Coping with mental illness in Stanislaus County

Stanislaus County probation deputies John Bettencourt, left, and James Gallagher talk with a homeless man in Beard Brook Park on Friday, Oct. 2, 2015./Andy Alfaro, Modesto Bee

This story originally appeared in the Modesto Bee

Economic calamity has a crushing effect on a community’s mental health, resulting in more people seeking treatment for mental illnesses, ranging in severity from depression to suicidal.

Three years ago, with Stanislaus County still in the throes of recession, its mental health department had been gutted by budget cuts, leaving many people suffering from bipolar disorder and schizophrenia with nowhere to turn for help. Homeless mentally ill people were visible on downtown Modesto streets and in city parks; many ended up in county jails, which were housing more inmates with mental disorders than ever before.

In hospital emergency rooms, people suffering from psychiatric emergencies were held for days because there was no space in mental health hospitals.

A spate of officer-involved shootings called attention to the need to train police to de-escalate confrontations with the mentally ill. 

Cherie Dockery, associate director for Stanislaus County’s Behavioral Health and Recovery Services, remembers that calamitous period well, particularly the unraveling of people’s lives.

“When you go back to 2008 when we had the housing crash … then they start to lose their jobs,” Dockery said. “Then, the third year, they started to lose everything. Once you get to the place where you lose everything, you have people who had been maintaining for at least three years. Family members who had been taking care of their loved ones couldn’t handle it anymore. We not only had multiple people coming in the door, but multiple people being homeless.”

The economy and mental health services have improved in the three years since The Modesto Bee and the Center for Health Reporting detailed the problems in an in-depth report in May 2012. The two organizations partnered again recently for an update on the state of mental health services in Stanislaus County. 

“A lot of people are getting opportunities and are finding places that they can get help,” said Joyce Plis-Hickman, the resource officer of the National Alliance on Mental Illness, Stanislaus County. “When we talked to you in 2012, we had one family advocate but now we have three. They have a place to go and opportunities here and there.” 

County Behavioral Health and Recovery Services has rebuilt staff and made modest gains in serving more clients – about 9,700 last year, or 700 more than in 2012.

The county’s mental health budget has also been rebuilt. At $91.6 million this year, it is almost a 40 percent increase over the budget in 2012. 

In 2014, the county opened a 16-bed psychiatric health facility to treat patients in emergencies. It also plans to increase capacity with a crisis stabilization unit and has poured Mental Health Services Act funding into wellness programs.

Despite increased resources, services for the mentally ill remain under pressure. Residents are keenly aware of the homeless mentally ill on the streets. Parents say they face interminable delays in getting appointments with pediatric psychiatrists for their children. Plenty of adults use primary care doctors to manage their medications because they can’t find a psychiatrist. 

“When I first came here, we had more psychiatric hospitals for children,” said Dockery, who has been working in the department for more than two decades. “So when we were referring, we had several different places where we could send them. Then over the last 15 years, that has changed drastically. We use three. One is in Bakersfield. One is in Sacramento. One is in the Bay Area. The decrease in the number of psych hospitals for children and adolescents has been a problem.”

Increase in mental health patients

Today, hospital emergency rooms are not seeing fewer patients with mental disorders come to their ERs. The data show they are seeing more. 

In Stanislaus County, emergency department encounters with patients who have mental disorders rose in number from 5,184 in 2011 to 8,335 in 2014, a 60 percent increase, according to the Office of Statewide Health Planning and Development.

“What we are seeing is lot more sick people,” Dockery said.

She attributes the increase to several factors: the lasting effects of the recession; people seeking care for mental illness since gaining coverage or Medi-Cal benefits through health reform; and untreated mental illness among the homeless.

Many of these patients are first evaluated in hospital emergency departments, and some are held there until beds open in psychiatric facilities.

The county also faces a continuing challenge dealing with former state prison inmates who were treated for mental illness and released and are now under county supervision. This public safety “realignment,” under Assembly Bill 109, took effect in October 2011.

Sheriff Adam Christianson said he believes realignment is one reason for a significant increase in calls that may result in “5150” involuntary holds (a designation derived from a section in the California Welfare and Institutions Code). 

Authorities are dispatched to 5150 situations when people with psychotic symptoms are violent or suicidal, or when the gravely disabled are unable to care for themselves. Those folks are often placed on involuntary 72-hour holds and sent to psychiatric hospitals for emergency care.

In unincorporated areas of Modesto and in Riverbank, Patterson, Hughson and Waterford, the number of 5150 calls jumped from 554 in 2012 to a plateau of 778 in 2013 and 768 last year, a 40 percent increase.

Modesto police reported 1,264 of the 5150 calls in 2013 and 1,387 last year, up from 975 in 2012. Officials expect calls this year to surpass last year’s total. 

“From my perspective, there is a noticeable increase in the individuals we encounter who need mental health care services,” Christianson said.

As a young deputy sheriff, he could go several weeks without encountering someone with a mental health issue. Now, it’s a daily occurrence for law enforcement, he said.

Deputy Probation Officer John Bettencourt works with homeless probationers, some of whom have mental health conditions. Since county probation noticed an increase last year in released offenders reporting they were homeless, Bettencourt and a partner go to alleys, parks and riverside camps to talk with probationers.

Bettencourt said it’s a challenge to get them into shelters or programs because of the antisocial mentality of many people with criminal records. Some of them use street drugs such as methamphetamine or heroin in an attempt to treat symptoms of their illness. 

“It’s hard to motivate them to get involved with a pro-social lifestyle,” Bettencourt said. “We ask them why they don’t stay at the mission, and their No. 1 response is they don’t like the rules. They don’t like being cooped up.”

Of the 138 subjects referred to county mental health for treatment last year under realignment, 59 – more than one-third – required assessment for severe mental illness.

Staff members from county probation and behavioral health and recovery services travel to prisons to pick up inmates who will need treatment outside of prison walls. They walk out of prison with 30 days’ worth of medication. Upon their return to the county, they are placed in transitional housing or with family members, and are set up with treatment and clinicians, officials said.

“They are so unpredictable if they go off their meds,” Chief Probation Officer Jill Silva said. “If they have a serious illness that causes hallucinations, they are the ones most disruptive and a danger to others.”

County behavioral health and recovery services has clinicians who work directly in the jails with AB 109 offenders who have mental health needs. Officials believe these individuals, many of whom are difficult to engage, are more receptive to treatment in jail rather than on the streets.

Clinician Terrie Vince said inmates sometimes open up when trust is established. Some have mental illness, worsened by drug or alcohol use, but they also tell of physical and sexual abuse, gang rapes or constant parental violence when they were children. Some have witnessed murders.

“I learn every day,” Vince said. “It is amazing what they have endured.”

Follow-up for ‘in-betweens’

A forensic team works to get them into housing, treatment or substance abuse classes at a day reporting center built recently near the public safety center on Hackett Road.

The state-funded realignment services are a far cry from days when the jail released people onto the street with a phone number, the clinicians said. The county is now better set up to provide out-of-custody care to people with mental disorders who have cycled in and out of jail, officials said.

Among the general population, about 43,000 county residents enrolled in Medi-Cal through the Affordable Care Act in the first of year of expanded income eligibility and benefits for low-income adults. Thousands more signed up in the second year. Many of these new enrollees have need of mental health services. 

Susan De Souza, 46, is one of them. De Souza has generalized anxiety disorder and bipolar disorder. Three years ago, she was uninsured. Then, she called herself one of the “in-betweens” because she was not sick enough to be eligible for public help, but was too poor to afford insurance on her own. 

She credits the Medi-Cal expansion with improving her access to mental health services. Now, she works in mental health herself as a recovery specialist at Telecare Corp., based at the Stanislaus psychiatric health facility. 

“Once I got well, I wanted to make sure that people would have somebody who knows what they’re going through, what they’re feeling, and to try to help them get the services that they need,” she said.

The county has emergency and outpatient services for adult Medi-Cal recipients with serious mental illnesses; for children, the criteria is broader – it’s any condition that potentially interferes with their development, said county mental health director Madelyn Schlaepfer.

The county’s two Medi-Cal managed-care plans, Health Plan of San Joaquin and Health Net, have providers and services for those not meeting the seriously mentally ill criteria.

One of those providers, Aspen Family Medical Group, has been an open door to Stanislaus County patients for years. Aspen’s CEO, nurse practitioner Matt Freitas, believes that access to mental health care starts with providers such as him.

“Primary care will be doing most of the psychiatric care in the future,” he said. “I’ve been living it.”

Freitas treats patients with varying mental health needs. He personally talks to these patients even though he is not a psychiatrist.

“We have become the place the county mental health department (and) various organizations ... refer people (to) because they know that we will see them no matter what their situation,” Freitas said.

Aspen has benefited greatly from the Affordable Care Act’s Medi-Cal expansion, as now it can enroll people in Medi-Cal and bill for patients who previously could not pay. Because of this financial boon, Freitas says, he has doubled his staff and increased his patient numbers tenfold since 2012. He now sees 20 to 25 mental health patients a day, about one-fifth of his clinic’s total visits.

“There are not many places where they know they can go and they will get help the same day. In mental health issues, tomorrow is too late,” he said. “I always wanted Aspen to be like that – filling needs. So for me, this was a need.”

Minimizing use of force

Law enforcement officials, too, have been filling the need for better interaction between officers and people in desperate circumstances. More of their front-line personnel are being trained for encounters with emotionally disturbed individuals that in the past escalated into violence.

Modesto police Chief Galen Carroll said county mental health’s crisis intervention classes enable officers to recognize behaviors of people with schizophrenia and other disorders, and minimize the use of force in dealing with them.

Officers used the techniques to de-escalate a recent situation at the transit center in downtown Modesto that could have resulted in force, Carroll said. During the August incident, police approached a man armed with a machete who urged officers to “bring it.” 

Carroll said the officers took their time and brought the episode to a peaceful resolution. 

The chief said the last officer-involved shooting in Modesto stemming from a 5150 dispatch was in 2011.

Phil Trompetter, who has taught the crisis intervention classes to officers since 2005, said he had no explanation for the 2010-11 spike in officer-involved shootings of mentally ill subjects, because those kinds of incidents are infrequent.

But because encounters with the mentally ill have become more frequent, he said, “It’s become more apparent to law enforcement that it’s important to teach officers to change their approach to individuals with mental conditions.”

“When it started, there was skepticism,” Trompetter said. Now, officers are volunteering because they see it as a problem and want to be part of the solution, Trompetter said. 

The sheriff’s department also provides training opportunities for personnel in the jails and on patrol.

The county’s Schlaepfer said it’s tough for smaller police departments to free up officers for the 40-hour class. A psychologist teaches the two 25-member classes held each year. The county is looking at developing a shorter course, and there’s a desire to open the classes to California Highway Patrol officers. 

“It is just amazing the difference in those trained officers and how well they can defuse a situation,” Schlaepfer said. 

Center data journalist Ron Campbell contributed to this report.

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