Editor: Mr. Blau, would you tell our readers something about your professional background?
Blau: I am a healthcare lawyer, and my practice within that sector is very broad. I work with hospitals, medical groups, healthcare management companies, health information technology companies, insurance carriers, biotech concerns, and so on. I am co-head of the firm's healthcare practice here in Boston, and I chair the firm-wide planning committee.
McDermott Will & Emery possesses the largest health law group in the country, and, I am proud that for the second year in a row, we have been ranked by The American Lawyer as the number one health law practice in the country.
Editor: In addition to a very busy professional life, you have enjoyed a parallel career at the Boston Bar Association. What are the highlights of that career?
Blau: I had the privilege of being appointed chair of the Boston Bar Association Health Law Section in 1998. Over the next few years I was able to revitalize the group and provide it with a foundation for growth.As part of this, a number of committees were established - a steering committee, a social action committee, a CLE committee, a legislative committee, a communications committee and a membership committee - all with extensive agendas. The Newsletter published by the communications committee constitutes the definitive word in Massachusetts health law developments today. I take considerable pride in the progress of the BBA Health Law Section.
Following completion of my two-year term as chair of the section, I assumed a number of roles relating to the BBA's children's mental health project, and I served as a member of the board of editors of the Boston Bar Journal from 2000 to 2003. I continue to serve as a member of the Health Law Section steering committee and as Co-Chair of the BBA's Child Mental Health Task Force.
Editor: What is the origin of the Parents' How-to Guide To Children's Mental Health Services?
Blau: The confluence of two factors brought the issues of children's mental health to the attention of the BBA. The Association has a social justice mission in addition to its administration of justice mission, and in this capacity it is engaged in a variety of outreach projects to children. The second factor has to do with the social action committee which had been set up in 1998 to pursue socially worthy causes. Some of the members of the committee had experience with the intractable issues of children's mental heath and were recommending that we tackle this area, just as several front page articles appeared in The Boston Globe highlighting those issues. Everything then came together to focus the BBA on this subject.
Editor: How serious is this situation?
Blau: Very serious. In the U.S. one child in ten suffers from some form of diagnosable mental health illness. About four percent have a serious disorder that is going to qualify them for some state-supported program. There is also the huge problem of undetected and untreated mental health disorders that result in a variety of social ills and behavioral problems, including school absenteeism, police involvement - and I point out that the primary issue for many of our youth in the juvenile justice system is of mental health rather than intentional criminal behavior - and teenage suicide. These are not new issues. When I was first learning about them in 2000, the then Massachusetts Commissioner of Mental Health gave me a book entitled "The Children's Mental Health Crisis in Massachusetts" that had been published more than 30 years earlier, in 1970.The fact that these issues have been with us for such a long time does not change the fact that we are dealing with what many in the field believe to be a continuing crisis.
Editor: What was the partnership that was forged between the Boston Bar Association and Children's Hospital Boston?
Blau: Children's Hospital Boston has been a wonderful partner with the BBA in connection with this project. At the very beginning, when we were first learning about children's mental health issues, Hospital personnel addressed us and provided background and expertise on priority matters that needed to be addressed. The Hospital also participated in the BBA's forum conducted by the Child Mental Health Task Force Summit in September 2001, to which we invited the principal Massachusetts stakeholders. This included legislators, commissioners from a variety of departments, the secretaries of education, and health and human services, academicians, and representatives of families, human, social service and healthcare providers, insurers, mental health advocates and the court system. The key questions revolved around what could be done in the near term to improve outcomes.The forum resulted in a BBA Task Force report with a set of recommendations for priority actions.One of the recommendations was to develop a resource guide to help families navigate the child mental health system in Massachusetts. Responsibility for drafting such a guide was divided among a variety of work groups, and people from Children's Hospital contributed to several chapters. They also participated in peer review and on the guide's editorial board. The Hospital also provided most of the funding to cover the printing and distribution of the initial edition of the guide.
Editor: Please tell us about some of the problems that families with children in need of mental health services face.
Blau: Very often families with children in crisis do not know where to turn. Indeed, they may not be able to differentiate between normal acting out and a serious mental disorder in their child. The first problem, accordingly, is lack of information. The guide is meant to assist families to decide whether their child needs help.If so, it introduces the family to the system and its resources and tells them how resources may be accessed and funded.It lays out the barriers to access and provides advice on how to get around those barriers.
One of the most intractable problems concerns the social stigma that is still associated with mental illness. Fear of employment discrimination, fear of being denied insurance coverage, and fear of derision are still with us, and families are often in denial as a result.
There are applications for state or private programs that are meritorious, but are nonetheless denied because there are insufficient resources available. And there are applications that are denied because they get caught between funding categories - for example, a child with a dual diagnosis of bipolar disorder and substance abuse may be turned down for services by the Department of Mental Health on the basis that the primary diagnosis is substance abuse, while the Department of Public Health may not fund substance abuse treatment, saying that the child's problem is principally his bipolar illness. Families can be literally bounced around in this manner among a variety of agencies. Dual diagnoses too often leads to this result.
There are issues about the availability of services on a geographic basis. What is available in Boston may not be available elsewhere, and where it is - at least on paper - the practitioner's practice may nonetheless be full. There are very limited numbers of child psychologists and psychiatrists in Massachusetts, and none are available in some regions of the state.Kids can be placed on long waiting lists for some services.
There are also limited resources dedicated to early detection of mental illness. People are aware that the system is already overwhelmed by the known incidence of mental illness, and are discouraged from committing more resources to the detection stage, where, of course, the possibility of a successful intervention is much greater.As a result, much mental illness goes undetected and untreated.
These are but some of the problems with the system.
Editor: Surely these are not new problems. Why are they coming to a head now?
Blau: These are problems of long standing. The situation has been recognized as constituting a crisis since at least the early 1970s - and there has not been any significant improvement. If these problems are perceived as rising to the top of the agenda now, it is because organizations like the BBA have given them a new visibility and urgency that did not exist earlier. That means that we are having some success.
Editor: Please tell us how the Guide was written. What resources were you able to draw upon as Editor-in-Chief?
Blau: The BBA's social action committee appointed a series of workgroups. They developed an outline and subject-matter for the various chapters. The people who participated represented a variety of constituencies: healthcare lawyers, personnel from Children's Hospital and other healthcare institutions, representatives of parents' advocacy groups, mental health professionals from a variety of organizations, and so on. Five workgroups developed chapter drafts over a period of a year. An editorial board consisting of four members of the BBA's Health Law Section then reviewed the work product and addressed how to turn it into an easy-to-read reference guide. Needless to say, lawyers may not be the most qualified people to make anything easy to read.So we enlisted the help of a professional copywriter who ensured that the language used would be accessible and understandable. An excellent graphical design was added to the text, including advocacy tips that appear in floating bubbles throughout the guide that reflect the real world experience of families who have been through the system. The final touch included a glossary - every culture has its own language - and a resource list with contact information.
Editor: While the primary audience for the Guide is made up of families with children in need of mental health services, I am certain it is meant to have an impact on others. Can you comment on this?
Blau: We expect that the Guide will have both a direct and an indirect impact. Most directly, it is an information tool, and we hope that in the hands of families who need it, that information will translate into access. For that reason, we are trying to distribute the Guide , free of charge, as widely as possible. Once the family has information and access, we hope they can focus on integrating services across state agencies on both a programmatic and funding basis. We are seeking to address the dual- or multi-diagnosis issue, among others. For the legislature, we hope that the Guide will encourage a focus on availability of resources and funding issues; and for the courts, we hope it will encourage a recognition of the distinction between criminal behavior and behavior that is the result of mental illness. For health care providers, we hope it will serve to make them better advocates for children and their families. And for insurers, we hope it will encourage them to see mental illness more in the way they see physical illness and extend their coverage accordingly.
Editor: What are your thoughts about the impact you hope the Guide will have? In Massachusetts and beyond?
Blau: The Guide is the first of its kind in the country. If the Guide is able to demystify the system and enable more families to access it with less frustration and discouragement, we will have accomplished a great deal. We want to draw attention to the need for earlier detection as well. A small intervention at an early stage is often infinitely better than a massive one down the road when a child is in crisis in an emergency department or police custody. Everyone understands that instinctively, but it does not happen often enough in our current healthcare system. We want to be able to reduce the number of children and families in crisis as a consequence of both undetected mental health disorders and the inability to access effective treatment when mental illness is identified. Any progress that we make is going to have a positive impact, and I would hope any significant improvement we achieve will receive attention beyond the borders of Massachusetts.