‘I Hate You; Don’t Ever Leave Me’

I used to work in behavioral health in Las Vegas. I have a B.A. in sociology and was a certified mental health associate. I could write up treatment plans, review provider notes, request mental health services (known as prior authorizations), and treat clients under clinical supervision. I was once a clinical coordinator at a predominantly black behavioral health agency, where I quickly learned that even in Las Vegas, most people who were served by this branch of Medicaid were black. The reason was that if you don’t have a physical disability, a mental health diagnosis is the only way to get Social Security Disability Insurance (SSDI). It’s a common claim for people who don’t want to work.

So how do you get a monthly disability check? You need a diagnosis of mental illness from a licensed therapist or clinician. Your medical records have to include a history of medication, psychiatry, etc., for a disease that has allegedly caused unemployment of 12 months or longer. To keep getting that check you have to keep proving you have a mental illness.

At the same time, since you are supposed to be so sick you can’t work, you must accept the therapy and services Medicaid thinks you need to get better. However, blacks think mental illness is a weakness, and that treatment is a white thing. Most didn’t want therapy, but they had to accept it to keep the checks coming. They constantly missed appointments and forgot to take their medicine — or sold it as a side hustle. Medicaid was so overloaded it was very spotty in enforcing the rules.

Privately-owned agencies handle the huge bulk of Medicaid services, and with enough crazy people for clients, they can make a lot of money. One way to cut corners was to hire student interns for therapy. That was not illegal, but interns were trying to complete the hours they needed for their license, and I thought it was unethical to let novices treat people who, in some cases, were considered “severely mentally ill.”

Blacks liked some of the services agencies provided. For example, some clients went to “adult daycare,” where they got free snacks, free cable, and a nice break from sitting at home. The agency billed this to Medicaid at $80 an hour, paid the “case worker” $27 an hour, and pocketed the remaining $53. All the case worker did was drive the client to the center, watch TV and eat free food, and then turn in “case notes” — often illiterate and full of nonsense — claiming to have helped the client: “Provider assisted client with they depression today.”

“Case management” was even more of a racket. Medicaid paid $60 an hour; the agency got $40 and the “provider” got $20. Usually, the “provider” didn’t even see the client. He just texted a link to a list of churches, or the Salvation Army, or places to go for free food, or shoes, or backpacks for children.

Medicaid paid at about the same rate for “basic skills training,” which was supposed to fight mental illness. Because of depression, say, a client was thought to be unable to communicate, deescalate conflict, cook, feel empathy, or respect authority. The idea was that if we could improve the skills lost due to depression, the depression would go away. The treatment plans I wrote covered a variety of “basic skills,” but the black case workers almost never followed the plans.

Their treatment was almost always about money, with the client complaining about how poor he was. This would lead to conversations in which the case worker would offer tips on how “they could get they stacks [spending] right, to help with they depression and communications.” What this would involve was a trip to the grocery store or the mall, where the case worker ran personal errands to “demonstrate budgeting.” I would emphasize that it was important to help with communication skills, for example — basic things like listening, eye contact, smiling, paying attention, sitting still — but that seemed to offend them. They would tell my boss I was insensitive to the needs of the client.

One advantage of going to the mall was that they could bill extended hours if the service was given in a community setting. That was why blacks made so few house or hospital calls, for which they could bill only a set fee. Home and hospital calls are important; you can check a client’s mental and personal state. Also — unlike in a grocery store — you could actually carry out a treatment plan, but that would be too much like work.

When I was interning for my first job, the white lady training me and whom I was to replace, whispered in my ear, “Be careful around here, this place is incestuous.” By that, she meant that clients were often related to service providers in some way — which was an ethics violation. She also said that with mental health diagnoses, the owner was billing Medicaid hundreds of thousands a month. The off-site clinician who supervised me was white, as was the office manager. I was doing the clinical coordination, so we were outnumbered by blacks, roughly 25:3. The place would have fallen apart without us.

In Southern Nevada, you would think many Hispanics would be getting these services, but that was not the case. To the best of my recollection, in all my years I remember one Cuban family and that was it. The owner of the agency where I worked, who was black, hand selected his clientele from his neighborhood and social circles. They claimed to have mental illnesses so they could get checks.

My main job was to review notes from case workers in the field and make sure they were in alignment with the treatment plans I had made. Clinicians provided weekly therapy and I incorporated their impressions, along with case worker notes, to determine progress or regress. I would then put requests into Medicaid for more or fewer services. There was even a formula to measure progress and regress.

A clinician has valid reasons for continuing treatment, reducing treatment, or deciding that a client can be discharged. However, any reduction or discharge means less revenue for the agency. The black owner hated improvement. If I dared recommend a discharge, I got chewed out. The owner would march into my office and scream that the clinical notes I was reading were all wrong and that I didn’t understand the problems of black people. He didn’t care about my clinical impressions, which were backed up by our clinical supervisor. If someone was no longer clinically depressed, it meant loss of revenue. He said the clients would just go somewhere else — which they might. Once he even said, “They’re playing the system; we’re playing them.” He loved to bill Medicaid for services that were no longer needed. He even knowingly let providers bill for a client who had gone to jail, and one who had died.

Medicaid will pay for therapy and medication forever if someone is acutely mentally ill, but the agency cut for therapy is a smaller percentage, and black patients were constantly missing appointments. You can’t bill for services not provided. What the agencies wanted was simpler work, such as “basic skills training.” To qualify as a provider, all you need is a high school diploma and an NPI (National Provider Identifier) number, which is a low-level administrative requirement. Black agency owners got their cousins and friends to qualify, and they milked the system together. Owners also milked providers, sometimes taking as much as an 80/20 cut for services, which was way over Medicaid guidelines.

If a black provider — usually a woman — asked for more money, the black owner would say such things as, “You think yo’ black ass deserves mo’ than what I pay you? Who you think you is? Royalty?” I overheard that conversation many times.

However, “basic skills training,” for example, is time limited for no more than two to three years, and is then supposed to be cut off. Black agencies didn’t follow that rule and kept putting in Medicaid requests until the feds figured out what was happening and eventually closed the agency for what amounts to fraudulent billing.

This was the game the owner of my agency was playing. He was also bipolar and could often be heard screaming at people on the phone, even when women and children were present. I also found out he was having sex parties at his house with his black service providers.

I did have a white client at that agency. Her husband had left her high and dry in Las Vegas — and she hadn’t worked in the 15 years since then. She became addicted to drugs and did some hooking for extra cash. She was interesting to me because, unlike so many of the blacks, she was not born into this; she fell into it. She said she had started taking drugs because when her husband left her with no money, she had no choice but to live in a poor area around blacks, where drug-taking was common.

When she came to us, she was diagnosed with major depression, but she was cooperative, kind, and really wanted to get better. She improved enough to come in as a volunteer once a week, and this turned into a part-time job. Her relations with her family improved.

This woman wanted very badly to get out of her neighborhood. She said blacks called her “white bitch” or “white devil,” but they would knock on her door and ask for food, money, or anything else they needed. She felt hated but needed at the same time. The apartment manager and staff were also black, and she thought they deliberately delayed making repairs to her apartment. It took many years but she finally got out of that bad neighborhood and ended up in a nice suburb with her family.

After a few years, the owner of the agency ran out of “mentally ill” friends and family and needed other clients to exploit, but he did no advertising or community outreach. He called an emergency meeting with Medicaid, where he blew up in a fit of rage. Medicaid shut us down 60 days later. I don’t know what became of him, but he’s lucky if he wasn’t charged with Medicaid fraud.

When the place finally closed, his black staff, with whom I had worked closely for about two years, went through my office and stole things. That included a $3,000 printer that a different agency had given me, food, and clothes that were supposed to be donated to a shelter. They also stole the case for my laptop, a lamp, and even a bowl of candy.

When I moved to a different job, I tried to get white clients to avoid the hassles, but there were hardly any. My first client was a black man with schizophrenia and mild retardation. He had seen his father murder his mother. She was lying in a hospital bed with him at her bedside, and the father burst in and split her head with an axe. I visited him to do an evaluation, but the apartment was a filthy mess, with garbage and food wrappers all over the floor. Other black men were coming in and out and I realized my client had no control over them. They appeared to be squatting in his apartment, which they used for sex. There were homosexual porn videos and lubricants lying around, and a camera mounted on a tripod in front of the bed.

My immediate recommendation was to move him into assisted living — an obvious solution. The agency disagreed, because turning him over to the state or some other entity would mean they could no longer bill for services. Instead, they had him sign paperwork agreeing to make the agency his representative payee (SSDI) and got total control of his finances. This, to me, was a clear fraud and exploitation of both SSDI and the client, whose checks were now being sent directly to the agency. I resigned the following week.

I used to volunteer at places such as Help of Southern Nevada. For a back-to-school event, I saw a black mother sign her two infant children up for three backpacks. I don’t know why infants need backpacks. There were tables with food, and tables where tutors sat and gave out school supplies. The food tables were always cleared out, but the tutors were almost never busy. One year on Thanksgiving, my job was to help recipients write thank-you letters to donors who had given them 12-pound turkeys. Some people — all of them black — were angry that they had to do that. One lady threw a fit, complained that she was tired, and refused to write a letter. She got her turkey anyway, and a nice helping of mashed potatoes.

Sometimes I worked with families. I had a black single mother with three sons, ages 15, seven, and six. The younger children were sweet, but the teenager was defiant and had a chip on his shoulder. When you work with children, it’s important to involve the whole family. Most days, the unemployed mother of three was too high to come down the stairs to let me in the door. Every time I came by, she was either slumped over on the couch or passed out in bed in a medicated stupor.

The teenager, K’veon, had gotten himself kicked out of so many schools the county was threatening to expel him from the entire school system and turn him over to the state. My agency told me to set up a meeting with his principal to tell him about K’veon’s chaotic home life, his diagnosis, and his mental limits — and to ask that he be kept in school. That wasn’t for K’veon’s benefit. If he were turned over to the state, the agency could no longer bill for mental health services that were doing him no good anyway.

I laid K’veon’s options out for him. If he didn’t clean up his act, he would have no education, no skills, and would be poor for the rest of his life. My advice came straight from the heart, but K’veon took it differently. He went home and falsely told his mother I called him the N-word. She reported me for racism. I was written up for this, but I refused to sign the papers, which would have been an admission of guilt. The accusation hurt my reputation around the office.

I worked briefly with homeless military veterans, and thought they might be more mature and honorable. I was wrong. My first client was a black man, and during my intake assessment for him and his four children, I reviewed birth certificates and other documents. I noticed he was glaring at me, but didn’t know why. Later that day, he called my boss and asked for a new case manager. The reason? He said he thought I was judging him because his children had different last names, and I would therefore be culturally incapable of serving him. This happened during my 90-day evaluation period, so I was written up.

This man wanted Linda, a white woman who had been training me, as his new case manager. He got what he wanted. Weeks later, Linda told me the man had made up the complaint about me so he could work her and “that thick white booty.” I told Human Resources about that because I wanted this false blemish removed from my personnel file. HR said sorry, but it had to stay.

A month later, my boss asked me for a favor. A black family under his care was being discharged, and wasn’t happy about it. He wanted me to go deliver bus passes and thank them for their military service. I had never met or talked to this family before in my life. I knocked on the door around noon — in July in Las Vegas — and waited outside in the blistering sun for 20 minutes. Finally, a black woman in pajamas opened the door. Black children were running around in diapers. I got her signature, delivered one month’s worth of bus passes for 10 people, and left. When I got back to the office, I learned the family had called to say I had been rude and insensitive because I did nothing to help with the husband’s cocaine and gambling addictions. I hadn’t been rude. This family was not under my care; I was just doing my boss a favor. They were upset about being discharged after their time in the program was up. And, of course, I got accused of “racism.” I was written up again, but refused to sign,

The frustration was cresting when I met Mike. Mike had gone to Brown University on a full scholarship. He was studying to be a computer engineer but failed to graduate because he was arrested for breaking and entering. For two years, he had been stealing high-end works of art, such as paintings and sculptures. He had made hundreds of thousands of dollars selling the stuff. He got caught and did six years of hard time. When he got out, he did two more stints for breaking parole.

Mike had a primary diagnosis of major depressive disorder and a secondary diagnosis of borderline personality disorder (BPD). Depression was a common diagnosis for “the underserved,” because Medicaid is willing to pay for it. It doesn’t pay to treat personality disorders like BPD, because they can’t be treated with pills, require lots of therapy and — often more to the point — there has to be family involvement. For certain populations, it’s a waste of time to try it.

Mike had three children out of wedlock with two different women and was living with one of the mothers and her two children from other men. When we met, Mike appeared kind, articulate, and willing to work with me. He just needed diapers, new backpacks for the kids, and rides to go see his parole officer. I was not supposed to provide those things, but doing favors can encourage people to cooperate more in treatment, and seeing your parole officer can keep you out of jail.

Mike participated fully in his treatment for the first several months. This included status checks with me, looking for work, and reporting to the parole office. Then one day, his attitude suddenly changed. He started being curt and hung up the phone on me.

He continued to need me and my help, however — so much so that one morning, he called me at 3 a.m. I assumed he was in trouble, but he was just lying in bed with his children, wondering why he was there with them. I was confused. I said, “It’s because you love them, that’s why.” Mike then said he didn’t like his role as a caretaker and was himself abandoned when he was a child. He was afraid it could happen again, and he wasn’t even sure who he was.

Mike had a fear of abandonment, which is common in people with borderline personality disorder. He didn’t like it that as a grown man he was living with his baby-mama who was supporting him. He had an unstable self-image, and with borderlines, that can change quickly. Mike was a criminal, but saw himself as an engineer, a motivational speaker, and even once said he wanted to work for NASA.

In that early-morning conversation, I repeatedly tried to reassure him that things would be okay. He got angry, said I did not understand him culturally, and hung up. I was worried about him. He had a parole meeting coming up soon, but he missed it and was ordered back to prison. I sent Mike a text saying that a warrant was out for his arrest.

He demanded that I get him a lawyer, but I told him that wasn’t my job. However, I could continue as an advocate for him to the judge and parole board. There was no reply. The next day, I woke up to find dozens of pieces of bologna all over my car, and the words “white prick” spraypainted on the trunk. The bologna stuck so tightly to the car that when I peeled it off, the paint came off with it. My car needed a new paint job.

Why did he do that? I had done my best to help him. I reread his case notes and thought more about his secondary diagnosis. Maybe BPD was the primary problem, not major depression. I learned that people with BPD may cling intensely to others for whom they have a great deal of anger and animosity. They also suffer from constant fears of abandonment. And if you let them, they’ll hurt you. There’s a phrase that describes this group’s attitude: “I hate you; don’t ever leave me.” When I read that, a light bulb went off in my mind. That’s exactly how they feel about us. That was the end of my work as a social service provider, and the beginning of my conversion to race realism.

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Postscript: Is the entire system hopelessly corrupt? No, but it is only as good as the people who run it. The system was designed by white people for white people, on the assumption that very few clients would fake mental illness to get benefits, and that very few service providers would bill for unnecessary treatments. There is some policing in the system, but when blacks get involved, there is just too much corruption to police, and it becomes part of the system.

As I noted, there were very few white or even Hispanics clients. There were no doubt some whites who were milking the system, but most were well-meaning and honest. And inevitably, when honest people saw how much money there was in being dishonest, it was easy for them to do the same. What I saw was a perfect example of something set up by and for whites that blacks turned into an expensive wreck.