Meeting production: the economics of contracting mental illness

This article presents a case study which illustrates the impact that economic forces can have on organizational structure and clinical practice. Specifically, the stresses and double-binds which staff experience as a result of having to manipulate different sources of funding in order to 'meet production' are examined. Ethnographic fieldwork conducted at a day treatment center connected with a Community Mental Health Center revealed that contracts are made and quotas are set each year to 'produce' different kinds of services. The two main types of services, habilitative and socialization, are not funded equally. Funding agencies pay the most for habilitative services because these are meant to be directed toward the most symptomatic clients requiring the highest level of care. However, who is billed habilitative at any one time may or may not have anything to do with who is actually symptomatic and receiving a higher level of care. The reasons for this are explored, with special attention paid to how staff must adjust to constantly changing funding requirements. Despite the obstacles, staff attempt to provide clients with the level of care that they need, regardless of whether or not this is reflected in production quotas. Taken together, these two elements--the efforts of staff to conform to funding agency requirements plus their attempts to provide clients with the level of care that they need--require that staff engage in a constant and very wearisome juggling act. It is concluded that as a consequence of the demands of meeting production, both staff morale and the treatment of clients is adversely affected.