Too many patients, too little housing in rural California county

As of Thursday, Michelle Rivera is a proud, degree-holding alumna of College of the Sequoias, a worthy accomplishment for anyone. For Rivera — a mental health patient with a past full of reasons to have low expectations for herself — the small piece of paper has given her a totally new outlook on life.

Rivera's home life growing up in Dinuba was nightmarish. Her father abused her mother (and ultimately left), her siblings were involved with gangs and drugs, and for many years the family lurched from one financial/housing crisis to another. It was out of these circumstances, Rivera says, she developed what her therapists have diagnosed to be major depressive disorder and generalized anxiety disorder.

But Rivera's attitude changed when she was referred nearly three years ago to Transitional Age Youth, a county-sponsored housing program operated by EMQ Families First, a private, Northern California-based nonprofit agency that offers comprehensive mental health treatment. It was the first stable environment in which she'd ever lived.

The result of her new-found safety and structure was life changing — she earned an associate's degree in American Sign Language and gained acceptance into each of the four universities to which she applied.

But the stable living environment Rivera said helped turn her life around is hardly a guarantee for other patients. County health officials say all transitional housing is maxed out and patients leaving transitional facilities often have nowhere to go.

Mentally ill patients with nowhere to go often land in the streets, in jail or in and out of the hospital, county health officials say. Many develop a second problem with substance abuse, what health care professionals refer to as a co-occurring disorder.

And there are more of these patients than ever before.

An infrastructure overwhelmed

The number of mental health patients who received outpatient care from the county in fiscal year 2012-2013 was 25 percent higher than it was 10 years ago. The size of the county mental health staff hasn't kept pace.

Since 2007, the number of adult mental health patients who are hospitalized as a result of their condition is up 98 percent. The rise in hospitalizations among juvenile patients rose even faster — up 136 percent over the same period.

The issue in the general public is mirrored, if not exaggerated, in the county's jails, where data obtained from Corizon, the jail health care provider, indicates that about one in four inmates receives treatment for mental illness.

In fact, more than 25,000 doses of medication prescribed for mental illness were administered to inmates in March of this year alone, according to data obtained from Corizon.

Mental illness is of such a concern to law enforcement that the new jail in the works in Porterville will have an entire unit dedicated to mental health and others with special medical needs, Tulare County Sheriff's Captain Keith Douglass said.

Recidivism

With limited resources, county officials say they are getting creative in how they move patients through the mental health system, putting a premium on making sure that patients who start programs, finish programs, and those who get healthy, stay healthy.

"People weren't flowing through the system as well as we'd hoped," said Kent Henry, a licensed marriage and family therapist with the county. "We were seeing a higher acuity of illness. We were having difficulty keeping people out of the hospital."

This mission will involve cutting down on patient recidivism, an issue that Christopher Adams, the interim director of mental health services at Kaweah Delta, says is a challenge everywhere.

Repeat customers are typically patients who fail to take prescribed medications, Adams said.

"They don't connect the dots," he added.

Besides not taking their prescription drugs, Adams said a lot of mentally ill patients self-medicate with illicit drugs, namely methamphetamine in this area.

Setting aside the physiological consequences of such behavior, drugs often lead to run-ins with law enforcement, said Visalia Police Sgt. Jim Carr, who serves as the liaison between Visalia police and county mental health. Many mentally ill patients are charged with drug possession.

Part of helping these people must involve increasing the number of chemical addiction services in the area, Adams said.

In an ambitious effort to improve patient outcomes and lower hospitalization rates, the mental health department is undergoing a complete remodel.

The department has implemented group therapy strategies that research has proven to be most effective in treating severe mental illness, Durick said. And group therapy, he says, allows the same number of staff members to provide treatment to more and more patients.

The most severe cases — a small group of people that eat up a disproportionate amount of the budget — are being assigned to the Assertive Community Team (ACT). Severe cases are defined as individuals who have had multiple recent hospitalizations; possess a co-occurring disorder; have been involved with the criminal justice system; or are homeless or on the verge of being homeless.

ACT is a six member group of care providers — each with different specialties — that takes a more holistic approach to care. Henry leads the team.

"You can't treat the head without a roof over it," Durick said. "We're trying to establish a relationship. Patients don't trust bureaucracies."

ACT works in conjunction with the Psychiatric Emergency Team (PET) — a 24-hour rapid response unit that intervenes in crisis situations.

The individuals served by these crews are afflicted with illnesses such as bipolar disorder, schizophrenia and schizo-affective disorder, Durick added. They may see each member of the ACT team depending on their needs.

The need for the ACT and PET teams is so great that Durick said the number of patients in their care could triple if additional staffing was available.

Three of the ACT team members work from the Transitional Living Center, one of three housing units designated for mental health patients on Tulare Avenue in Visalia. The 36-bed TLC, at 546 E. Tulare Ave., is reserved for the most severe cases. And like its neighboring housing units, it's maxed out.

County officials say outcomes are good for patients who move through transitional housing, but without more permanent supportive housing, the patients in transitional housing may be discharged prematurely.

'We're not incapable'

It would've been hard to believe when Rivera arrived at the TAY program in 2011 that she could be accepted into a university, let alone four of them.

She'd tried COS before, never making it through a complete semester. She commuted from Dinuba, but where exactly in Dinuba was never the same. She and her mother moved frequently.

"I would stop unpacking," she said. "I just kept my stuff in bags."

When she started the TAY program, Rivera admitted she smoked marijuana, a habit she picked up at 14 and tried in vain to quit before.

"I didn't smoke for the high, I smoked to function — to counteract the depression," she said. "I did it with friends, then I did it alone, then I started stealing from my family to support the habit."

At TAY she was assigned a roommate, a girl with a similar background. The two hit it off, quickly becoming good friends.

"We understood each other," she said. "We were compassionate and had more empathy for each other."

With the support of her peers, Rivera quit smoking marijuana. She finished a semester in school. Then another semester.

"Being here, having a stable place, setting boundaries with my family, meeting with support staff and being closer to COS — school was easier," she said. "I had time to focus on myself. I started passing my classes, I raised my GPA."

She also reduced her dependence on pills.

"I'm down to a really low dosage," she said. "I've been on pills since I was 9 — I got so dependent. Now I have control. I don't just pop a pill."

Now, Rivera says she's found her calling. She developed a love of writing in English class that led to a tutoring job that Rivera thinks could lead to a career.

"I like reading other people's thoughts and stories," she said. "I implement writing techniques and also self esteem... I want to do this as a living."

Rivera heads to San Jose State in the fall, armed and ready to prove to society that people who struggle with mental illness are not incapable.

"I work, I'm getting a degree, I volunteer," she said. "No one thought I'd do that."

This story was originally published in the Visalia Times-Delta

Photo credit: Ron Holman/Visalia Times-Delta.