Compassionate Mental Health Reform Began With Taking Off the Handcuffs
Greg Sturgill had been working as a nurse in Central Appalachia for 15 years when he was diagnosed with bipolar II disorder in 2006.
Sturgill was treated and hospitalized more than once while doctors attempted to balance his medication against pre-existing heart problems. He was startled to learn that his father had also suffered from mental illness and even received electroshock therapy, but had hidden his condition from his children.
Six years later, while working at a Kentucky hospital, Sturgill hit a rough patch in life in which he separated from his wife and his father was diagnosed with severe incurable health problems. He decided to check himself in for treatment. When he returned to work, he saw that the stigma surrounding mental illness remained strong, even among hospital workers.
“I could see a big difference,” Sturgill says. “People stayed away from me. Everyone was afraid of what I was going to do, even though I’d never done anything before.”
Two years later, Sturgill publicly acknowledged his struggles in a column for the Harlan Daily Enterprise. After it ran, his girlfriend ended their relationship. Sturgill later moved from his longtime home of eastern Kentucky across the state line to Wise, Virginia, to be closer to his employer and to escape the ostracization he’d been experiencing.
Today, Sturgill sees a therapist regularly. Finding additional treatment can be challenging, though. Rural health care providers have struggled to remain open. The community hospital in neighboring Lee County closed in 2013. When his therapist recommended he go into a hospital because his heart problems were interfering with his medicine, he was initially told the nearest available placement was three hours away in Knoxville, Tennessee, before a bed was found nearer to his home in a unit with patients much worse off than he was, he says.
Margo Walter, a licensed counselor in Blacksburg who also had struggled with bipolar disorder, says that in rural parts of the state there’s still an uphill push for acceptance of mental illness.
“Stigma is still very much active in the area,” Walter says. “That creates problems with access. You go far enough out in the counties and you’ll find some people still think depression is a sin. We’re trying to fight a couple of battles there.”
Sturgill now is trying to open a new local chapter of the National Alliance on Mental Illness, but so far there’s not been much interest.
“Obviously there’s that stigma,” Sturgill says. “Maybe I’m wrong, but I’m afraid that’s one thing that’s keeping people from coming. It’s more culturally accepted here to be a drug addict than to be mentally ill. If you get addicted, it’s because someone prescribed you something, and if you can come out through rehab to the other side, you’re a champion. But if you struggle with mental illness, you’re just crazy.”
A legislative fix
Experiences like these are what’s driving the state of Virginia to reform its mental health care system. Those efforts have been helped along by a state legislator who knows firsthand how the system can fail the people.
In late 2013, state Sen. Creigh Deeds’ 24-year-old son Gus was detained after a magistrate issued an order of involuntary commitment. When a bed in a psychiatric ward couldn’t be found before the order expired, he returned home with his father to their rural western Virginia farm. The next morning, Gus stabbed his father multiple times in the head and chest before Deeds stumbled out into the road, where he was picked up by a relative who saw him. Gus returned to the house and fatally shot himself.
When Deeds returned to the Virginia Senate in 2014, scars still fresh on his face, he brought a new passion for reforming the state’s mental health system. Lawmakers passed a law in response to Deeds’ 2013 incident that created a registry of open beds for psychiatric placements, extended the amount of time patients could be held while officials looked for an open bed, and required the state to find a so-called “bed of last resort” if no other was available.
The legislature also created a multi-year joint subcommittee to reform the commonwealth’s mental health laws, now informally known as the Deeds Commission.
“I’ve told other people it’s like eating an elephant,” Deeds says. “You take a big bite and feel like you’ve done something, and then you look at what you still have to do. I’m proud of the work we’ve done, but we still have so much to do. It’s bone-crushing.”
Reforms that work
The commission has recommended a steady stream of policy reforms and new programs, which are then considered during Virginia’s legislative session at the start of each year.
One potentially transformative reform was the launch of a program that expands and standardizes what services are offered by Community Services Boards, which make up the backbone of Virginia’s mental health care system. The 40 CSBs located across the state manage the delivery of mental health, developmental, and substance abuse services to people who need them, and used to be available only for nonemergency situations.
A major improvement was the elimination of multi-day waits to see a clinician. Now at 18 CSBs (and soon at all the others), a person who calls or shows up must be seen by a clinician the same day. The policy has greatly increased the rate at which they return for more treatment, says Margaret Nimmo Holland, executive director of Voices for Virginia’s Children.
Another significant improvement is what happens when someone in crisis needs transport to a care provider. This often is something police have to handle. The Deeds Commission obtained funding for crisis intervention training, so they can better respond to people’s mental health crises without escalating the situation.
A newer program provides alternative means of transport for people in crisis so they don’t have to be taken by police. That experience can be degrading or even traumatic for those in crisis and pulls officers off their regular patrols.
“When you handcuff individuals, it criminalizes mental health,” says Sandy Bryant, executive director of the Mount Rogers CSB. “They feel like they’ve done something wrong. They’re already in crisis, so when they have to be put in handcuffs, it increases the trauma and stress. A lot of them talk about how, even if the police officer was gentle and kind, the experience still was traumatizing to them.”
Inspired by a program in North Carolina, Virginia launched a pilot program in 2015 for adults who need to be detained at Mt. Rogers Community Services Board in southwest Virginia. Drivers who transported them wore plain clothes, were unarmed, drove unmarked vehicles, were trained in mental health first aid and crisis intervention, and were prohibited from using restraints. The program lasted 14 months and grew to encompass more than half of all transports in that time.
One of the program’s first participants was a person who had a history of hospitalization and was known to be a challenging patient. When he was transported under the new program, he was reported to be calm and cooperative during the trip. He maintained that demeanor throughout his stay at the institute and was released sooner than in previous visits. According to the report, “he has since utilized alternative transportation a few more times and has remarked at enjoying not being handcuffed or ‘treated liked a criminal,’ not riding in a police car, being able to listen to the radio, and appreciated how the drivers treated him through the process.”
“That program will be a game changer, especially for rural areas,” Deeds says.
The Deeds Commission also launched a program to provide permanent supportive housing for people with serious mental illness. About 5,000 people in Virginia are in this category. These are people who regularly visit CSBs and too often bounce between homelessness, hospitalization, and jail, says Rhonda Thissen, executive director of NAMI Virginia.
The idea comes from an early-2000s housing study in New York City that showed applying a “housing first” model for people with serious mental illness improved their participation in treatment programs, therefore their overall stability.
In the Virginia program, which launched in 2015, the individual chooses their housing—generally an apartment on the open market or in a complex dedicated entirely or partially toward supportive housing—and must abide by the terms of the lease. He or she pays 30 percent of their income, a percentage set as a standard by federal housing laws, toward rent. The program covers the rest.
“Because there’s no immediate expectation that you get housing because you’re a good boy and follow your treatment plan, we’re able to house people and work with them to see benefits of treatment,” Thissen says. “This model is much more successful in working with this population of people.”
The program was expanded this year when lawmakers approved a budget that for the first time included the expansion of Medicaid to cover more lower-income people. With the federal government now covering 90 percent or more of the cost, expanding Medicaid frees up state money for other services. The previous high-water mark for spending on mental health in Virginia was $42 million in 2008, approved the year after the mass shooting at Virginia Tech but before the Great Recession. The 2018 budget includes more than twice that, totaling $84.1 million for community mental health services.
One of the biggest challenges for the Deeds Commission going forward will be to rework the 2014 law that requires the state to provide a “bed of last resort” for individuals who need psychiatric placements. The law is an attempt to prevent the situation that led to Gus Deeds returning home with his father in 2013 instead of receiving treatment, but one unintended consequence has been overcrowding in state hospitals.
“Some are running from 95 to over 100 percent of capacity. Best practice is you should average no more than 85 percent,” Thissen says. “This is not sustainable, not good for patients or staff.”
Deeds says he recognizes the problem but wants to find a solution that leaves the “bed of last resort” requirement intact. The alternative transport program might provide one key for doing so. Currently, Virginia is among the states that has the shortest mandated period in which people can be held against their will for an initial evaluation, Deeds says, partly to limit the amount of time that an accompanying law enforcement officer is pulled off patrol. If the alternative transport program reduces the need for police involvement, the window of time that a person can be held might be extended, which allows more time potentially both for that person to stabilize and for officials to find an open bed in a private facility.
These sorts of issues are part of the reason why the Deeds Commission has been extended for another two years. Ultimately, however, Deeds wants to make it permanent.
“It seems to me that if you really want to reduce stigma, you’d put this with other health-related issues,” Deeds says. “Our commission had built up some expertise around mental health and ought to be allowed to continue to work on this.”