In my last column, we looked at the critically important topic of mental and behavioral health and major efforts at the state level to improve Virginia’s public behavioral health system. Counties across Virginia recognize the importance of mental health care in building strong, vibrant communities and have worked hard to provide needed services and promote public awareness about this vital issue.
Access to Mental Health Treatment
Access to mental and behavioral health services is a major challenge across the country. Mental Health America’s The State of Mental Health in America 2018 report noted that although 18 percent of Americans had a mental health condition, 56 percent of American adults with a mental illness did not receive treatment. Virginia ranked 42nd among the states in access to care (a measure based on factors such as access to insurance, quality and cost of insurance, access to treatment, and workforce availability). The report estimates that 53 percent of Virginians with any mental illness received no treatment. Several major efforts to address structural factors contributing to this situation have been undertaken in recent years, such as federal legislation that generally requires parity between insurers’ coverage of mental health and substance abuse services and coverage of other medical care, and the state’s STEP-Virginia plan, which will phase in a standard menu of services at all Community Services Boards over the next several years. Local governments provide critical financial support to CSBs, as well as in-kind support such as contributions of space or equipment.
In implementing same-day access to assessments, Chesterfield County’s Community Services Board (CSB) focused on an important individual factor that might discourage residents from seeking care – lengthy waits for an initial appointment. An individual seeking services from the CSB may have already exhausted other options, and by the time he or she arrived at the CSB could be approaching crisis, only to be asked to return in two to four weeks. CSB staff worked extensively to redesign their internal processes to enable more immediate access to intake and assessment, successfully eliminating the wait list in the clinical division. Staff documented a significant improvement in clients’ willingness to follow through with requests for appointments after implementing same-day access: prior to implementing the program, 55 percent of adult mental health clients followed through with appointments; afterwards, 76 percent did. As part of STEP-Virginia, all CSBs will offer same-day access by July 1, 2019.
Addressing Mental Health Needs in the Criminal Justice System
Meeting the treatment needs of individuals with mental illness who are involved in the criminal justice system is a major challenge for localities. A recent report by the Department of Behavioral Health and Developmental Services (DBHDS), citing statistics compiled by the Compensation Board, reported that an estimated 17.63 percent of the jail population in Virginia in June 2017 suffered from some form of mental illness, with 9.55 percent experiencing serious mental illness. The vast majority of funding for mental health services in jails – 76 percent — is supplied by local governments, according to the same DBHDS report. There is a growing consensus that diverting nonviolent individuals with serious mental illness away from the criminal justice system, to the extent possible, is a better model; jails were never intended to be primary mental health treatment facilities and recidivism among individuals with mental illness is high, particularly for individuals with co-occurring mental illness and substance use disorders.
Rockingham County began intensive planning efforts to reduce the number of inmates with serious mental illness in its regional jail in 2012. Working with the City of Harrisonburg and community stakeholders, Rockingham County established an array of options for individuals with mental illness who are involved with the criminal justice system, including a Crisis Intervention Team training program for local law enforcement, additional mental health services at the regional jail, a crisis intervention team assessment center at the local acute care hospital, and a day reporting center to prevent recidivism. Rockingham County’s Mobile Crisis Unit documented an increase in its new client contacts and in following up with released inmates this year; CIT Coordinator Kelly Royston cited a drop in referrals from the regional jail as a positive sign, noting, “We have been following up with more [released inmates] and keeping them out of the judicial system.” She also pointed to an increase in court services and law enforcement requests for Mobile Crisis services as indicators of success; she said, “We are getting [individuals in crisis] to the resources they need before ever getting to the jail.”
Fairfax County launched its Diversion First effort in 2016 after extensive preparation with a large group of stakeholders. The program follows a “sequential intercept” model, in which there are opportunities to prevent individuals from entering the criminal justice system, or to avoid deeper involvement with the system, at specific points of interaction with the system (for example, at first contact with law enforcement who are called for a situation involving trespassing or disorderly conduct). Fairfax County initially focused on that first point of contact with law enforcement, and has since expanded to the individual’s involvement with the court system, jails, and re-entry after incarceration. The concept of “Intercept Zero” was introduced nationally in 2017, as Fairfax County’s 2017 report on Diversion First points out, and involves a focus on prevention by helping increase community members’ awareness of how to help community members who might need additional supports so as to avoid experiencing a mental health crisis. Mental Health First Aid training for community members provides tools to assist in this process. Chairman Sharon Bulova wrote in the 2017 report, “Thanks to incredible cross-collaboration between our public safety personnel and health and human services staff, 778 people have been successfully diverted since the program began.”
Both Fairfax County and Rockingham County, along with Loudoun and Arlington Counties, are participants in NACo’s Stepping Up initiative, which seeks to reduce the numbers of individuals with mental illness in jails. Extensive resources are available through NACo’s Stepping Up website.
Access to Substance Abuse Treatment
The toll of substance abuse in Virginia is high, with 1,227 Virginians succumbing to opioid overdoses in 2017 and an estimated 16.3 percent of adults identified as binge drinking in 2015 (defined as the percentage of adults who had five or more drinks or four or more drinks, for men and women, respectively, in the last 30 days). Making treatment available to individuals recovering from addiction is critical, but can be a challenge, especially in rural areas. Caroline County developed an innovative public-private partnership with a nonprofit based in Richmond that specializes in recovery programs; because the Richmond-based programming was too far away for Caroline residents to reach on a regular basis – especially for residents without access to a car – Caroline County, working with the McShin Foundation and the Commonwealth’s Attorney’s Office, established the Caroline County Recovery Community Center Program in 2011. The program, which relies on peers in recovery to support participants, may be used as a diversion option for some criminal defendants, and it has had impressive success in reducing recidivism among participants.
One barrier for women seeking treatment for addiction is the possibility of separation from their children if they enter residential substance abuse treatment. To address that problem, Albemarle County, working in partnership with the City of Charlottesville, is providing critical financial support to the new Women’s Center at Moore’s Creek, which is operated by the Region Ten Community Services Board and will allow women to bring their young children with them while they undergo treatment. The facility will provide essential treatment options for women; it is the only women’s treatment center providing residential substance abuse treatment within a 50-mile radius.
Many communities are working to increase community awareness about mental health treatment options and to reduce stigma associated with mental health conditions. Mental Health First Aid, a course that helps everyday citizens learn how to help others who may be experiencing a behavioral health issue, is offered through many Community Services Boards. Similar to learning basic first aid and CPR, learning how to connect fellow citizens with the appropriate care to address their mental health needs can be an empowering experience.
Knowing what to say when you suspect someone may be having suicidal thoughts is another important element in improving communities’ awareness of mental health needs. Fairfax County’s extensive Suicide Prevention Information and Resources webpage provides excellent community resources, including resources tailored to the needs of older adults and youth. Chesterfield County’s suicide awareness and prevention resources include a resource booklet providing information about warning signs and community resources. Community activities such as 5K races or walks also help raise awareness about the issue and help to reduce stigma; the Middle Peninsula-Northern Neck CSB, working with the Middle Peninsula-Northern Neck Suicide Prevention Task Force, organized Suicide Prevention Awareness Walks in Lancaster County and in Gloucester County last fall.
In my last column, I discussed some of the research surrounding the long-lasting effects of childhood trauma – Adverse Childhood Experiences – on health outcomes for adults. The consequences of intense childhood stress can be severe, but research is also focusing on ways to build resilience, by reducing the effects of trauma and helping children and adults heal. Virginia’s Secretary of Health and Human Resources has been directed to convene a workgroup to improve how agencies in the secretariat address childhood trauma, and many communities across Virginia are already working to understand and mitigate the impact of childhood trauma. The Roanoke Valley Trauma-Informed Community Network Initiative is one of those efforts. The Initiative, which was recently formed, is led by Juvenile and Domestic Relations Court Judge Frank Rogers and Janice Dinkins-Davidson of the Children’s Trust Roanoke Valley, and includes work with local child welfare and foster care social workers, juvenile court staff, and guardians ad litem. Participants are working on specific aspects of building community resilience, such as mental health and education, and often looking at their approach to their own work in a different light. Ben Jones, Supervisor for Foster Care, Adoptions, and Resources at the Roanoke County Department of Social Services, wrote in an email, “The effort to raise awareness of the pervasiveness of complex trauma in the families we work with, as well as our own trauma histories, has helped reframe our discussions of treatment from pathologizing the effects of trauma to increased empathy and understanding.”
I am excited to learn from all these communities as their work continues. Next month, we’ll be looking at early childhood and how investments in our youngest residents can reap dividends in healthier communities in the future.