What Most Mental Health Agencies Don’t Want You to Know
A Field-Level Exposé from Inside the System
I didn’t write this lightly. And I didn’t write it fast.
Because what I’m about to describe isn’t a bad week at work. It’s a pattern I personally witnessed across multiple behavioral health agencies in Arizona—under different job titles, different leadership, and with the same sickening results.
You’re not going to find this in a marketing brochure. You’re not supposed to.
Let’s Start with the Crisis Response Model
As part of earning college credits toward my bachelor’s degree, I worked as a contracted mobile crisis therapist, trained to respond to people in acute distress—suicidal episodes, psychotic breaks, domestic violence, child abuse, overdose calls, and more. I was frequently dispatched to police calls, responding directly alongside law enforcement in the streets. That meant riding in patrol cars, entering homes after domestic violence incidents, assessing individuals in parking lots, sidewalks, jails, or gas stations—wherever the crisis unfolded. My job was to de-escalate the situation, assess risk, and determine whether someone needed psychiatric hospitalization, medical care, or could safely remain in the community. It was high-stakes, unpredictable, and often emotionally volatile.
But once the immediate crisis was stabilized, there was pressure—mostly from individual supervisors—to push clients toward long-term outpatient therapy, even when those clients showed no interest or consented reluctantly.
I can’t speak to official policy, but this was a pattern I observed repeatedly across multiple agencies during my time in crisis response.
The reasoning was simple: ongoing care meant ongoing billable hours, and without formal outpatient enrollment, Medicaid wouldn’t reimburse the follow-up.
That may not sound sinister to someone outside the field. But let me say it plainly:
forcing someone into therapy they didn’t choose isn’t healthcare.
It’s revenue protection with a clinical mask.
I refused. I wasn’t going to coerce someone into outpatient sessions so the agency could check a box and send an invoice.
Eventually, I started getting fewer hours. I got the message. I left.
Then Came the Caseload No One Could Manage
As part of my master’s degree practicum, I took on a role as a clinical liaison working with adults diagnosed with serious and persistent mental illness. That contract came with another impossible standard: each liaison was expected to see a caseload of approximately 175 clients face-to-face every single week.
Most of these clients were:
– Transient
– Homeless
– Cycling through jail, rehab, or hospitalization
– Or completely unreachable due to disconnected numbers and no fixed address
On top of that, there was drive time, paperwork, required check-ins, and sudden “urgent” visits for new crisis situations. The math didn’t work. Not even close.
Everyone knew it. No one said it.
Liaisons were judged on volume, not quality. If you couldn’t hit the number, you were told to “catch up.” But you couldn’t. And most of us burned out trying.
Then the Audit Prep Happened
One day, word came down: the state was coming to audit the clinical files.
And somehow the clinical director at the time already knew it was coming.
Audits were supposed to be unannounced. That was the whole point. To this day, I don’t know how she found out. But what followed was frantic, coordinated, and anything but honest.
You’d think that kind of news would spark reflection. A chance to review records, correct gaps, maybe improve care.
But no.
That’s not what happened.
And because the charts were audited at random, nobody knew which ones they were going to choose. So, the clinical director told case managers to look into every client file—not just their own—and “fill in whatever blanks are missing context.”
Translation:
If a session wasn’t documented, fake it.
If a required field was missing, make something up.
If a note looked light on detail, stretch it.
Didn’t see the client? Didn’t matter.
Wasn’t your case? Still didn’t matter.
The goal wasn’t accuracy.
The goal was to make the records look clean.
They didn’t care if the client hadn’t been seen in months.
They didn’t care if the case manager had never met the person whose file they were updating.
They didn’t care if one CM rewrote another’s notes on a case they knew nothing about.
As long as the documentation hit the checklist, no one asked questions.
They didn’t want real care—they wanted audit compliance.
And they were willing to manufacture it if they had to.
I lived near the clinic. I drove by and saw the file rooms lights still lit up at 1:00 AM. Case managers inside, retrofitting notes into files they never worked on. Rebuilding timelines. Creating sessions that never happened—just to make it all appear “complete.”
That’s not catching up.
That’s fraud. It’s federally illegal under Medicaid billing laws and HIPAA.
And it’s not just unethical.
I refused to participate.
And that was the moment I decided to change my PhD from Forensic Psychology to Applied Ethics.
Because what I saw wasn’t bad management.
It wasn’t burnout.
It wasn’t just a broken system.
It was calculated dishonesty—dressed up as mental health care.
Later, As a Clinical Director
After earning my PhD, I eventually became the clinical director of a trauma clinic. And this time, I did it differently. I worked directly with state compliance auditors—no midnight scrambles, no fabricated documentation, no bending the rules for billable hours. We followed the law, respected the client, and did real trauma work.
At the same time, I worked with private therapy clients and I never accepted insurance. People would ask why. I told them the truth.
Why This Matters
If you think this is a localized story—something that only happens in Arizona, or only happened years ago—you’d be wrong.
These practices are still happening.
Across the country.
In agencies that preach mental health awareness on Instagram or YouTube, while pressuring their staff to hit numbers that require corner-cutting to survive.
I know this because other professionals have quietly told me the same things. But most of them won’t go public. The risk is too high. The NDAs are too strict. The retaliation is too real.
But I’ve been around too long—and seen too much—not to say it now.
Disclaimer: the events described in this article reflect my personal experience as a contracted clinician working across multiple Arizona behavioral health agencies in decades ago. These accounts are based on memory and are shared as a matter of public interest and ethical concern. I no longer have access to contemporaneous records or direct witnesses from that time, and no accusation is intended beyond my firsthand perspective of the workplace practices I observed.
Sources That Don’t Suck:
Office of Inspector General (OIG), HHS. Medicaid Fraud and Abuse. https://oig.hhs.gov
Arizona Health Care Cost Containment System (AHCCCS). Behavioral Health Fraud Waste and Abuse Reporting. https://azahcccs.gov
U.S. Government Accountability Office. (2022). Behavioral Health: Available Information on Behavioral Health Treatment Use and Insurance Coverage. https://www.gao.gov/products/gao-22-104597
National Association of Medicaid Directors (NAMD). Protecting the Integrity of Medicaid. https://medicaiddirectors.org
Center for Health Journalism. When Billing Drives Care. https://centerforhealthjournalism.org