Compare it to drowning.

A person is slowly sinking in an ocean while a crowd gathers to watch, horrified. They know the swimmer needs help, but no one there is trained to give it. Heck, everyone there would pay for someone to help this poor guy — they all have the money. They’d even tack on an extra incentive for whoever does it. But still, no one comes forward, despite the crowd’s best pleas.

This is the situation providers of mental health care in Western North Carolina find themselves in daily.

They aren’t the ones drowning — those would be the residents of WNC suffering from some form of mental illness who find themselves struggling to get the care they need. Some estimate that as many as one in five suffer from some kind of mental health problem, though not that many need treatment.

The dire lack of trained professionals in the region is a situation providers like the Smoky Mountain Center for Mental Health — which oversees care for patients in 15 western counties — are acutely aware of. Funding isn’t the problem. Recruitment is. And as a result, patients are suffering.

“There are some that are getting enhanced services,” said Tom McDevitt, area director for the Smoky Mountain Center, “and then there’s a reasonable amount that are getting limited to no services.”

“I think that’s fair to say,” agreed Doug Trantham, Smoky Mountain’s service management director. “Providers could serve more consumers if they could fill all the positions they need filled.”

The professional to patient ratio is staggering. Psychiatrists and subtance abuse professionals in particular are hard to come by. For example, Macon County had zero psychiatrists in 2006, but 2,591 people in need of one. Haywood County had a ratio of 524 substance abuse patients per each professional.

Long waits, limited services

Recruiting licensed professionals — those with master’s degrees in psychology, psychiatry, counseling and related fields — is harder than ever, and patients are feeling the effects.

“We have longer wait times to get appointments than we’d like. We’d like to be able to serve everybody very quickly when we get a call, but our psychiatrists are booked out and very, very busy. We’re always struggling,” Trantham said.

Getting in to see a doctor quickly is just as critical for mentally ill patients as it is for those with a chronic medical condition. Judy Sipes, a local advocate for the mentally ill, equates it with having diabetes. If that patient’s insulin suddenly stopped working properly and they weren’t able to get hold of a doctor for several weeks at a time, the recovery process would be hindered, Sipes said.

Sipes has had to go through the waiting process with her brother, who suffers from bipolar disorder and substance abuse issues.

“It’s like a lot of times if they’re having emotional issues, and they’re having anxiety attacks or panic attacks, you can’t hold somebody down for two weeks,” she said.

Sipes is currently in the process of moving her brother to a private provider.

In contrast, Smoky Mountain Center is a state-funded local management entity and is not private. The Center contracts the largest portion of its dollars to Meridian Behavioral Health, a local non-profit provider.

Sipes said she feels like Meridian is too overwhelmed to provide the level of care her brother needs.

“We just feel like Meridian doesn’t have the personnel. They’re too overstressed right now to give any amount of individual attention,” she said.

Sipes’ brother recently went through a time of “upheaval,” she said, and is especially in need of individual attention, which, she says, seems hard to squeeze in at Meridian.

Officials with the Smoky Mountain Center admit there is a lack of a broad range of services, including individualized ones, available for those in need.

After being hospitalized, patients “come back out and there is a tremendous gap in the availability of community-based services,” said McDevitt.

“There are some waiting lists, but (the problem) is probably just a smaller menu of services that are available to people,” agreed Steve Puckett, director of clinical services for Smoky Mountain Center. “Instead of enhanced, they may get a more generic service.”

Enhanced services refer to a more comprehensive combination of services, involving something called an Assertive Community Treatment, or ACT, team. An ACT group includes a licensed professional, and the team is required to visit with a patient for a certain amount of time per week. Basic level services are things like medication management, outpatient therapy, and occasional visits with a psychiatrist.

Recruiting proves

tough locally

Why it’s so hard to recruit trained professionals to provide services to the mentally ill is a broad question. The dilemma is statewide, but seems to affect rural areas more than urban ones.

“In some urban areas of the state, it’s a very different picture. They have a lot of providers, though maybe not the quality of providers. In the far west, it’s a relatively large rural area and it’s always been challenging to recruit enough staff,” said Trantham.

It’s particularly challenging in the most rural areas of WNC, like Cherokee, Clay and Graham counties, said Denise Gaskin, Meridian’s director of quality assurance. The seven western counties treat up to 12,000 mental health patients a year.

“I think the hindrance is if we recruit somebody from out of the area, we don’t know if they’re going to enjoy a very rural place,” she said. “And most of the time, people want to move to Asheville. If they want to work in Sylva or Bryson City or Franklin, that just becomes a really long commute.”

State reforms impede

care process

Statewide, the mental health reforms of the last few years have made it hard on those already in the field, and discouraging to those who are considering entering it.

“It’s been a very challenging several years. The funding is challenging, and the system has been changing rapidly. Requirements are significant and hard for us to keep up with,” said Trantham.

The reforms focused on placing mental health care back in local communities with outpatient services. This has posed a problem for areas like WNC, where the necessary outpatient services were lacking. The reforms also put emphasis on the individual patient and require providers to create “person-centered plans,” which are meant to focus on the specific needs of each individual and move away from general diagnoses. Though nice in theory, this meant an avalanche of paperwork for those providing care to the mentally ill.

“We added it up one time, and to get a brand new person registered to begin receiving services was 80 pages of paperwork,” Gaskin said.

Gaskin said the mountains of paperwork have been a hindrance to those in the field. But “it’s not just the paperwork,” she added. “It’s also the constant change. Every time you turn around, there’s a brand new service definition or implementation guidelines.”

On top of that, providers face intense monitoring and productivity standards. An individual working for a provider is offered a certain salary contingent on working a set number of hours. Each hour of service must be documented by more paperwork at the end of the day and billed to Medicaid.

“You’re trying to make a schedule first of all, and make it so you make productivity standards, then leave enough time to do paperwork because you have to document service in 24 hours,” Gaskin said.

“There’s a lot of pressure to be very organized. We actually call that being a good practice manager. It’s a different skill set from being able to really work with people and being able to provide a really good service. What we’re asking our folks to do is be good at both, and that’s what people are struggling with being able to do. Some people just throw up their hands and say, I just want to work with people; do skill-building; do treatment,” she continued. “Some people say, ‘I didn’t go to school to be a master’s of paperwork.’”

Dr. Marsha Hammond, a local psychiatrist and outspoken critic of mental health reform, denies there is a shortage of trained professionals at all. Instead, licensed professionals simply don’t want to deal with the amount of paperwork that comes along with clients whose care is funded solely by the state.

“There’s only a shortage because people are not willing to work with the criteria,” she said. “You could submit buckets of paperwork, then they would go over it with a fine-toothed comb, pick it apart and your services still won’t get authorized.”

Sadly, Gaskin thinks the obstacles to providing mental health care have driven people away from the field. When the reforms initially happened, some professionals chose not to go through with it at all, and went to work for the Department of Social Services or Department of Health. Others stayed on for a year or more, only to give up in frustration.

Word of the difficulty complying with the mental health reforms in North Carolina has spread to other states, said Gaskin.

“I think people have gotten the word that North Carolina is going through a major change process, and that is really difficult. I think that has discouraged some people from entering this field and moving to North Carolina,” she said.

“I think when you look at the type of fields people go into and where they choose to live ... factors come into play, such as is this a stable field to work in? The challenges of the last few years have not been real helpful in that regard,” added Trantham. “What we’ve got to do is provide an environment where people that want to work in this field will be supported.”

Substance abuse positions

toughest to fill

In WNC, professionals specializing in treatment of substance abuse issues are the hardest to come by.

“It’s hard to find people who have a dual credential both in mental health and substance abuse,” said Gaskin.

For example, Smoky Mountain Center currently has five proposals out saying it needs agencies to provide substance abuse assessment services for continuity in the jail system, said McDevitt. So far, there hasn’t been a response.

The training one must undergo to become licensed in treatment of substance abuse is incredibly intensive, time-consuming and often expensive. For this reason, providers are reluctant to invest in the certification process.

Those with substance abuse issues also have a low rate of Medicaid eligibility, Trantham said, meaning patients must rely on state funds to pay for care. Substance abuse receives less state funding than other disability types. Professionals are reluctant to go into the field because the income is from a less stable revenue stream.

“Without any question, the shortage we have of professionals, particularly in the substance abuse arena, creates huge challenges,” said McDevitt.

There are few enhanced services available to substance abusing adults and methemphetamine addicts in the seven counties west of Asheville that Smoky Mountain Center oversees. Instead, treatment consists of intensive outpatient therapy given at three recovery education centers in Haywood, Jackson and Cherokee counties. Addicts attend classes on how to understand and manage illness, and how to develop a plan of recovery.

The centers are “heavily peer run by people with substance abuse or mental issues,” said McDevitt. This style of therapy is known as peer support, where people who have faced mental health issues go through a certification process and eventually help others in recovery.

“The peers aren’t designed to replace the professionals,” cautioned McDevitt. But peer support does allow patients to receive some help in the case of a dearth of substance abuse professionals.

“It’s not designed to replace treatment, but when we have that void, to have some support available is better than providing nothing,” said McDevitt. “Where it doesn’t exist, we’re trying to fill the gap where someone would be supportive and efficient.”

Patient support in group settings can also be cost-efficient and allow the maximum number of patients to be seen.

“It allows us to see more individuals than we would if we were doing one hour outpatient sessions. We created that program so we could really maximize state funds,” said Gaskin.

In the absence of professional treatment, most would agree that something is better than nothing. But peer support is not without its detractors.

Sipes said that the intensive outpatient therapy isn’t intensive enough, and the ability to intervene in a crisis is something the program lacks.

“For substance abuse people, you don’t have a lot of time when they start slipping and sliding into regression. They need someone with influence who can act quickly,” said Sipes. The program “is just not far-reaching enough to grasp the needs of individual patients,” she said, and added that “individual attention has got to be thrown in somewhere,” in the recovery processes.

Hammond said that Smoky Mountain Center has “put its eggs in that basket because they thought it would be an economical way to treat people with mental illnesses.” But Hammond cautioned that peer support isn’t a substitute for one-on-one therapy, which involves “a much more intimate development of a relationship that is supposed to be life-changing.”

Solutions?

There is hope on the horizon for the situation in WNC. In the field of substance abuse, things are “slowly improving,” Trantham said. “More people are pursuing that credential, and we’re starting to see some new social work graduates in the substance abuse track.”

To help things along, the Smoky Mountain Center is unveiling a new initiative that officials hope will entice more people to become licensed in substance abuse treatment. The Center will give subsidies to provider organizations as an incentive to encourage professionals to receive their licensed clinical addiction specialist degree.

In the meantime, Smoky Mountain Center has recently opened its doors to the possibility of contracting with individual practicioners specializing in substance abuse who aren’t part of a larger provider organization.

“We’re going to say if somebody were here and had the right credentials and experience, if they wanted to provide treatment, that we would contract with them,” said McDevitt.

Smoky Mountain Center hopes this will provide a short-term fix. Mental health reforms initially proposed that local management entities would receive basic services from enhanced service providers. This hasn’t happened in the field of substance abuse.

“If they can’t do it, then we might as well look at other people to pick up the void,” McDevitt said.

The downside of this is that individual practicioners can’t provide anything except basic services, since enhanced services would require them to be available to patients 24/7.

Mental health statistics

Persons in need per psychiatrist (2005)

Macon 2,591

Haywood 1,911

Swain 955

Jackson 794

Persons in need per mental health professional, including psychologists, clinical social workers, professional counselors and marriage and family therapists (2006)

Macon 81

Haywood 55

Swain 64

Jackson 26

Persons in need of substance abuse services per substance abuse professional (2006)

Macon 358

Haywood 524

Swain 148

Jackson 313

Psychiatrists per county (2005-2006)

Macon 0

Haywood 2

Jackson 3

Swain 0

Mental health professionals per county (2006)

Macon 6

Haywood 7

Jackson 9

Swain 6

Source: N.C. Department of Mental Health Quality Management Team, 2007