that spectrum, I'm sure we recognize that children have been affected by cocaine, and a variety of -- Aspergers maybe, I'm not in that -- I'm not enough in the field to know anymore, but I think we're probably no better there.
But it was my conviction when I was doing Child Protective Services that the consequences of being abused, whether in domestic violence or child abuse, the consequences of being sexually abused were lifelong.
That what happens is that you use the crisis, if you have the opportunity to use the crisis therapeutically to bring about change, in an ideal model, you would be able to assist families to recognize how much -- for individuals, children and their families, recognize how much progress had been made, celebrate that, but remind them that at the next developmental crisis in their life, this is all going to come flooding back, because it does for all of us.
And that there'll be another window of opportunity which you need support again, maybe mental health treatment, maybe substance abuse services, and maybe just somebody to talk to, somebody to help get things stabilized again, but this is going to come up. We would build a model in which there were -- we expected recurrences of these things, we reached out in anticipation on -- and we did it in a non-judgmental manner that didn't require courts.
I know more about that than I know about substance abuse and mental health treatment, per se, but I believe that the same principles apply that what we have to anticipate is that these are illnesses that even when people appear to have them under control, that is, we all go through the developmental stages of our life, and experiences the losses and crises that occur inevitably, that there are going to be times of risk and times of relapse, or --
and even if somebody doesn't begin to drink again in the case, or they don't go off all their meds, although, you know, for somebody who is experiencing a serious mental illness and may be being medicated and various ways to manage that depression or whatever, there will be times when it all needs to be adjusted again, and they'll be acting out in behavior that's not acceptable to them or to the other people around them during that period.
If we don't build a mental health environment, a behavioral health environment that contemplates the whole person who has a developmental -- a life that will develop over time, that will experience developmental crises, which supports are made available on a routine, non-judgmental coherent way that is not dependent on qualifying for Medicaid at that given moment, if we don't build that, then we will continue to have jails and hospitals be overfilled because the crises are inevitable.
They just -- it's just a given. So that anybody that expresses any surprise about it, and looks at the providers as failing somehow, is missing the point that what we keep asking providers to do is a model of treatment that simply cannot work. It is insufficient from start to finish. Better than nothing.
Section 11: You know, when I -- when I was doing -- first practicing in the '70s, God, we did so many things that were -- you know, I look back on. But I thought -- I said at the time, and I thought even more, we'll look back, I'll look back on my practice as social worker, and God knows I have, as Child Protective Services worker, I'll look back on it and feel like the doctors must have felt who were leeching George Washington had they had the advantage of going forward some number of years.
You do what you can do with the technology and the knowledge and the resources you have, the support you have in community, you do what you can do; but if you're the least bit intellectually honest, you don't get too whetted to it because you appreciate that you're operating with way too little information and way too few resources, and largely in a political environment that is so non-supportive of human beings generally -- BILL SCHNEIDER: Right.
MYRA MUNSON: -- that it can't succeed. I mean, a society that was supportive of human beings, every family would have supports from the day there was child conceived, certainly by the time the child was born, it would recognize that all human beings require support and help from other people.
Some are lucky enough to get it in their families or from close friends somehow, it's just there in their community for them. But even they may need more than that sometimes. And for lots and lots and lots of people, those things aren't there, for a large -- lots and lots of reasons, they are just not there. BILL SCHNEIDER: Uh-hum. MYRA MUNSON: I should be paying you to -- BILL SCHNEIDER: Say, what?
MYRA MUNSON: I said I should be paying you to get the chance to rant about some of these things that I care so much about. BILL SCHNEIDER: Yeah. Well, I'm -- I think your perspectives are refreshing, and they add to the record here, that they haven't -- haven't been emphasized in that way.
The complexity of the delivery and the need to recognize that it's not a cure at one point for all time, that there are you need a safety net. MYRA MUNSON: Yeah.
Section 12: BILL SCHNEIDER: Well, how well do you think the trust has worked out? MYRA MUNSON: I'm probably not the best judge of it because, in some respects, at the point at which I left the commissioner's office, I think I mentioned when we were talking earlier, last -- or a week or so ago, that I served on the JAMI board, I was privileged to serve on it for some time.
The -- I pretty much chose to stay out of it. I mean, the trust was still -- all those issues were still going on. I stayed somewhat aloof from it. I felt like I'd had my shot and other people were going to sort this out. And there were things that I was interested in, but that was not one of them, that particular political fight.
There's no question in my mind they've been the voice for tremendous expansion, they've -- they've -- it appears to me that they pilot things, and they create opportunities to -- to pursue ideas and to try to bring some coherence to a system, and so on, all of which I think is probably good.
I'm constitutionally probably perhaps just too cynical. I'm -- I distrust institutions. You can't -- you can't get by without them. I mean, we needed the trust, no question in my mind about that, but I worry about institutions that begin to be certain that they know the answer and begin to impose it through their funding mechanisms, or their -- which things they'll support and which things they won't.
And so on one hand I celebrate the power, relative power that the Mental Health Trust appears to have in the legislature and the administration, and on the other, I'm -- you know, I'm pretty cynical about it, and wonder -- and I'm not -- you know, I'm not part of that community, so I -- in terms of the work I'm doing now, so I -- I -- everybody may be totally happy, but my guess is they are not, and they feel like they sometimes have to go in the direction that the trust goes.
You know, fundamentally, all social human services in this country have shifted around based on where the money is. Well, the trust simply became the newest source of money, so Medicaid pulls you in one set of directions, the trust pulls you in one, whatever the latest national initiative is, where there might be new grant funds pulls you in another.
Do any of them really provide a vehicle for this kind of coherent, lifelong, integrated service system to human beings? I'm doubtful. Can they? Probably not in the political environment we're in.
And so do I fault the trust for that? No, not particularly. I wish for them the same intellectual honesty that we described before is to recognize that no matter how certain they are that the step they are taking now is the best step they can take at any given moment is the one they think is best, that they recognize that the odds they are right is just about -- you know, I don't know if it's 50/50 or if it's 20/10 -- 20/80, you know, I don't know.
Our record isn't all that great and haven't been forecasting the right way to do this kind of work. And so, you know, I don't know.
Section 13: BILL SCHNEIDER: But you would think, you would think with a state with the resources that the trust has that -- that we could have the best delivery of services. MYRA MUNSON: One might think, but we may have -- you know, there -- there are a lot of resources, no doubt about it, but the demand is -- is so huge.
I -- I don't have any -- any notion what the percentage of the population in Alaska that needs these kinds of services, but the kind of model of delivery that I think had -- needs ultimately to be there is one that's serving everyone from the walking wounded, the folks that were somewhat dismissed in the early '80s when folks were fighting over the pennies, those folks who experience a crisis after a divorce or the loss of a parent or child abuse, neglect, who don't have a diagnosed illness at that moment, may never have one, but may very well at some point down the road if we don't provide some support intervention.
You know, to -- the problem, the extent of alcoholism in the state, the extent of the alcohol abuse is still extraordinary. People are still experiencing the losses of the tuberculosis epidemics and the time spent in boarding homes and the loss of language and the economic environment in villages in ways that are so profound as to be hardly -- hard -- hard to even conceive of in many respects.
The impact of mental health issues, the impact of fetal alcohol syndrome, impact of developmental disabilities, you know, those are all huge things. And you know, I don't have a -- I have a sense the trust has got more resources -- I mean, there are more resources devoted to these issues than there would be absent the trust, but I don't have a sense of them being anywhere close to that which is necessary; and in part, I guess I judge that on the basis that the system is largely -- has become largely driven by Medicaid.
BILL SCHNEIDER: What has -- ? MYRA MUNSON: By Medicaid. The whole system -- BILL SCHNEIDER: The system. MYRA MUNSON: -- of health care is being driven by Medicaid. And we began that while I was commissioner -- I mean, there were no options. If there were federal money out there to be had by taking advantage of Medicaid dollars, well, any nitwit would have taken advantage of the Medicaid dollars.
But our political environment is such that, instead of keeping this general fund dollars there to supplement for the things that Medicaid won't do, it's not designed to do, because Medicaid is designed to treat individual illnesses; but in the process of doing that, you lose all that development -- that work that needs to be there, all those pieces that need to be there when a person isn't experiencing that crisis that will somehow justify a Medicaid intervention. BILL SCHNEIDER: The net.
MYRA MUNSON: The net. And that's really what the -- you know, my view of the mental health, behavioral health system, substance abuse, all those programs, was that there should be kind of three pieces of them. In terms of money, Medicaid buys individuals, and private insurance, too, although, obviously, to a tiny extent, maybe it will be better under health reform, maybe not, but it buys services, it pays for certain services that individuals certainly need, and it provides a source of funding;
but for folks who don't have access to Medicaid or other insurance, or whose illnesses won't meet the criteria for payment for those services, then there still needs to be somebody to pay for that service because the need for the service didn't go away because the person didn't qualify.
And the need for basic fundamental prevention and education programs in communities, the kind of outreach, the -- the work that goes on to help families appreciate, help individuals appreciate that what they are experiencing is not unique, that everybody needs help sometimes, and they should get it when they need it, and that there's a place to get it when they need it, and to create non-judgmental, non-court related kinds of -- of services for folks that are out in the community, you can't bill Medicaid for that. Not much.
I mean, you know, if you tie -- if you can only provide those services to the extent you can put a group together of people who are eligible, well, you're back into the model of let's find some sick people, that doesn't get you to a model in the community that acknowledge -- in which people who are not -- who may never be qualified for those services or may never be willing to acknowledge that are still able to get some -- get some service.
And until we have that mix in our community, then I think we will continue to see lots of kids in the child welfare system, lots of domestic violence, lots of substance abuse, lots of mental health issues resolved by people ending up in jail.
And again, where developmental disabilities fit in here is some -- is -- I have the least sense of it. I was very actively involved in issues around Harborview closing and thinking through issues about building that system of -- of community supports. I've always sort of viewed that as a little bit in isolation from the other two parts of the system.
I think there are -- I think there's some -- a little bit of overlap, and there's certainly people who are developmentally disabled who are experiencing mental health issues and substance abuse issues, which now you have these sort of three -- you have the worst triumvirate possible at work, and I think the folks who experience all three issues are really in trouble.
I mean, I think we really truly don't have much to offer them systemically. But at least when children -- when people are young, or if they are severely enough developmentally disabled, they are not perceived as being at fault in their own life problem. And this concept of fault is so bound into the way in which we treat people in this -- in Alaska and in this country that I think anyone who can avoid that is -- at least has one tiny step up on everybody else.
Section 14: BILL SCHNEIDER: Why do you think Harborview was closed? MYRA MUNSON: I -- during my tenure as commissioner, there had been efforts before I was commissioner to close it. We got really close to closing it or being ready to close it by the time my term ended at the end of the '90s, and then that collapsed later. And then it took another round, whole another cycle before it finally closed.
I think it closed for a number of reasons. It was enormously expensive to operate. And for many -- I mean, there was a -- there -- many of the parents and family members of people who had grown up at Harborview and had lived there virtually their whole adult life, in some cases not even into their childhood, were desperate about it closing, they were frantic, because they didn't trust that their community-based system would meet the needs of their family members.
I don't think their fears were unwarranted, I think they are entirely warranted. Institutions are frightening, really frightening. Harborview seemed to me -- although, you know, I wasn't there often, it seemed to me to be one of the better run, fewer abuses, fewer terrible stories coming out of there, it seemed to be a pretty good place. But it's still an institution.
So to the extent that we can provide care for people outside of institutional settings, then sort of the obvious human thing to do is to try to do that. And there were lots of advocates, particularly people who -- who -- the advocates are keeping it open came from two communities. They were the families of people who were there forever, and they really didn't want their care disrupted. That was really their home and their families didn't want that changed.
And there was the community of Valdez, which didn't want to lose Harborview. It was the base of their hospital, it was the -- you know, it was a huge economic engine, it was a big deal. And they looked around and said, look, we are running a good program here, why would you close it? Institutions are huge, you know, they just are in terms of the economy of communities.
On the other side of that were all the -- were the advocates, Todd Risley, you know, who came to work for me as a deputy, or actually as the Director of Division of Mental Health and Developmental Disabilities, and his pred -- you know, other people who have been there, all the folks who had worked in developmental disabilities were working on trying to find community-based solutions, and building individualized treatment plans in which people could get all their needs met someplace else, no matter how impaired they were developmentally or certainly physically.
And so there was this huge pressure to -- to make it available. I became convinced that it was possible. I -- I wasn't when I started, or, I mean, I at least was doubtful, but I became convinced that it was possible to build really truly individualized plans that could meet all the needs that an institutional setting was.
And I learned that from -- from -- God, a young woman who was a quadriplegic who had grown up in a nursing home here, she wasn't mentally impaired, huge physical disabilities, who became a tremendous advocate for deinstitutionalization that if you put enough supports in. Well, if you put enough supports in to somebody in her situation, you can put enough supports in for somebody with developmental disabilities.
The crunch and the piece that I was not confident of then and I remain not confident of today is when, in an institution, if a staff person leaves, it's an institution, somebody's still there. Now, can the institution collapse and become a terrible place? Of course, they can.
But it's -- in a community-based system, if a person has -- in order to have a decent plan of care, they have to have somebody who -- a van driver who picks them up and takes them someplace, and a place to go, and somebody who brings meals, and somebody who makes sure they are getting whatever medications they need, mental health care they need, and on and on and on and on,
it takes a huge array of people to provide all that care, if the person who is managing that care quits their job, do we know that there will be somebody stepping in who actually knows that whole plan of care and can keep it alive and working? And what happens when pieces of it start to collapse?
Does that person simply become homebound in a much worse situation than they would have been in the institutional setting because really basic things may not be being done. They could be -- you know, they could really get into serious trouble.
Section 15: So because I have a certain measure of cynicism about how all institutions work, and ultimately, the home-based system is -- becomes its own institutional system, it's tremendously dependent on the person who's responsible for that care plan, and on all -- and on all the financial supports for all those pieces remaining in place.
If they start to fall off, then you can have people with tremendous disabilities living in the community, or not living ultimately in the community, with nobody really making sure that they are okay. And you don't have a failsafe anymore because that institutional setting is gone.
And so I worry about it, you know, because of this tremendously vulnerable population. We saw it in hospitals, psychiatric hospitals were closed in anticipation of community-based services that never came to pass or didn't come to pass fast enough or comprehensively enough.
BILL SCHNEIDER: Or when Morningside closed -- MYRA MUNSON: Or when Morningside closed down. BILL SCHNEIDER: -- John Malone spoke about -- MYRA MUNSON: Yeah. BILL SCHNEIDER: -- people, the Dear Johnny letters that patients would bring back and, you know, here's my medications and here's what I'm supposed to take -- MYRA MUNSON: Right. BILL SCHNEIDER: -- but there was no network.
MYRA MUNSON: Right. And we still have that. I mean, we still have that here. We have -- we downsized API to make it both affordable to build and because we had an image of a community-based system, and reliance on community-based hospitals that could do these things, but we didn't support the private hospitals adequately to actually provide those -- BILL SCHNEIDER: Services. MYRA MUNSON: -- mental health services, inpatient services that people need on a short or a little bit longer term.
We don't have an adequate community-based system that actually -- you know, really is engaged in outreach and follow-up, so we still have people being sent to API, or -- or having no place to be sent if they are -- you know, necessarily. If they are not -- if they are not involuntary, they may have no place, really, to be sent, if -- if they don't qualify for -- for Medicaid.
So we still have these huge gaps, and when they get home, we don't have -- my impression is there's actually a lot of stuff going on to try to build those links. I mean, tele-mental health appears -- what people tell me that I'm reading suggests that there's really a lot going on that -- that may make that better, that connect -- ties the community back to the hospital much more effectively than they ever were before.
So I'm not pessimistic about that. But technological solutions are still a long way away from making sure that all the pieces are in place at the other end, and I don't think we have that yet.