Part three of Spotlight PA’s The Cost of Failing series:
The online reviews of Scranton Counseling Center can be as scathing as they are glowing.
“I really like this place it makes me feel safe to talk to people.” Five stars.
“I have been a waitlist for ten months now for therapy.” One star.
This is the reality of providing mental health care in Pennsylvania.
Scranton Counseling is a community mental health provider serving Lackawanna and Susquehanna Counties where staffers try to stick to a simple ethos: Help everyone they can.
To achieve this, the center employs psychiatrists, psychologists, nurses, counselors, social workers, and more. The crisis center is open 24/7, to provide a place for people to stay and stabilize. Specialized teams of clinicians and case managers meet clients wherever they are to help with whatever they need: medication, housing, groceries.
For more than 75 years, the people who work there have tried to provide the intensive, high-level services that state officials envisioned replacing restrictive state-run psychiatric hospitals.
But community mental health care is expensive.
Pennsylvania’s mental health system is, on paper, set up to account for the cost of quality care.
The state provides so-called “base funding” to counties to pay for services that insurance or Medical Assistance doesn’t cover. Counties in turn use the money to provide mental health care themselves or contract with providers such as Scranton Counseling.
But the funding is scarce. Cuts in 2013 went unrestored for a decade. In recent years, Gov. Josh Shapiro has put an additional $60 million into the system, but the infusion hasn’t restored the cut or kept up with inflation.
Some counties pool their resources to maximize their dollars. Lackawanna and Susquehanna Counties formed such a mental health joinder.
They give Scranton Counseling roughly $3 million a year in base funding, about an eighth of the company’s overall budget.
As the primary provider for community mental health in a college town, Scranton Counseling also serves students, many of whom are not on Medical Assistance. Their care must be paid for by the limited funds as well.
Long wait times, staff turnover, and unanswered phone calls are frequent complaints
But despite those setbacks, the staff at the center know what their clients need, down to the tiniest of details.
Crisis unit workers delouse and launder patient clothes when they check in so they can have clean clothes when they leave. Case managers become experts on their clients, learning the kind of cigarettes they like and the triggers that might undo days or weeks of progress. Peer specialists know what it’s like because they’ve been there themselves.
Every day, there are too many people, often in crisis, and not enough money, time, or resources to help them all.
In March, Spotlight PA spent two days getting an inside look at how the people on the front line of the mental health funding crisis try to make it work in spite of all the obstacles to delivering quality care.
When Becki Dunkes had her first panic attack in 1992, she made her then-partner drive her to a church in the middle of the night for an exorcism.
She pounded on the rectory door for 45 minutes, but no one responded to her desperate attempt to find peace. Back at home, still unsettled and afraid of her own mind and body, she threw away all her forks and knives. She was just 19 years old.
“I didn’t know what I was doing or why, I just felt I couldn’t trust myself.”
For years after, Dunkes resigned herself to a life away from other people. Her panic disorder made her emotional, erratic, and mistrusting. She lost custody of her kids. She spiraled through suicide attempts, and couldn’t keep a job for longer than four months.
In 2010, she started the partial hospitalization program at Scranton Counseling. Every weekday for a year, Dunkes showed up to the old building that used to house a Sears Roebuck department store and worked on herself.
She learned to trust herself again. Sitting across from people with the same problems as her, day after day, provided the structure and security she needed to break her self-imposed isolation.
“I always heard, ‘Oh, but you're not alone.’ But I felt alone because I didn't ever know anybody or see anybody that felt like I did.”
After a year, one of the practitioners encouraged Dunkes to apply to become a peer specialist, a person with lived experience who helps others going through the same thing she did.
When she applied, the program accepted her.
“That was the first time I looked at me,” she said. “I saw that maybe I am worth it.”
Dunkes has been a certified peer specialist at Scranton Counseling for 14 years.
By all accounts, Dunkes is a success story. Her experience is in many ways the model of what Pennsylvania sought to achieve with a community-based care system. But working as a peer specialist has also given her a window into the parts of the system that have degraded over the past decade, or were never built.
When clients come to the center for appointments, they meet with Dunkes or another peer specialist first. She checks up on their health, logging how they’re reacting to specific medications. Is it hard to swallow? How are the side effects?
She asks about life stuff. Do you smoke? Do you want tips to quit? Together, they find a “personal medicine,” something like music or knitting or birding, that helps the person feel calm and in control.
The questions create a health report the client can take to their doctor or nurse. This document of experiences and intentions makes the client an active participant in their care, not just a passive recipient.
Sometimes, though, people don’t want to do the report. They’d rather vent or unload, telling Dunkes why their daughter won’t speak to them. That’s OK, Dunkes said.
On days like that, Dunkes can fall back on a resource library that the center subscribes to for answers.
But just as often, Dunkes hears about things she can’t fix.
One of her clients makes too much for public insurance through Medical Assistance, but doesn’t make enough to afford the prescriptions he needs out of pocket.
“He's one that just kind of fell through the cracks,” she said.
Others wait months for help from one of the center’s case managers.
“It's frustrating to me when they tell me about it, they're like, ‘I'm waiting for a case manager. I can't figure out my grocery list on my own. I really could use the help of a case manager,’” Dunkes said.
“That's the part that frustrates me, … that I can't fix something.”
When Nick Deneen explains his job as a case manager to other people, it’s often easier to describe what he doesn’t do.
He doesn’t administer medication. He doesn’t provide therapy or clinical care. But everything else? Yes.
Deneen and his team call doctors and dentists to set appointments. They find therapists to suit specific needs. They drive clients to the pharmacy; assist them with budgeting and financial management; make grocery lists; help with housing.
A case manager’s client might also be in treatment, and have a psychiatrist. They might have a therapist, or a probation officer, or a child with special needs.
“[The] case manager is sort of like air traffic control,” Deneen said. “They keep all of the information flying in all directions so that nobody gets confused.”
Clients can pay for case management services through Medical Assistance. If they don’t qualify, and they’re a Lackawanna or Susquehanna County resident, the county can sponsor their care through base funding.
It’s the same funding the state cut in 2013, and never restored.
A case manager’s goal is to work themselves out of a job by helping a person stabilize to the point of no longer needing help. But the money that in some cases pays for case management also goes toward the resources Deneen’s clients need to build an independent life. That funding has become increasingly scarce. This financial trap means Deneen’s team will always have another person in need of their help.
There are always waitlists for clinical care, Deneen said. Supportive housing is sorely needed. And the number of people who need a case manager isn’t dwindling.
“We have more referrals than we can manage at any given moment,” Deneen said. And it’s also harder than ever to find people who want to do the work.
“It’s a hard job,” he added. “It takes a certain kind of person to do it.”
When all his positions are filled, Deneen oversees 22 regular case managers who can work with up to 30 clients each. They visit people at least once every other week. Scranton Counseling also staffs six forensic case managers who work with people who are entangled with the law.
There are three vacancies on staff, Deneen said, and they keep case loads intentionally a little shy of full capacity because the rate of turnover requires remaining staff to take on cases when someone leaves.
To prevent burnout among the case managers, Deneen tries to take a high-level perspective. Sometimes a client needs something that doesn’t exist or makes a decision that sabotages progress, issues that lead him to the same question: What can we do?
When the answer is nothing, case managers must be comfortable with that possibility, Deneen said.
“Recognize that your job is incredibly difficult and you are not going to change the world,” he said he tells staff. “You're going to do everything you can.”
If Janice Mecca woke up every morning and tried to plan the day for Scranton Counseling’s assertive community treatment team, it might look like this:
She would drop off medications.
The nurses might help a patient with her injection or run through what she needs to know about a diabetes diagnosis.
The therapists would work through scheduled appointments.
The peer specialist would help someone find his “personal medicine.”
The vocational specialist might drive a client to a job interview, or help someone learn more effective workplace communication skills, or maybe teach them how to format a resume.
The case manager might be putting the finishing touches on a client’s housing application.
“But then you come into work, the phones start going off,” she said.
“This person is in crisis.
This person's on the [crisis receiving and stabilization unit].
This person had a med error.
This person has no food today.
This person's access card stopped working.
“So it turns into like, maybe you do half of what you thought you were gonna do, and then you're doing a whole bunch of like, keeping people afloat, in a sense.”
Treatment teams like the one Mecca oversees at Scranton Counseling, groups of mental health professionals who provide support for people with complicated and serious needs, are considered a vital part of community care. The teams exist to meet needs that a typical level of outpatient mental health care couldn’t.
“If you call your outpatient therapist, they're not going to be able to get up, go get you food,” Mecca said. “We can get up, take them, go to the food pantry, make sure they have food tonight.”
State officials formalized standards for the teams in 2008, writing at the time that they “could play a vital role in our efforts to transform the mental health service system.” Today, there are 43 licensed teams throughout the state, serving about 3,200 people.
Scranton Counseling’s “modified” team, staffed by a doctor, two nurses, two therapists, a peer specialist, a vocational specialist and a case manager, can help up to 50 people. Modified teams, under state standards, are designed to serve more rural areas with smaller caseloads.
In theory, the eight-person team should be big enough to handle the needs of the people they serve. But the world doesn’t always follow theory.
As often as the team is delivering mental health care, they’re running to the pharmacy to get a refill on medicine that ran out or to the gas station to get cigarettes, Mecca said.
“Cigarettes are a big thing,” she said, “which might not seem like a crisis, but you know that can set someone into an episode.”
Mecca’s team maxes out at 50 clients. But that doesn’t mean there’s only 50 people in Lackawanna County who could use their help.
“I know that if we had 10 more spots, I'd have 10 more people.”
But under state standards, if the team at Scranton Counseling added another person, they would become full-size, “which means double the caseload, double the staff,” said Mecca.
Finding staff is difficult as it is. The work is draining, and turnover is a major barrier. This year was the first Mecca had a full and consistent complement of staff since she started overseeing assertive community treatment in 2021.
There are also people Mecca has to turn away. Private insurance doesn’t cover assertive community treatment, and people often don’t qualify for subsidized insurance through Medical Assistance. If someone is a good match for the kind of intense support the team provides, but they make too much money to qualify for Medical Assistance, Mecca can’t take them.
Someone who makes around $1,500 a month
“which is nothing,” she said, could make too much money to get their services.
It’s hard to say no to people, Mecca said. If they can’t take someone, they try to direct them to a collection of services that can somewhat replicate what a team like hers provides.
But does that really exist?
“No.”
After more than two decades of experience in Pennsylvania’s mental health system, Monica Mongiello knows how things have changed for the better — and for the worse.
When she completed the partial hospitalization program at Scranton Counseling in the mid-2000s, it was almost like going to college. There were specialized sessions to choose from and different cohorts of people going through the program at once. There were roughly six therapists with master's degrees, and another eight or so bachelor’s level counselors, she said.
“I didn’t know how good I had it,” Mongiello said of that period.
In 2013, Medical Assistance stopped covering many aspects of partial hospitalization, said Kristen Simpson, the crisis service director at Scranton Counseling, who ran the program at the time.
“It was awful, and it was heartbreaking for those of us who did this for our whole life, and a lot of folks just ended up not being able to come to program here,” Simpson said.
Around the same time, the state slashed funding for community mental health, which covered these services for people who didn’t have Medical Assistance. Over the next decade, as the state government failed to restore the cut, the counties that run the mental health system lost about $150 million in spending power — reaching about 85,000 fewer people.
Mongiello saw the decline firsthand when she returned to the program in the mid-2010s. When she first completed it, there were about 200 participants. When she returned, there were maybe 30.
“My first reaction to that was, ‘Where are they?’” she said. “Because there were some people who weren't going to leave that program because they moved on. It was going to be that they lost that service and didn't have anything to replace it.”
Her years have made her clear-eyed about what isn’t working. But they’ve been galvanizing, too.
After 20 years as a client at Scranton Counseling, Mongiello is now also a colleague. Like Dunkes, she is a certified peer specialist, working with people to achieve the stability she’s been able to find. When people sit down with her and find out she also has a serious mental illness, they “light up,” she said.
“You want people to know you're not just a collection of symptoms that need to be medicated,” she said. “You can have a good life with the illness. And we're here to help facilitate that.”
Pennsylvania has 48 different mental health administrations across its 67 counties. Because different counties have different resources, it can be hard for someone in need to know what’s available to them.
Mongiello seeks to change that by building a database that Scranton Counseling can use when people need things beyond what the center provides. She’s digging into everything the community has to offer — housing, food, utilities assistance— and gathering it into a comprehensive list.
She has her questions ready: “Here's what I can do for you, here's what you can expect from your treatment here, here’s what's available here? Here's what you can have outside of here.
“What do you need?”