Death By A Thousand Cuts
By Mighty Crow CEO, Dr. Gretchen Clark Hammond
There are many times in my 26 years of working in behavioral health and human services systems that make me think of the expression "death by a thousand cuts" and the historical implications. One of my first experiences working in the field was adjusting to abrupt and unexpected funding cuts to our system of care while the expectation to serve everyone with excellence remained.
The news last week of cuts to a large number of grants by the department of HHS was similarly abrupt and took me back to those other moments. While not a surprising turn considering the methodologies of the current administration, the suddenness with which the grants were ended- pulling back money that was already promised and budgeted for has left many organizations scrambling to figure out how they will continue the provide the important services they offer. These cuts have left us with a lot more questions than answers at this point. The constant negotiation for scarce resources is normalized behavior in abnormal situations like these where cuts occur with little to no notice and for no direct reason other than "just because" or "budgets." To better wrap my head around our current situation, I thought back to the first years of my career, it felt like we were being sliced, bit by bit, to the bone as a system. There were fewer and fewer providers of residential treatment - a level of care desperately needed for many people with substance use disorders. There were fewer and fewer women's treatment programs, youth treatment programs, and nearly zero hospital-based programs. At one point, there were very few beds available for what we used to call "detoxification services" and we thought those would probably go away too.
I worked in a facility that served women and children and saw their Medicaid eligibility end, leaving only about 30% of the population eligible. Here was a specific case where the expectations on what we should deliver, and work alongside the clients to achieve, remained the same despite these deep funding cuts.
What does this do to a person who has dedicated their educational pursuits to this profession focused on helping others? Or someone who feels called to do the work? It creates severe compassion fatigue. Severe. So severe that many professionals simply walk away from what had been their life's calling because they cannot figure out how to keep going without feeling like they might collapse - physically, emotionally, and spiritually. And I fear we’re quickly headed toward another round of that.
Before I knew what compassion fatigue was, what it looked like, etc., I saw skilled colleagues leaving in the prime of their careers. And then, it happened to me when I was 35 - I walked away from doing a job that I loved with clients that were remarkable people because I couldn’t keep going . I was not sure what was wrong with me until I started doing some reading as part of my continuing education requirement for my license. I read about compassion fatigue, the symptoms (all of which I had), and the comorbidities that come with it like secondary traumatic stress, depression, and anxiety. That was over 13 years ago; and while I've done a lot to help myself heal- including creating my own company where one of our primary tasks is helping organizations navigate these complicated systems- I am starting to feel some of these symptoms creep in due to the current circumstances our system is facing again with unknown cuts across the federal government.
Too many people do not understand how impactful federal funding is at the local level. Block grants, allocations, discretionary grants, and professional service contracts are what funds a considerable amount of work at the state, county, city, and organizational level. For example, when Ohio started waking up to the realities of the opioid epidemic, there were numerous questions about why we had such scarcity in our treatment services - or why there were hardly any residential treatment options in the state - or why no one could get into detox. People from outside the field were shocked that our system was limited in so many parts of the state. Those of us on the inside were not shocked at all. We'd been cut, cut, and then cut some more.
Federal dollars to help states address the opioid epidemic started to become available through grants and these dollars provide much needed assistance, but our system of care that had been so underfunded was struggling to grow fast enough to keep up with demand. Right before the COVID-19 pandemic, our system was enduring significant cuts to Medicaid rates, known as "behavioral health redesign" where many providers were down to 30 days of cash on hand. It appeared that our system and the cuts we had endured again would finally lead us to our death. Again, federal dollars were the reason our system did not collapse at a time when it was needed most. Those dollars were impacting providers across the state as we grappled with the opioid/fentanyl/methamphetamine crises and the mental health exacerbations brought on by significant stress and grief due to the pandemic.
By the middle of 2024, I thought that perhaps we were finally at a place where we understood that our system needed this kind of support and funding to finally be built as it was promised - a full continuum of care for people in need. However, that's not the case. We are now again facing our death by a thousand cuts, or so it seems. I'm no longer 35 and wondering what is happening - I know what is going on.
Awareness is helpful in fending off compassion fatigue, but just being aware isn’t going to fix the mess that has been dumped in our laps. The need for behavioral health and human services remains great and that need is not going anywhere. The need for innovative thinking about how we survive these challenges and perhaps find a way to even thrive is also great. We need to start strategizing and planning what that looks like in our new reality. For now, my focus is going to be on personal wellness to fend off the fatigue, while I figure out how to navigate these waters without federal support. I don't have any easy answers at this moment. What I do have is 26 years of experience that I can share. Stay tuned to this space for additional thoughts, because I'm not ready to die by a thousand cuts.
