By Taylor Sisk
Nicholas Stratas refers to mental illness as a â€œfragmentingâ€ problem.
Stratas, a Raleigh-based psychiatrist and former state deputy commissioner of mental health, explains that as we become adults, individuation takes place â€“ boundaries develop, thoughts, feelings and actions are forged â€“ and we go through a process of internal integration. We begin to form relationships.
But with mental illness, instead of integration there is fragmentation, and that restricts our ability to connect with other people. Family relationships suffer, and problems often spill over into the wider community.
Consequently, whatâ€™s needed is a unified, community-based approach to mental illness. What we have now in North Carolina is a fragmented effort, says Stratas.
His sentiments are echoed by mental health advocates throughout the state. Weâ€™ve suffered, they say, from a lack of leadership and the absence of a cohesive vision of how to deal with those who are stigmatized because of their disease.
They argue for an approach that brings to the table the objectives and concerns of those with mental illness, their families and mental health care professionals â€“ voices that have been inadequately heard for at least three decades. They also argue for a firm commitment of resources and money.
Last spring, Gov. Mike Easley vowed to fix our mental health care system by the time he left office.
But as he transitions out, the system is largely in shambles. State institutions are overcrowded and are losing federal funding. The new $138 million facility in Butner, Central Regional Hospital, has just been determined by state inspectors to be unsafe. And mental health care services are all but nonexistent in many areas of the state.
In sum, the measures promised by House Bill 381, the reform legislation passed in 2001 that called for moving the mentally ill out of state institutions and into community-based services and for those services to be offered by private providers, have failed.
â€œAssuming heâ€™s a good man,â€ says Stratas of Easley, â€œIâ€™ll say heâ€™s managed by remote control. Heâ€™s out of touch.
â€œThis culture of neglect [in the state institutions] weâ€™ve read so much about lately begins at the top.â€
â€œWe have had terrible leadership [on mental health issues],â€ Chapel Hill psychiatrist Clay Whitehead says, â€œenormously damaging and destructive, short-sighted leadership in this state under the Easley administration.
â€œHeâ€™s done enormous damage and the next couple of decades are going to be seriously affected by it.â€
In her campaign position statement on mental health care, Governor-elect Beverley Perdue promised to â€œadopt a disciplined approach with lots of two-way learning between government officials and the mental health community.â€
David Cornwell, executive director of the advocacy group North Carolina Mental Hope, is skeptical. He observes that at Perdueâ€™s transition team meeting on mental health last week, â€œItâ€™s my understanding that few, if any, [of those invited] were individuals with an illness.â€
That, says Stratas, is â€œvery distressing.â€ He believes consumers should comprise roughly half of any such advisory team.
For the time being, though, Stratas is maintaining an open-minded approach to the incoming administration.
Meanwhile, he has clear ideas on what needs to happen, proposing, first of all, a statewide patient and provider inventory to identify and classify the population in need of mental health care and pinpoint available treatment.
â€œWe have to scan the whole state, county by county, patient by patient,â€ says Stratas. â€œWeâ€™ve got to see whatâ€™s out there so that we can move forward with some intelligence.
â€œWe donâ€™t know right now whatâ€™s working and whatâ€™s not. So the first thing is mapping the system.â€
Stratas proposes developing computer-based models that each Local Management Entity (LME), formed to oversee the private providers, could use to determine its communityâ€™s specific needs.
â€œWhatâ€™s needed in Vance County isnâ€™t necessarily whatâ€™s needed in Wake County,â€ says Stratas.
Also imperative, according to Stratas, is that each LME be directed by a board-certified psychiatrist.
Services provided by LMEs should include a 24-hour crisis intervention program, outpatient psychotherapy and pharmacotherapy, both day and night inpatient programs and community-support services. LMEs should consult with and educate other agencies, including law enforcement, social services, public health, public instruction and the courts.
Stratas sees the money budgeted in 2008-09 for mental health care â€“ money thatâ€™s already been cut and is likely to be cut again â€“ as being far too little.
But, he adds, â€œI must tell you that, until weâ€™re clear about what we have and what we need, it may be more money down the drain.â€
A new direction
Among the changes made in the course of mental health care reform in North Carolina was the recruitment of an out-of-state company called ValueOptions to review and process all Medicaid payments.
Chapel Hillâ€™s Rep. Verla Insko, a sponsor of the mental health care reform legislation and co-chair of the joint legislative committee on mental health, says of that decision, â€œIt was a mistake. It undermined the basic goals of reform, which were to have the public sector manage a unified budget â€“ a Medicaid, state-dollar and local-dollar budget â€“ to provide services within each catchment area.â€
Instead, today we have a two-payer system, further fragmenting the funding and delivery of services.
The legislature is now taking action to remove ValueOptions from the equation.
Insko says that LMEs serving 30 percent of the stateâ€™s population will this year reassume the management of Medicaid dollars, and that if all goes well 30 percent more will do so next year and 40 percent the next.
Another move in the right direction, according to Insko, is an effort to integrate mental and physical health care services through Community Care of North Carolina, which operates out of the North Carolina Office of Rural Health and Community Care. Itâ€™s an effort championed by Governor-elect Perdue.
Given current conditions, itâ€™s hard to imagine a committed mental health professional wanting to establish a career in North Carolina. But advocates say that the ability to attract talent to effect the changes that need to take place within our communities is at least as critical as any other concern.
Thomas Smith has been practicing psychiatry and advocating for those with mental illnesses in this state for over five decades. Heâ€™s written and circulated a â€œRescue Plan for Mental Healthâ€ in which he writes that we must â€œinstitute a vigorous outreach and recruitment program.â€
Smith has been enlisted in recent years to recruit talent and, he says, â€œItâ€™s like pulling alligatorâ€™s teeth. To come into an atmosphere like this, where everything is in a state of disruption â€“ who would want to come and join this force?â€
Still, he writes, we â€œabsolutely must initiate a full-court press when it comes to finding, training, fielding and retaining psychiatrists and other mental health workers. Otherwise we could end up quite destitute in this respect.â€
But the message that most clearly emanates from advocates with mental illness â€” those who suffer when services arenâ€™t available â€” and those who work most closely among them is that change must first come from within â€“ from within our communities and ourselves.
North Carolina Mental Hopeâ€™s David Cornwell says that among elected officials and the public â€œthereâ€™s simply going to have to be a parity of concern for mental illnesses on par with that of other physical illnesses and other societal issues.
â€œ[W]ere it not for the crushing stigma of mental illness, maybe our cause could have a Michael Fox, a Lance Armstrong, a Jerryâ€™s Kids telethon.â€
In an open letter to outgoing-Gov. Easley, Nicholas Stratas wrote: â€œYour administration has for eight years failed to appreciate that, as we treat those unable to help themselves, so we treat ourselves.â€
That treatment, says Smith, involves challenging those with mental illness to navigate through a fragmented, labyrinthian system, and to do so while, quite often, â€œsuffering the tortures of the damned.â€
â€œWe really need to recognize the errors of our present system,â€ says Clay Whitehead. â€œThen we have to tap the public sentiment and the values of our communities, and we have to explore where we have leadership, and followership, and in what direction that takes us.
â€œDo we want to throw these people into the streets and prisons? … Because thatâ€™s what weâ€™re talking about. And if we donâ€™t want to do that, then we have to take care of people.
â€œThereâ€™s no relativity theory involved in that. If we want to take care of people, we basically know how to do it. And if we donâ€™t, what are we going to do with them, and where are they going to go?â€
Next in the series: Efforts to improve mental health care in Orange County, including the recent formation of a Chapel Hill Mental Health Task Force, a joint town/university effort to discuss, examine and assess mental health care services in Chapel Hill.