This is the beginning of a five-part Undercurrents series examining the subject of mental illness in the Virgin Islands – its scope, its effect, and how it is and is not being addressed.
The headlines scream:
- Man Released from Behavioral Unit Assaults Passersby on Street
- Vagrant Dies in Fire Police Suspect He Set
- Man Charged with Killing Family; Has History of Mental Illness
All of these stories happened in the Virgin Islands. But there are other stories. If they were told their headlines might read:
- Traumatized Boy Arrested While Awaiting Counseling
- Promising Student Suddenly Confronting Schizophrenia
- Mother Must Pay Transport for Daughter’s Police Escort to Hospital
All of these stories spring from a system that mental health officials, advocates, and families agree is just not working well. They speak of “gaps,” of a lack of facilities, of continuing funding cuts, of disorganization, of underused human resources, and, at bottom, of a lack of public will to accept and deal with the reality.
The U.S. Centers for Disease Control and Prevention estimates that 25 percent of American adults have some sort of mental illness. Perhaps more staggering, it says that half of all adults will develop at least one mental illness sometime in their lives.
There’s no reason to think the Virgin Islands numbers are much different, according to the experts interviewed for this series. A 2003 class action suit filed against the local government in an attempt to force improvements relied on similar estimates, and concluded that about 18,000 people in the territory are at risk because of its inadequate delivery of mental health care.
No one voices more concern – or more frustration – with the problems than the woman who has been the director of the Division of Mental Health, Alcoholism, and Drug Dependency Services since June 2010, Doris Farrington Hepburn.
“It’s a broken system. That’s it,” she said. “Nineteen years ago the system was working, not perfectly, but a lot better.”
She blames budget cuts that have curtailed programs, limited facilities and caused staff shortages by promoting attrition. “It took 20 years for Mental Health to get to this mess…These things were working, but as people quit, they were deleted” from the list of positions. Even the post of director was vacant for four years before she stepped in.
Just in the three years she’s been director, Hepburn said the division has lost between 15 to 20 staff members territory-wide. Those left are stretched to the limit. It’s very difficult for administrative personnel, and especially problematic for clinicians who are assigned caseloads that are unmanageably large.
“How can you possibly do a good job and follow up when you have 400 people in your care?” she asked.
“It’s not to say that it’s all negative,” Hepburn also said. The system is full of people who really care and are trying to make a difference.
She and others pointed to two particularly bright spots on the horizon. One is an upgrade of the long-term care facility on St. Thomas. The other is an outgrowth of the class action suit; after three years of work by a special commission, a consultant will soon present a draft, five-year plan for overhauling mental health care in the Virgin Islands.
Gov. John deJongh Jr. has made mental health a priority, said Angeli Ferdschneider, a special assistant to the governor. She has oversight for mental health and for some areas of overlap, including homelessness and early childhood initiatives, as well as functions under the Departments of Education and of Human Services.
“Everything is not being coordinated when it comes to mental health,” Ferdschneider said. “That’s one of the problems.”
There are several entities in the mix, besides the Mental Health division.
Human Services provides psychological care for children and teens. Education has school psychologists and guidance counselors for youth. A number of non-profit groups serve clients who have problems with mental illness and/or substance abuse, and most rely on local grants and federal grants channeled through the local government for at least part of their funding.
Ferdschneider estimated that “close to $20 million a year” of government funding goes to non-profits, but added that the funds have been dropping. In effect, the government relies on some non-profits to provide services on its behalf. And then the Bureau of Corrections houses many patients who have run afoul of the law.
Mental Health itself relies heavily on outpatient services for adults who need care.
The division operates four clinics where patients can come for counseling, group sessions, and monitoring of their medication.
On St. Croix, a full time psychiatrist and a full time psychologist are on staff at the Charles Harwood Clinic in Christiansted , and a second psychiatrist will be added soon, Hepburn said. In Frederiksted, the division operates a program at the Ingeborg Nesbitt Clinic, where the non-governmental Frederiksted Health Care Inc. also provides services. On St. Thomas, the Mental Health clinic is at Barbel Plaza, where patients can also receive substance abuse counseling. The St. John clinic is open four days a week and staffed by a nurse, with periodic visits from a psychiatrist.
Hepburn gave the number of regular clients at each of the clinics, as of a few weeks ago, as 309 in Christiansted, 117 in Frederiksted, more than 400 on St. Thomas and 59 on St. John.
Mental Health operates only one residential facility in the territory, the Eldra Schulterbrandt Facility and Annex in Estate Tutu on St. Thomas, designed for severally mentally ill patients.
“We want to call it a transitional home facility,” Hepburn said. But in fact most of the residents have been there for years. It was designed for both voluntary and court-ordered clients, but most are court-ordered.
Schulterbrandt serves the entire territory, but “St. Croix needs its own,” Hepburn said.
That’s both because of the numbers of people needing a residential facility and because it is generally accepted that in most cases it’s best for people to be near to family.
The Virgin Islands also sends patients off-island to residential facilities in Puerto Rico, Texas and to St. Elizabeth’s Hospital in Washington, D.C. At the time of this interview, Hepburn said there were 17 V.I. residents being treated outside the territory. Some are receiving specialized treatment not available in the territory. But some could be returned home, if there were space for them at Shulterbrandt or if there were another facility. Five are on the current waiting list.
“We’re sending a lot of money off-island,” Ferdschneider said.
Hepburn did not have a total cost, but said, “One facility that has nine of our patients we pay close to $50,000 a month.” When you’re looking for ways to save money, “that is a biggie.”
One “gap” in the system is more of a gaping hole: emergency, crisis-driven care and stabilization.
On St. Thomas, patients whose functioning markedly deteriorates often end up at the hospital. There they are seen by a psychiatrist, evaluated, treated and stabilized. Depending on the circumstances, they may be kept in the behavioral unit for a period of days and then released, or they may be referred to a residential facility off-island or to the Shulterbrandt facility, when it has room. The unit also serves patients from nearby St. John.
On St. Croix there is no behavioral unit. It was closed a year ago and no one seems to know when or if it will reopen. In fact, there are conflicting accounts of exactly why it closed. Some blame it on a decision by the federal Centers for Medicare and Medicaid Services. But some mental health advocates think it was more of a cost-saving decision.
“Mental health service is not a profit center,” said advocate attorney Archie Jennings of the Disability Rights Center of the Virgin Islands. He thinks major cuts were made at the unit and that CMS only became involved after the fact, when it refused to allow the unit to be reopened because it was understaffed.
Longtime advocate Judy Bain, a founding member of the non-profit 10,000 Helpers, said since the unit has been closed, patients in crisis on St. Croix are taken to the emergency room and seen by a psychiatrist on-call. More often than not, they are given medication and sent home, so “the pressure is on the family.”
Sometimes they are sent to St. Thomas, said advocate Marla Matthews, of NAMI (National Alliance on Mental Illness) St. Croix. That’s better than the original plan – which was Miami – because it’s closer, but still, she said, “We need to have our behavioral unit back.”
Further complicating the challenges of mental health care is the fact that a large number of mental health patients also exhibit addiction problems. The number of people with so-called “co-occurring disorders, ” or “dual diagnosis” depends somewhat on how these problems are defined. However, there is consensus that there is a significant correlation between the two.
According to the National Alliance on Mental Illness, about 29 percent of all people in the U.S. who are diagnosed as mentally ill also abuse alcohol and/or drugs. Of those who are severely mentally ill, about half are affected by substance abuse.
There are a number of theories about co-occurring disorders. Jennings suggests one reason may be that people with mental disorders “self-medicate” with alcohol or other drugs.
Hepburn points out that the full name of her division includes both mental health and substance abuse and it has responsibility for addressing both. Government-run outpatient mental health clinics include treatment and counseling for substance abuse. However, the territory’s only actual rehabilitation center is run by a non-profit on St. Croix, the Village, Virgin Islands Partners in Recovery.
(Next: Our children in crisis.)