Quality of care aside, a bigger problem looms in Nevada’s mental healthcare system: We can’t make patients use it.
In the aftermath of the Sandy Hook Elementary School shooting in Newtown, Conn., people are calling for new policies: arming teachers, banning automatic weapons and a slew of other passionate but unlikely scenarios. After gun control, however, the next most discussed issue is mental health care. If we had a better system in place, proponents say, massacres such as Newtown and Aurora might be avoided. Is that true? If so, what services should we have, and how should they be implemented? Mental health experts in Nevada have different ideas about what’s broken and how to fix it.
FIRST, A LOOK AT WHAT WE HAVE
Kelly Wooldridge, deputy manager for children’s mental health with Nevada’s Department of Child and Family Services, says there are services available at the city, county and state level, but the challenge is getting the word out.
“I’m not sure if it’s better services, more services, or just helping people know what services are there,” she says.
DCFS cares for children from birth through age 18, who carry Medicaid or are uninsured. It serves patients who are suicidal, homicidal and are generally considered to be highest risk.
In Clark County, the state runs Desert Willow Treatment Center, a psychiatric hospital for young people who want to harm themselves or others. The state has long-term, in-patient residential treatments, outpatient treatment programs for children from birth to 6, then 7 to 18, and group homes, though those are often limited to children who have private insurance.
Clark County, Wooldridge says, offers individual and group counseling and psycho-social rehabilitation.
The best way for a person to access these services for a child, she says, is to go through a school: Talk to school counselors, ask a teacher. If a family is insured, Wooldridge suggests finding an approved provider through the insurance company. The stigma of mental illness — not lack of services — is what keeps most families from seeking help. But if they do, she says, the help is there.
THE PROBLEM OF FOLLOW-THROUGH
Gary Waters, founder and school psychologist at Beacon Academy of Nevada, says there are a few mechanisms in place to deal with troubled youth, but the system is incomplete.
Under the Tarasoff decision, a 1974 court case, teachers are mandated to report homicidal threats to the police. However, if the threat is merely a perceived one, and hasn’t been verbalized, there isn’t much teachers can do. In Nevada, qualified psych professionals can summon a “Legal 2000,” which calls for 24- to 48-hour mental health hospitalization and evaluation, but beyond that, there’s no accountability.
After the initial holding period, “they may stay, they may not,” Waters says. In a best-case scenario, doctors are able to convince the patient to remain at the hospital and complete treatment. If the person poses a harm to himself or others, he can be involuntarily hospitalized through mental health court, but it’s a “rare thing to happen,” Waters says.
Still, there is no guarantee of care, or continuity of care. Barring an involuntary commitment, a patient cannot be forced to stay, or to seek treatment after he or she is released.
Shortly after Sandy Hook, Beacon Academy received a threat from one of its students. The threat was taken seriously in light of the recent shooting. Police were notified, they searched the student’s home and confiscated items including a computer, the parents were warned, and the child was disenrolled from school. The student was directed to undergo a mental health evaluation and was told he could be reconsidered for enrollment after seeking treatment.
Still, Water says, there’s no guarantee the child will follow through. Beacon Academy can’t force the student to get help, and can’t stop him from enrolling in another school.
In response, the school ramped up security measures and polished its protocol.
“Did that prevent a violent act in Las Vegas three weeks ago?” Waters asks. “I have to say it might have.”
WHAT WE’VE LOST
Following the tragedy in Newtown, The Practice at UNLV was inundated with calls from parents and grandparents seeking help for their troubled youth.
The Practice, a training clinic staffed by grad students and supervising professionals, is a cash-only clinic that charges patients based on a sliding scale. Visits typically range from $5 to $30 depending on a person’s income.
The clinic had a waiting list of about 10 before the shooting at Sandy Hook. After the incident, the list quadrupled to almost 40.
There are other groups around town that offer treatment on an income basis, such as the marriage and family therapy center at UNLV, the Community Counseling Center and nonprofits such as Nevada PEP, which stands for “professionals educating parents.” But based on the length of waiting lists, these services are not enough.
Nevada ranks 41st in the nation for mental health expenditures per capita, at $68 dollars per person, the last time figures were calculated, in 2010. The national average is $121. Maine is best, with $348.98 per capita, and Idaho is worst at $36.60, according to statehealthfacts.org, a Kaiser Family Foundation resource. To Waters’ point, Connecticut ranks in the top 10 for per capita expenditures. Just because services are in place does not mean they will be utilized.
The state of Nevada has lost crucial services in recent years due to budget cuts, says Dr. Michelle Carro, director of The Practice. Cuts have come mostly in the form of psychologist positions lost. With fewer mental health professionals, the patient-to-doctor ratio has worsened. Southern Nevada Adult Mental Health Services, the local state-run agency, tries its best, Carro says, but has a limited ability to provide individualized therapy. Instead, it must turn to group sessions.
“Budget cuts affect positions and force services to become less individualized,” Carro says.
Furthermore, “it can be a difficult system to navigate,” she says. Where there was once a mental health crisis hotline and the ability to send a crisis team, patients are now forced to go to an emergency room, where specialized mental health services aren’t necessarily available.
WHAT WE NEED
“Stigma” and “integration” are buzzwords in mental health reform. Waters sees the problem with the current system as threefold: One, we need to integrate mental health care and medical health care. Most people are comfortable visiting their family doctor, but because of the stigma of being mentally ill, they are less likely to see a therapist, even if their doctor has recommended it. As Waters puts it, no one wants their car to be seen in the parking lot. The solution?
“We need to embed mental health care in primary care,” he says.
Two, we need to reduce stigma, such as assigning terms like “crazy” to people who seek treatment. Three, having a mental health history has negative consequences in people’s lives, sometimes making it harder for them to find a job or gain credit. Those issues need to be addressed.
Carro says we also need to bulk up public awareness, and let people know what services are out there and that there’s no shame in accessing them.
Basically, it takes a village, Carro says, referencing work by the late Russian psychologist Urie Bronfenbrenner and professor James Garbarino of Loyola University, who specializes in rehabilitating violent children.
“We aren’t raising our children in vacuums,” Carro says. “We come into their world with our own biologies and dispositions, but we also exist within systems” — families, neighborhoods, schools, communities, churches and government at the local, state and federal levels. When all of those institutions are working well together, children have a better chance of doing well.i
“It’s really about intervening about all levels of the system,” Carro says. “This country we live in has some exploring to do around a number of factors.”
Tuesday, the state of New York expanded its definition of assault rifles and limited the allowed size of gun magazines from 10 rounds to seven. The legislation also limits people with mental illnesses from accessing guns. On Wednesday, President Obama urged Congress to follow suit, with expanded background checks for gun permits.
Waters says the idea isn’t a novel one and advocates for a national registry that prevents mentally ill people from accessing firearms. Tuesday morning, Waters posed the question to Sen. Harry Reid on KNPR 88.9’s State of Nevada. Reid gave an indefinite answer, but did not oppose the idea.
“I’m sure that it’s something that would be very important,” he said. “… I think his idea is something we need to take a very close look at.”
In regard to improved mental health care, Reid pointed to the Affordable Care Act, which goes into effect in January 2014 and will require insurance agencies to cover mental health treatment, on par with medical care.
“We have a really serious problem,” Reid told State of Nevada. “Obamacare will be a big help to it because it’s going to allow more mental health care.”
Perhaps the biggest obstacle facing mental health care is the patients’ initiative to use it. Regardless of services available, there are few cases where people are required to get help. They may seek it if they want it, but if they don’t, it’s impossible to enforce. What is the value of an improved system, with more doctors and resources, if the people who need it most don’t use it?