State Of Mind: Community Mental Health: Bearing the Burden
In a special series of reports, VPR is examining Vermont's mental health system: where it works and where it doesn't.
Previously, we examined the state's plan for the new state hospital and acute care facilities. The new system has fewer beds for the most severely ill patients than it did when the old state hospital in Waterbury was in service.
The only way that will work is if community mental health centers and private providers are able to prevent people from going in to crisis to begin with.
But mental health centers around Vermont are already feeling overburdened and underfunded.
Nonetheless, they say they're trying to connect with people who need help beyond traditional therapy.
Finding The Right Support
Sitting at the dining room table in her sunlit Burlington house, Paige Corologos looks back on a painful time in her life. She says she was 14 years old when she was raped. She told no one about the rape, but when she tried to commit suicide, her mother took her to their local doctor.
"I always wondered why I didn't go to the hospital. And I think that it was out of, I think my mother was just afraid of the neighbors finding out that this was happening in her home and with her daughter, her special daughter. That was very common back then."
Now a mental health advocate, Corologos believes that the rape triggered her bipolar disorder, which she has struggled with ever since.
"It was very secret and very traumatic and very hard to hold. But, gosh, when you're 14 and that sort of thing happens and you're so embarrassed and ashamed, you blame yourself. I just held it in and it made me sick."
Corologos says there is a history of mental illness in her family. Her great-grandmother had a severe case of bipolar disorder, but it wasn't something the family talked about.
Over the years, Corologos attempted suicide several times. She was hospitalized frequently and underwent electroshock therapy, which she says wasn't effective in treating her disorder but resulted in significant memory loss.
But now Corologos is stable. And happy, she says. She's on medication to control her anxiety, depression, and mood swings. And she sees a private psychiatrist twice a month who she trusts deeply.
"I have to pay her out of pocket," Corologos says, "because she just can't afford to take insurance. I understand that and I want her and she apparently wants me enough to let me do that." She pays a discounted rate of $50 per session.
Corologos is unable to work a regular job because of her disorder but she has a lot of volunteer positions at nonprofits around the city. And she gets social security and disability to help cover her bills.
When she starts to feel like her ordered life is slipping, she turns to a program called ASSIST.
"It's a wonderful place. It's simply a house where you can go to for a short period of time and it gives you a breather from the stressors in your life."
Corologos hasn't felt the need to use the program for a number of years, but she says she took advantage of its availability half a dozen times in the past.
"And that's kept me out of the hospital many a time. I would stay three or four nights, get my act together in my head, and talk to their people and just be there and do art therapy, which I love, and it was a good place for me to calm down and get myself back together so I could come home."
Dr. Sandra Steingard is the medical director at the Howard Center, which runs this six-bed crisis stabilization and hospital diversion program.
"Going into the hospital, although it may give solace and comfort, it's also very disruptive," she explains. "So ASSIST is just a little less disruptive. If you're at ASSIST and you're a student, if it's all safe and everything, you can go to school. Or you can go to your job. It's just a lot easier for people to be easier to visit. You can go outside. It's just much lower stress."
ASSIST is one example of the kind of step-down treatment facility that Governor Shumlin is hoping will help ease the need for more beds at the new State Hospital.
These kinds of programs are often run by what are known as designated agencies. Howard Center is the designated agency in Chittenden County. These private non-profit centers receive state and federal dollars, and they're required to administer mental health services to people in need. In addition to mental health, they also deal with developmental disabilities, child services, and substance abuse.
Designated agencies cropped up around the country in the early 1960s as part of the deinstitutionalization movement. State hospitals, like Vermont's, often held a thousand patients or more. People with mental illnesses were sometimes warehoused, living in these massive facilities for years, or even decades.
"Deinstitutionalization came through and community mental health says 'okay, we can do that.'" Psychologist Peter Lebenbaum spent three decades working at Counseling Service of Addison County, one of Vermont's 10 designated agencies. He explains that the deinstitutionalization movement began with the Community Mental Health Act, signed by President John F. Kennedy 50 years ago. It shifting federal dollars into local non-profit services with the idea that community institutions would be better at providing mental health care than state governments.
"And so the state hospitals were emptied," Lebenbaum goes on. "That population still had a mandated right to treatment. But that treatment became community wraparound treatment. The money that went to the state hospital was diverted so you could hire case managers and there'd be a psychiatrist available and an emergency team available and all of those ancillary services."
Vermont's designated agencies now serve more than 25,000 people per year for mental health issues. In fact, most of the Vermont Department of Mental Health's nearly $200 million budget goes to fund these agencies, primarily through money from the federal government, in Medicaid funds.
Redirecting State Funds
Since the closure of the Vermont State Hospital, some of the money that used to go to that facility has been funneled into the agencies, to bolster community care.
Frank Reed is Deputy Secretary of the Department of Mental Health. He says "with the closure of the hospital, there was the opportunity to use those same funds to then provide Medicaid-reimbursable services in the community in the form of crisis stabilization programs, the intensive residential recovery programs, peer support programs, opportunities for outreach in our emergency services and collaborations with law enforcement."
The state urged designated agencies to use that new money in innovative new ways. Dr. Steingard says the Howard Center used some of that money to create a program called START. This program operates by going to people and families struggling with mental illness, rather than waiting for them to come to the center.
The START team is staffed by people who have battled mental illness and found stability.
"So if someone is hearing a lot of voices and doesn't know how to manage or doesn't know whether there will ever be a side," Steingard explains, "to sit with another person who has gone through this and has been able to weather the storm and pull his life together and shows it, it's better than words. It's a really powerful thing!" Steingard credits the START program with helping its clients avoid hospitalization.
Even with added state dollars, the designated agencies struggle to serve their communities.
Designated agencies work on what they call a zero-reject model, meaning they have to serve everyone who walks through their doors, regardless of insurance coverage or ability to pay. But that doesn't mean people always get help right away.
Eric Grims is the executive director of Northeast Kingdom Human Services. This designated agency serves all three Northeast Kingdom counties, and treats about 2800 people a year for mental health services. He says that at his agency, the wait time to get an appointment for counseling is up to two months. If people aren't seen right away, Grims says they often don't make it to their scheduled appointment two months later.
"What it does mean is people fall off the map. And they're not seen."
Grims says he can't just hire more therapists, social workers, and psychiatrists to handle the number of people who walk through their doors asking for help because Medicaid dollars are capped.
"Parity's a myth, as far as I'm concerned. We don't see it here. Eighty-five percent of our business is Medicaid."
Grims says that means the people on his staff face enormous caseload pressure, and they just can't keep up.
"And that's a serious issue for us because people aren't getting care. We're spread very thin. But, that's the kind of care you need to avoid hospitalizations or more serious care"—the exact scenario the state's new focus on community care is designed to avoid.
According to the Department of Mental Health, more people have been using the outpatient services of the designated agencies in the last few years, and the pressure just increases.
In the Northeast Kingdom, director of outpatient services Gail Middlebrook says some things are hard to overcome.
"We're so rural. And we have the highest rate of poverty and the lowest per capita income. So I think we have real needs and we don't have the resources."
The state says the additional funding directed to the designated agencies post-Irene will continue once the new state hospital is built. But even now, Vermont's 10 mental health agencies struggle with oversized case loads, long wait times, and populations with major health and stability problems.
The challenge will be finding more innovative ways to catch people before they hit a crisis stage, and to do it with limited funds. Given that the whole system of mental health care in Vermont rests on the shoulders of these designated agencies, that challenge is crucial to the health of the state, and a very difficult one to overcome.