By Taylor Sisk
Valerie Kramer calls Carrboro her â€œfairy-tale town.â€ She and her son, Jeff, moved here when Jeff was entering the second grade and left, in 1997, when he was 14. Kramer was ending a bad relationship, was diagnosed with clinical depression and decided she and her son needed a new start in a new environment. She and Jeff moved to Asheville.
While in high school there, Jeff fell in with the Rainbow Family, to whom Kramer attributes his introduction to drugs. Jeff was busted for distribution of marijuana and was facing both felony and misdemeanor charges.
Around this same time, Jeff had begun to often act strangely.
Nothing he said made sense, Kramer says. â€œHe said God sent him to this Earth to grow marijuana for sick people, and that was his mission.â€
Jeffâ€™s defense attorney advised her to pay a forensic psychologist to have Jeff evaluated. He was diagnosed with paranoid schizophrenia and deemed incompetent to stand trial. He was 19.
â€œI didnâ€™t know what schizophrenia was,â€ Kramer says. â€œBut at 17 and 18, he really did things that I knew were not normal for him. And everyone said, â€˜Well, heâ€™s just a teenager â€¦â€™ But I always knew. I mean, I had nightmares about it. I knew something was wrong.â€
It must be drug-induced, Kramer believed. â€œI said, â€˜When he gets off the drugs, heâ€™ll be fine, right?â€™â€ She was assured by the doctors otherwise.
So she packed up all of her and her sonâ€™s belongings and moved back to the Triangle.
â€œI thought, â€˜Weâ€™ll go back to Chapel Hill where, in general, there are more people with a higher education.â€™
â€œI asked around â€“ everyone I knew â€“ and they said that as far as state hospitals go, John Umstead is the best because youâ€™ll have the brightest people there, the most resources â€“ and so by moving here, Iâ€™m doing my son a favor. UNC Hospitals will take care of him and John Umstead is the best place. And now, five years later â€¦â€
Her nightmares persist.
Last week, the newly formed legislative Program Evaluation Division released a long-awaited report titled â€œCompromised Controls and Pace of Change Hampered Implementation of Enhanced Mental Health Services.â€ The report is largely focused on the now well-documented excesses in the provisioning of community support services and chronicles the general mismanagement, overspending and lack of oversight in our mental health system since the passing of reform legislation in 2001, which called for privatizing services.
Community support services include, for example, assistance with grocery shopping or homework or chaperoning to movies or ballgames. The News & Observer reported that between March 2006 and January 2008, the cost of these services rose to nearly $1.4 billion, or 90 percent of all spending for community-based mental health care services. The cost of community support services was then nearly 20 times the stateâ€™s original estimate.
State officials now acknowledge that too much money has been wasted in the provisioning of community support services and â€“ granting that these services are vital for many who are poised to reintegrate back into their communities â€“ that too much money is being allocated to them at the expense of services that are more time- and cost-intensive to provide â€“ local inpatient care, for example, or everyday counseling.
The legislative report cites delays in securing federal approval of new services, which led to a delay in the implementation of oversight procedures, which in turn led to some new providers taking advantage of the system by â€œdelivering an unchecked amount of servicesâ€; a failure to establish a baseline â€œagainst which to measure system performance and assess utilization and expendituresâ€; and reports to decision-makers that included â€œexcessively dense data that are neither synthesized nor interpreted.â€
In sum, the report is about mismanagement and abuses in the overhaul of our stateâ€™s pre-existing mental health care system â€“ an initiative that most everyone now acknowledges is in serious need of some overhauling of its own.
What the report is not about is how mental health care reform is failing people â€“ most particularly, those people most critically in need.
What remains unaddressed is whether the system weâ€™ve put in place is structured to provide these more-intensive services.
More to the point: Is it possible to provide comprehensive, effective mental health care services and make money at it?
Dr. Nicholas Stratas doesnâ€™t think so. Stratas, a psychiatrist now in private practice in Raleigh, is one of the architects of a mental health care system in North Carolina that was, many years ago, considered a model of success. He served through the 1960s as deputy commissioner of what was then the state Department of Mental Health, which eventually was moved into the Department of Health and Human Services.
â€œHow can you make money without cutting services?â€ Stratas asks. â€œI think itâ€™s possible to make money at this, but itâ€™s going to be at the cost of cherry-picking servicesâ€ â€“ providing only those services that are most cost effective â€“ â€œand youâ€™re going to have to provide truncated services. And you lose the integration of a unified system.â€
A unified system, Stratas says, is essential to providing continuity of care, and continuity of care is â€œabsolutely critical.â€
â€œBut now,â€ says Stratas, â€œweâ€™ve got this person doing this piece and this person doing this other.â€
Under the previous state-run system, community mental health clinics provided a broad suite of services under one roof.
Dr. Thomas Smith, an Asheville-based psychiatrist, is another longtime mental health care advocate whoâ€™s been vocal in his opposition to reform measures. He underscores the critical nature of those comprehensive, under-one-roof services.
People with mental illness, he says, often face prohibitive transportation issues â€“ no driverâ€™s license, no car, little money for a taxi and, in rural areas, few if any public-transportation options.
â€œSo to have everything in a central location within a community mental health clinic,â€ Smith says, â€œthat was great. And to let that be destroyed was absolutely atrocious.
â€œNow there are private providers out there scattered here from hither to yon, all over the place, and itâ€™s hard for these folks to get to them.â€
Of cherry-picking services, Smith says: â€œNobody wants to treat the difficult-to-manage folks,â€ those with whom itâ€™s necessary to build a relationship over time, those who are most in need.
Jeff Kramer occupies a quiet space outside Weaver Street Market as a Friday afternoon gathers energy. Heâ€™s undisturbed; focused, in his manner. Heâ€™s a handsome young man; steady for the moment and sturdy. Heâ€™s on an outpatient commitment order, required to report once a month to Orange Countyâ€™s community resource court.
The court is a cooperative effort of the Orange County judicial and mental health systems that strives to help people who have mental health issues by linking sentences for selected offenses with services and support.
After another brush with the law, and yet another brief stay in Umstead, Jeff is once again tasked to regain his footing.
Jeff has been refusing to take his medication. Heâ€™s taken it intermittently in the past, and his mother sees clear improvement in his ability to function when he does. He says now, though, that heâ€™s through with it.
â€œThey want to see me on medicine that is not doing anything but damage to my brain,â€ Jeff says. â€œWhen you put chemicals in the brain, they donâ€™t do anything but harm. Antipsychotics will make someone sick.â€
â€œHe says he doesnâ€™t have schizophrenia,â€ Valerie Kramer says. â€œHe says itâ€™s too bad that they convinced me of that. He says he thinks that itâ€™s something that he did when he was younger, when he took the wrong path in life; maybe the drugs he did. He always blames himself for the way he feels and thinks he can eventually work it out. He told me the other day that heâ€™d rather die than take the medication.â€
Kramer has been frustrated by the care her son has received at UNC Hospitals: â€œTheyâ€™ve turned him down; theyâ€™ve released him after several days. The last time he was in there â€“ it was January of this year â€“ he stayed only several days, was very sick, very delusional, paranoid, and this womanâ€ â€“ another patient â€“ â€œkept kissing him.â€
â€œThey would say, â€˜We canâ€™t help him because heâ€™s noncompliant. He doesnâ€™t want to take his medicine.â€™ At the same time, thatâ€™s a classic symptom of paranoid schizophrenia. They also say he has zero insight â€“ another classic symptom â€“ and so they send him home.â€
â€œThe first time at Umstead,â€ Kramer says, â€œit was before all of these laws changed, and it was a good time. That was 2003. They kept him for, like, six weeks. They gave him the best treatment. I mean they really seemed to care.â€
When Jeff was given his outpatient treatment plan, Kramer says, â€œthey took so much time with me and Jeffâ€ â€“ doctors, social workers, a team of clinicians that he was to work with on the outside all participated.
â€œWe all sat down and we covered this outpatient treatment plan in depth and my son actually followed it. Itâ€™s the only time in the five years that he has done that.â€
Eventually, though, Jeff stumbled.
â€œAnd then they changed everything,â€ Kramer says, â€œand they started keeping him two days, three days, a week if youâ€™re lucky.â€ Most recently, he stayed two weeks.
A pill, a platitude, a pat on the back
The liaison community mental health clinics used to have with hospitals was an important element in continuity of care, helping ease the transition back into the community. Once out, an ongoing relationship with a trusted professional is the next critical step.
â€œIt takes time to build those things,â€ says Thomas Smith. â€œBut they just threw that all to the four winds. Now itâ€™s just a piecemeal thing.â€
Smith refers to â€œP-P-Pâ€™â€ clinics: â€œYou come in and you get a pill, a platitude and a pat on the back.â€
He hastens to add that there are certainly still good providers out there â€“ but believes most are just in it for the money. And the continuity of service, that comprehensive suite of services delivered by a team, as a team, is what appears to be lost.
In order to be effective, says Nicholas Strata, that team should include a representative from a state institution, another from a local inpatient program, another from an outpatient program; a team to provide whatever the patient needs.
â€œThe survivor in me, my inner peace,â€ says Jeff Kramer, â€œwill find a way to survive and figure out some kind of method of dealing with reality.â€
His mother isnâ€™t nearly so sure.
This story is the first in a series about mental health care in North Carolina. The names of the mental health care recipient and his mother have been changed.