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Mental Health Systems Under Stress

By Rob Waters

As the U.S. economy remains mired in the worst funk since the 1930s, public services for the country’s most vulnerable populations—children, the elderly, the mentally ill—are being cut or disappearing at a time when the need for them is greater than ever. Faced with gaping deficits, states have slashed $1.6 billion from mental health programs over the past four years, according to a report by the National Alliance on Mental Illness. Cuts to the Medicaid program, now being debated in Washington, may well worsen the situation.

In Detroit, the county mental health program has lost $30 million in state funding over the past three years, forcing numerous cuts to the agencies it supports. Detroit Central City Community Mental Health, which provides outpatient treatment and reentry programs for people leaving jails and psychiatric hospitals, lost a quarter of its funding and cut its staff by a third. Charlotte House, a transitional housing program for people with psychiatric disorders discharged from the county hospital, closed its doors.

California has cut mental health funding by $765 million, or 21 percent, since 2009. On December 1 of this year, 38,000 elderly residents—a quarter of them with dementia and almost half with mental health diagnoses—were slated to lose access to the health centers they depend on for daytime meals, therapy, and healthcare. This cut, being challenged in court, may force the closure of 300 centers that are intended to keep fragile seniors out of nursing homes. Illinois has slashed $187 million from its mental health budget and plans to close three of nine psychiatric hospitals. A budget passed in November by the Chicago City Council will close half the city’s 12 mental health clinics.

Meanwhile, homelessness, domestic violence, and child abuse are rising. Nationally, nearly 1 million schoolchildren were homeless in the 2009–2010 school year, up 38 percent in four years, according to the U.S. Department of Education. Researchers reviewing hospital records from parts of Washington, Pennsylvania, Ohio, and Kentucky found that the rate of children younger than 5 brought to emergency rooms with abusive head trauma—brain injuries from being shaken or struck—was 65 percent higher during the 19 months of official economic recession that began in December 2007 than in the previous four years. Sixteen percent of the children died. Over the past three years, therapists from Valley Community Counseling in San Joaquin County, California, treated 60 percent more children who’d been exposed to domestic violence and 50 percent more whose parents were substance abusers.

In some of these places, individuals and communities are taking things into their own hands. In late 2009, as the unemployment rate in San Joaquin County reached 18 percent and 1 in 12 homes were being foreclosed—the twelfth highest rate in the nation—two high school students in the town of Ripon, population 15,000, committed suicide within two months of each other. More suicides occurred every few weeks in neighboring school districts, and by the time the following school year had ended, a total of at least 18 schoolchildren in the county had taken their own lives—a pattern that public health researchers call “suicide contagion.”

Years of declining budgets had cut the number of counselors, nurses, and psychologists in county schools, impairing the ability of individual districts to handle the needs of grieving students, parents, and communities on their own. To bridge the gap, school officials in the cities of Ripon, Stockton, Lodi, and Linden turned to each other for help—a grassroots response seen more and more across the country as communities look to their own resources to address pressing needs.

The school districts made use of a mutual aid pact, like those employed by firefighters and police. On the morning after each death, school nurses and counselors trained in suicide response, along with a team of therapists from Valley Community Counseling, converged on the school the student had attended. They met with pupils and parents, focusing on kids who knew the victims or seemed to be at particular risk.

In each affected community, charities, church groups, parents, and friends pitched in to help out. The mother of 17-year-old Marissa McLeod, the second of the Ripon students to commit suicide, opened a store, Marissa’s Closet, where girls can get free dresses for proms and formal occasions, fulfilling one of her daughter’s dreams. The spirit of cooperation helped the team fashion an effective crisis response and ease the pain of some survivors, says David Love, executive director of Valley Community Counseling. But, by definition, it came too late, he adds.

“We’re doing everything we can to partner, so if something happens, I can call up six different school districts and ask for a couple of counselors at 7 a.m. tomorrow,” Love says. “But we’re still band-aiding. When you’re doing crisis work, you’re at the back end. The tragedy is we don’t have the resources early in the process.”

Today, the 900 students at Ripon High, where the suicides started, have just two guidance counselors to help them. That’s better than the statewide student–counselor ratio of one counselor for every 810 students, the second worst of any state. The neighboring city of Manteca has no elementary school counselors and has gone from four to two at each of its seven high schools, says Caroline Thibodeau, the district’s director of health services.

Meanwhile, students’ needs keep increasing. The number of homeless children in Manteca has doubled in the past five years, Thibodeau notes. Rates of alcoholism, drug abuse, and child abuse are climbing, putting families under enormous stress, says Love.

“It’s a big circle,” he states. “Family stress, community stress, student stress equals higher levels of depression and related issues among caretakers and children. With school cuts, counselor cuts, and classroom sizes going up, the schools are seeing more mental health issues and have fewer resources. We’re getting more kids sent to us with clinical depression, PTSD, or behavioral issues. And all this increases the possibility of suicide.”

One social worker whose resilience has been tested by the economic downturn is Deidra Thomas-Murray, director of homeless services for the St. Louis schools, where the number of homeless children has almost doubled in the past three years, to 3,000. Thomas-Murray spent many years in her native New Orleans working in schools and with juvenile offenders, and then became a refugee after Hurricane Katrina destroyed her home. She and her five daughters and foster daughters spent two weeks sleeping on the floor of a friend’s house in Baton Rouge, and then went to Missouri, drawn by a relative’s offer of help. For a while, she says, five families were crowded into a two-bedroom apartment while she collected food stamps and hunted for work.

She found a job as a drug counselor, then as a family therapist, and in 2006, was hired as a school social worker. Since 2009, she’s coordinated the program for homeless students, networking constantly to solicit donations of clothing and sleeping bags for families. Her main focus is getting teachers and principals to know their kids so they can identify those who are homeless and make sure they get the services they’re entitled to by law.

“A lot of times we’ll see stuff happening with kids, but never ask what’s going on,” she says. “We just assume they’re some BAKs (bad-ass kids)—which in many instances, isn’t the case. We, the educators, play a major role in how we embrace this population.”

Thomas-Murray is painfully aware of the damage that homelessness inflicts on kids. “They worry about where they’re going to sleep at night,” she says. “They have difficulty separating from parents. If there’s been violence in the family, they’re preoccupied with whether the parent is safe. They have difficulty focusing. They stare off into space. They can be invisible in a crowd of kids. Or they can be the most disruptive in the class.”

The stress of economic uncertainty isn’t confined to the jobless, or to people who’ve lost homes or services. Therapists working in government-funded agencies themselves are under intense pressure as they absorb the distress of their clients, handle heavier caseloads, and fret about their own flat salaries and job security.

“It’s not a good feeling that there are 50 kids on a waiting list and you can’t hire more clinicians,” remarks Stacey Katz, director of the West Coast Children’s Center in Oakland, California. “How do we decide who needs services the most without violating our mission that kids should have mental health services when they need it?”

In April, Places for People, a St. Louis agency serving the city’s mentally ill, opened a drop-in center that offers assistance to anyone in need. The number of help-seekers climbed from 248 in May to 509 in August. “It’s off the charts,’’ admits executive director Joe Yancey. The spike in demand has been so intense that the agency is grappling with whether it has the capacity to continue helping all comers.

The ability to meet the needs of the poor and distressed depends increasingly on the dedication of service providers. Social worker Megan Heeney, 26, is an outreach specialist with Places for People by day, helping individuals who are being released from psychiatric hospitals. At night, she’s part of a Catholic Worker community that provides housing for homeless women and children. She helps organize volunteers to bring homeless people off the streets when the temperature dips below 20 degrees, and she’s recruited local churches to provide shelter.

“We try as hard as we can to help people manage their crises,” she says. “We want to aid people in moving toward recovery, yet because of economic conditions, we’re constantly doing crisis management.” In a system so out of joint and lacking in resources, dedicated social workers can only do so much.
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