Critics urge reform of state’s mental health system

ADDISON COUNTY — Mental health care professionals around the state say Vermont’s mental health system is overburdened, and that too often the mentally ill end up in the state corrections system.
Nearly half of all inmates at Vermont prisons seek mental health treatment, making the Department of Corrections likely the largest mental health care provider in the state.
Mental health care providers, including the Counseling Service of Addison County, are working on ways to keep the mentally ill out of the corrections system and other treatment centers of last resort like hospital emergency rooms.
Ed Paquin, executive director of Disability Rights Vermont, a statewide nonprofit that advocates on behalf of people with disabilities and mental health issues, said about a third of the work the organization does deals with the mentally ill.
Paquin said it is because many Vermonters do not have health insurance that much of the mental health treatment in Vermont is done by community mental health centers, like the Counseling Service of Addison County in Middlebury.
Even at local mental health centers, intensive treatment can be hard to come by.
“In the community mental health system, to quality for major long-term support, it’s unlikely that you’ll qualify unless you’ve had several major qualifications,” Paquin said. “You have to be near destitute to qualify for Medicaid.”
Paquin said inpatient care at community mental health centers and hospitals are “resources of last resort,” but mentally ill patients often end up there because of lack of access to outpatient care.
“Community mental health centers have outpatient programs, but standing funding for the outpatient programs has not kept pace,” Paquin said.
Paquin said the Legislature’s reluctance to raise taxes has resulted in this growing funding gap.
“States are financially limited and don’t want to raise taxes,” Paquin said. “Given the political choice we’ve made as a society, our state finance system is thin at a number of levels.”
CSAC Executive Director Bob Thorn said many people are currently on waiting lists for care, but this is nothing new.
“We have a waiting list for a number of our services,” Thorn said. “I’ve been here 30 years and I don’t remember a time we didn’t have a waitlist for our outpatient programs.”
Since there is no prison in Addison County, Thorn said CSAC does not administer any corrections-related programs, but does treat people who have come into contact with the corrections system.
Thorn said the professional staff at CSAC focus on treating patients before they end up in jail, and getting them into treatment programs when they return to society.
“We ask ourselves, ‘what can we do to keep them from going into those facilities, and what can we do to keep them from going back once they’re out,’” Thorn said.
Thorn acknowledged that there are gaps in the state’s current framework of mental health care, but CSAC is working to close them.
“How you keep people out of those expensive alternatives?” Thorn said. “That’s a win-win situation because if they’re not going in, that means their lives are better.”
Paquin said that because those suffering from mental illness often face many barriers to the care they need, they often end up crossing paths with police.
“Instead of having a system that naturally steers them towards community support, too many people end up interacting with the judicial system through law enforcement,” he said, adding that people don’t seek mental health treatment through the corrections system, but rather end up there by default.
“People don’t turn to corrections as an option. Their living situation may get so bad that one way or another, they run afoul of the law.”
Wendy Beinner, executive director of the Vermont chapter of the National Alliance on Mental Illness, said the organization is concerned about the lack of local care available to people who suffer from mental illness.
“(People) are ending up in corrections because mental illness is not being treated,” Beinner said.
Beinner added that once the mentally ill are released from prison, they often return to the same environment that led to their incarceration. “In the beginning they end up in corrections because there’s a lack of services, and then there’s a lack of services when they get out.”
The state judicial system, Paquin explained, is simply not set up to provide care for the mentally ill.
“The system is set up to pass judgment on criminal activity, which is very different from what a person might need in terms of mental health support,” Paquin said. “There’s a dearth of alternatives that makes it so that people end up in a system that doesn’t gear up to their needs.”
While the corrections system does provide mental health care to inmates, Paquin said jail is hardly the best place for the mentally ill to receive treatment.
“An incarcerated environment is not one where it is easy to be mentally ill,” Paquin said.
Whatever the reason, the Department of Corrections administers mental health treatment to thousands of Vermonters.
Meredith Larson, the chief of mental health services with the Department of Corrections, said 46 percent of the 1,600 inmates housed by Vermont’s seven in-state correctional facilities participated in active mental health treatment in 2013. So far this year, that number is about 47 percent.
Of the 6,800 who cycled through Vermont’s prisons in 2013, about 3,000 received some form of mental health treatment.
“This makes the Department of Corrections one of the largest, quite likely the largest, mental health care provider in the state,” Larson said.
Larson said that each inmate is screened by a mental health professional when they arrive in prison. If they had been prescribed medication for an ailment, orders can be filled by state psychiatrists.
Larson said inmates receive care in the form of group therapy and one-on-one time with mental health professionals. She added that inmates, at any time, have the right to refuse treatment.
“We respect this right and do our best to see that all inmates and staff remain safe,” Larson said.
If an inmate’s condition deteriorates to the point that they can no longer care for themselves, the Department of Corrections will place them under emergency care at a psychiatric hospital, under the state Department of Mental Health.
But Larson said there is not always room for these facilities to accept inmates.
“Unfortunately, those beds have been pretty scarce, but the Department of Mental Health does try to help,” Larson said.
The destruction of the state hospital in Waterbury during Tropical Storm Irene in 2011 left Vermont with few places to put mentally ill patients. Three years later, the state is still struggling with a shortage of beds.
“With far fewer psychiatric hospital beds in the state, not all people who are ordered by the court to have in-patient forensic evaluations are able to find beds,” Larson said. “When that happens, the person is held at one of the Department of Corrections facilities until a bed comes open.”
Larson said she hopes this problem is alleviated as the newly opened state psychiatric hospital in Berlin accepts more patients.
“Prisons are no substitute for hospitals,” Larson said.
An alternative that Paquin endorses is called “sequential intercept,” where people who are arrested, if found to be mentally ill, could be diverted to treatment instead of jail.
“If a person comes into contact with the system and has mental health or addiction issues, we can sequentially intercept the course of that person’s interaction, and change the outcome,” Paquin said.
One such situation that police officers handle regularly, Paquin said, is when someone calls law enforcement for an individual that is acting scary or strange. In many instances, Paquin said these individuals need treatment, not to be placed under arrest. “Rather than make an arrest, you can get social services contact, and get connected with community mental health services.”
If an arrest is necessary, Paquin said, other counties should adopt what Chittenden County has done — create a special docket to deal with mentally ill defendants.
Thorn agreed that court diversion programs are much more effective than sending those suffering from mental illness or substance abuse to prison.
“I think that’s absolutely the direction we should go,” Thorn said. “Are we going to treat people; are people going to get better in terms of recidivism if we put them in jail? I don’t think so.”
Thorn cautioned that diversion programs are not intended to help criminals avoid prosecution.
“Not everyone gets into a court diversion program — you have to be someone who has some potential to benefit from it,” Thorn said. “There are a lot of statistics on how much money it saves.”
This shift in treatment, Thorn said, is part of a larger shift in the health care industry toward preventative care.
“What’s really at the bottom of health care reform is a shift in the paradigm from an illness paradigm to a wellness paradigm,” Thorn said.
Under this new mindset, Thorn said CSAC has expanded its employment in housing programs and placed a greater emphasis on the social determinants that contribute to mental illness.
“If someone comes in to us and has severe depression and they’re sitting with a therapist for an hour a week, are we really doing our job if we’re ignoring the fact that they might be homeless and unemployed?” Thorn said.
Paquin said that the crux of the issue is how Vermonters want the mentally ill in this state to be cared for.
“That’s a fundamental question Vermonters need to ask themselves — what sort of social services structure will you be satisfied with?” Paquin said. “What kind of life are you comfortable with for your friends and neighbors that have serious needs?”

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