Advocates say the fix for Virginia’s broken mental health care system isn’t necessarily more beds

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Mapping mental health care: Governor McDonnell’s proposed budget expansion includes millions over the course of two years for two highly regarded community-based mental health care programs: Crisis Intervention Teams, which consist of police officers trained to defuse mental health crises and steer patients to the care they need, and Program of Assertive Community Treatment, or PACTs, outpatient care networks designed to keep the severely mentally ill out of hospitals.

Large swaths of Virginia lack access to either program, but the Charlottesville area is among the regions in Virginia with both—and advocates say building up such programs is the best way to keep people healthy and help them avoid costly, restrictive hospital stays. Mapping mental health care: Governor McDonnell’s proposed budget expansion includes millions over the course of two years for two highly regarded community-based mental health care programs: Crisis Intervention Teams, which consist of police officers trained to defuse mental health crises and steer patients to the care they need, and Program of Assertive Community Treatment, or PACTs, outpatient care networks designed to keep the severely mentally ill out of hospitals. Large swaths of Virginia lack access to either program, but the Charlottesville area is among the regions in Virginia with both—and advocates say building up such programs is the best way to keep people healthy and help them avoid costly, restrictive hospital stays.

A month ago this week, State Senator Creigh Deeds was critically wounded when his son Gus attacked him with a knife outside their Bath County home. Deeds survived, but his son shot himself before police arrived and died on the scene. Anger was added to shock and grief in Deeds’ district and beyond when news reports revealed Gus’ family had sought to have him involuntarily committed for treatment for bipolar disorder the day before the attack, but were ultimately turned away when their local community services board failed to find him a psychiatric bed before they were legally required to release him.

Now, three weeks before it’s set to begin, a Deeds staffer has confirmed that the senator will return to Richmond for the 2014 legislative session, and nearly 5,000 people have added their names to the MoveOn.org petition “Stand with Creigh Deeds” calling for bipartisan reform of Virginia’s mental health system. Outgoing Republican Governor Bob McDonnell, who won the seat over Deeds in 2009, didn’t wait for the legislature to take up the issue. His budget proposal for the upcoming fiscal year includes $38 million to expand crisis care and treatment.

Mental health care advocates in Charlottesville and Richmond are greeting the announcement with optimism cut with a healthy dose of caution. They’ve been here before—an influx of more than $40 million for mental health services allocated in the wake of the Virginia Tech shootings in 2007 evaporated when the economy tanked the following year. And some worry the massive focus on psych ward capacity that followed the Deeds tragedy will distract from what they say is the real need in Virginia: more community-based care.

“There are pieces of the governor’s proposal that are heartening, and there are pieces you just have to shake your head about,” said Colleen Miller, executive director of the Disability Law Center of Virginia (dLCV), a private nonprofit group that until October 1 of this year operated as a state agency, the Virginia Office for Protection and Advocacy. The day after the governor’s funding announcement, the group issued a seven-page report titled “Broken Promises: The Failure of Mental Health Services in Virginia.”

The report’s key claim is a point Miller said the governor’s budget proposal overlooks: that rather than more psychiatric beds, Virginia needs more outpatient programs to keep mentally ill people out of hospitals in the first place, and help them transition back into the community after release. The dLCV report cites state Department of Behavioral Health and Developmental Services data that shows 133 of the patients currently being held in state hospitals for mental health treatment—almost 10 percent of of the statewide total—are there despite their doctors agreeing they longer need inpatient care.

And that means Miller takes issue with a state budget that puts almost $16 million toward expanded inpatient care, and only $13 million toward programs designed to keep mentally ill people out of hospitals. The state’s own discharge studies show the cost of treating people in psych wards is five times higher than treating them without having them committed.

“I would invest all of it in the community,” Miller said. “Why we’d want to invest a lot of money into increased bed space instead of more money to outpatient services is baffling to me.”

Robert Johnson, executive director of Region Ten, said there are other good reasons to treat hospitals as a last resort.

“Stigma intensifies the greater the level of confinement,” Johnson said, and that makes it harder for those with mental illness to return to normal life. People wear their time since their last hospitalization like a badge of honor. “It’s a big deal to have an anniversary of three, five, or more years.”

Layers of care

How do you keep someone with severe mental illness healthy enough to avoid hospitalization? Advocates say the best way is with an integrated network of related services—and Charlottesville is an example of how such a network can work well.

The city is at the center of a region with a comparatively enviable slate of outpatient community mental health programs anchored by Region Ten. A Wellness Recovery Center offers 14 beds and a seven-day therapy program for people on the brink of crisis. Some housing is available for those transitioning to living on their own. A Program of Assertive Community Treatment, or PACT, acts as a one-stop shop for those at high risk for hospitalization—a familiar team of caregivers managing meds and other treatments for some 80 individuals. Police officers extensively trained in recognizing and defusing mental health emergencies make up a local Crisis Intervention Team (CIT).

These programs “are designed to help the most fragile individuals in the mental health system who are at the greatest risk of being rehospitalized,” said Johnson.

The programs exist elsewhere in the state, but few municipalities have access to so many. PACTs have been established in only half the state’s service regions, for instance. Only a little more than a third of Virginia municipalities have put police officers through CIT training.

Mapping mental health care: Governor McDonnell’s proposed budget expansion includes millions over the course of two years for two highly regarded community-based mental health care programs: Crisis Intervention Teams, which consist of police officers trained to defuse mental health crises and steer patients to the care they need, and Program of Assertive Community Treatment, or PACTs, outpatient care networks designed to keep the severely mentally ill out of hospitals. Large swaths of Virginia lack access to either program, but the Charlottesville area is among the regions in Virginia with both—and advocates say building up such programs is the best way to keep people healthy and help them avoid costly, restrictive hospital stays.
Mapping mental health care: Governor McDonnell’s proposed budget expansion includes millions over the course of two years for two highly regarded community-based mental health care programs: Crisis Intervention Teams, which consist of police officers trained to defuse mental health crises and steer patients to the care they need, and Program of Assertive Community Treatment, or PACTs, outpatient care networks designed to keep the severely mentally ill out of hospitals.
Large swaths of Virginia lack access to either program, but the Charlottesville area is among the regions in Virginia with both—and advocates say building up such programs is the best way to keep people healthy and help them avoid costly, restrictive hospital stays.

For Gail McDermott’s family, the access to community support in Charlottesville has made a big difference. McDermott’s son, whom she asked C-VILLE not to name, suffered a break 12 years ago, when he was a bright 20-year-old sophomore studying graphic design at VCU. It was the first sign of the schizophrenia that would develop and worsen over the course of the next decade.

“We would get phone calls in the middle of the night, and he would be talking about things that weren’t reality-based,” she said. “He would say things about his best friend, how he had to breathe into his lungs. My husband and I thought maybe he was experimenting with drugs.”

Eventually, they grew alarmed, and got him to a doctor, who told them their son was highly psychotic and needed to be hospitalized. McDermott has vivid memories of the weekend they got him committed in Charlottesville. As her husband struggled unaided by social services to figure out how to get a judge to agree to the Temporary Detention Order required to force him into care, their son was by turns lucid and lost.

“He had no awareness of his body,” McDermott said, remembering an effort to cross a city street. “He was clutching this book that seemed to be very important to him, and he had no awareness of cars. He was completely in another universe.”

He was treated at UVA Medical Center—the first of a number of hospitalizations over the years. For a time, he lived at a private care community in Massachusetts, but today, he makes his home in Charlottesville, and through his experience, McDermott has seen local community care improve.

It’s far from perfect—she said Region Ten staff have heavy caseloads, and newcomers to the area sometimes have to wait months to be accepted into programs. But her son is in supportive housing, and his medical treatment is carefully monitored. Once, when he was walking up Route 29 in winter without a coat, an officer with CIT training stopped and got him safely home.

Still, she sees how people without the kind of family support her son has struggle. More money isn’t going to be an automatic fix, she said. There are no easy answers to treating people with serious mental illness.

“It’s not like cancer, where you can put your finger on it, and look at strides that are made in research and measure and quantify them,” she said. “It’s like a stepchild that nobody wants to think about or deal with. Things get cut.”

Action, or reaction?

McDonnell’s proposed budget would provide funding to expand several of the programs available in the Charlottesville area, bringing them to underserved parts of the state. PACT programs would get $2.9 million over two years. Another $5.4 million will go to new CIT assessment centers. Other community-based efforts that would get millions more in funding over the next two years include programs tailored for teens and young adults, telecommunications equipment that will allow for more offsite patient evaluations, and peer support groups.

But a larger portion of the money would go toward expanding capacity at hospitals that can hold patients involuntarily—something that Miller said shouldn’t be the state’s top priority. She said it’s not clear just how far the rest of the money will go.

“The question I don’t know the answer to is whether it’s anything even close to enough,” said Miller.

For those who have long pushed for more funding to shore up the public mental health system in the Commonwealth, celebrating steps forward isn’t easy.

“It’s frustrating, but it’s more heartbreaking,” said Bonnie Neighbour, executive director of the Virginia Organization of Consumers Asserting Leadership, a peer support organization for people receiving mental health care with its main offices in Charlottesville.

Frustrating because the fact that the media attention and the money only seem to come in the wake of violent tragedy makes it harder to break down the stigma around mental illness, and shrouds what Neighbour wants people to remember: that it affects as many as one in four people, the vast majority of whom are nonviolent.

“When something public happens like this, people get hold of it and start chewing on it, and often people become afraid to seek out services,” Neighbour said. “They don’t want to be connected to that at all.”

It’s also heartbreaking because it’s a reminder, she said, of the suffering that happens quietly every day. Neighbour lost a friend to suicide on April 19, 2006, exactly a year before the massacre at Virginia Tech.

“There was no public uproar,” she said. “There was not an expansion of funds for preventative services.”

Mary Ann Bergeron is head of the Virginia Association of Community Service Boards, the umbrella agency that oversees the state’s regional mental health care hubs—including the Rockbridge Area Community Services Board, whose failure to find a psych bed for Gus Deeds last month is the subject of two state investigations. Bergeron joined McDonnell when he announced the funding expansion at a press conference last week, and praised both the outgoing governor and the soon-to-be-inaugurated Terry McAuliffe, who has pledged to make mental health care funding a top priority.

But she, too, expressed some frustration at the pattern of attention.

“None of these things are new,” Bergeron said. CSB staff around the state, who work on the front lines of the public mental health system, have for years argued in favor of exactly the expansions announced last week. “The two-hour extension has been brought up before. The 72-hour TDO has been brought up before. All the treatment strategies that have been outlined already exist. They don’t exist to the capacity we need them, and they don’t exist as they should in a number of parts of the state”—but they offer a framework, a proven model.

There’s a sense now that political will is once again catching up with need, but Bergeron acknowledged that the budget expansion isn’t enough to fund what she wants to see: crisis intervention teams working in every service area in Virginia.

“It builds on what has been successful already, and it expands it to more localities,” she said. “But we need to do more, and it’s going to take additional funding.”

  • John Jones, Virginia Sheriffs’

    There was no mention of the 6.000 plus mentally ill that are currently housed in Virginia’s jail. over 3,500 of which are seriously mentally ill. There is a critical need for beds to get people out of jails that are mentally ill and that does necessarily require more beds.

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