Vermont’s mental health crisis

ON MARCH 21, police in Burlington, Vermont responded to a call about an elderly man, Ralph Grenon, behaving erratically and threatening other tenants in his apartment complex. Grenon, who suffers from paranoid schizophrenia, had locked himself inside his apartment and refused to speak with police.

After five hours of making little progress, police entered the apartment and found Grenon in his bathroom and holding two knives. Shortly after, according to the official account, one of the officers shot and killed the 76-year-old when he advanced toward them.

This is the second time in two and a half years that Burlington police have killed a mentally ill man that they were supposed to help. In 2013, a mother called police for assistance because her 49-year-old son Wayne Brunette was wielding a shovel and destroying property. Two minutes after police arrived, Brunette was dead.

Brunette's death brought attention to the chronic underfunding of community-based mental health care services. After the financial crisis hit in 2008, Vermont, like most other states, began gutting social programs in order to fill budget gaps. Mental health services were among the hardest hit.

In response to criticism of the shooting, then-police chief Michael Schirling bluntly stated, "We simply do not have the resources to adequately respond to folks who have critical medical needs in the form of mental health care."

With inadequate services in the community, people in crisis were increasingly having run-ins with police. Between 2008 and 2013, police saw a 400 percent increase in mental health-related calls.

Despite making statements reaffirming his commitment to providing quality mental health care, Vermont's Democratic Gov. Peter Shumlin continued gutting the system with more budget cuts. Without access to necessary services, it was only a matter of time before someone else got killed.

In both Brunette's and Grenon's deaths, there are important questions about how police handled the situation. But there is another equally important question that needs to be answered: Where were the mental health services that could have avoided these crises altogether?

GRENON'S DEATH comes on the heels of multiple reports detailing the chronic underfunding of the mental health care system in the state. Vermont's mental health system is almost completely privatized. The Department of Mental Health contracts with 11 private, non-profit providers referred to as Designated Agencies (DAs).

With 1,400 employees and a $90 million annual operating budget, Howard Center is the largest DA in the state. The agency provides a wide range of critical services including 24-hour crisis response, substance abuse treatment and school-based services.

The Green Mountain Care Board (GMCB) analyzed the budget and Medicaid rates of Howard Center, and its conclusions were damning:

In summary, our analysis revealed that Howard Center's current budget does not adequately fund the institution's desire to accomplish its client service missions, as evidenced by lengthy waiting lists, over 100 staff vacancies, and the closure of valued community services...Further, we believe that the underfunding and resulting understaffing of this institution results in substantial unmet needs, which in turn affects many Vermonters.

Medicaid reimbursement rates, which make up roughly 80 percent of revenue for designated agencies, have either remained stagnant or been cut for several years. As a result, critical community services for people like Brunette and Grenon have been curtailed or altogether eliminated.

A white paper released by Vermont Care Partners (VCP), an organization with representatives from all 11 designated agencies in the state, identified poor recruitment and retention due to low wages as the single biggest obstacle to delivering necessary mental health services.

DA funding levels are now 15 percent below increases in the Consumer Price Index. According to a 2015 survey, almost a quarter of the 13,000 employees make under Vermont's livable wage amount of $13 an hour.

There are currently 350 vacancies across all the agencies, and it's common for positions to go unfilled for a year or more. Of the positions that do get filled, most don't stay that way for very long. For the last three years, designated agencies averaged a staff turnover of 27.5 percent annually--more than double the turnover rate of many other state employees.

With so many workers leaving every year, it's impossible to maintain a well-trained and experienced workforce. "We are faced with using less educated and credentialed staff, who will work for lower wages, to provide services which Master level/licensed staff should be performing," VCP reports.

Chronic understaffing, according to VCP, means larger caseloads for the remaining employees and longer wait times for clients:

Underfunding of the system of care has led to wait lists for various services including hundreds of people waiting for outpatient therapy; nearly 500 children and youth waiting for family, school and community based services; and hundreds of people are waiting for substance use disorder and outpatient mental health treatment.

The problem has gotten so bad that GMCB raised concerns in their report about how much longer Howard Center "can meet its programmatic and statutory mission."

VERMONT HAS relied heavily on designated agencies for community-based services since the 1960's, but until 2011, there was still a state-run psychiatric facility, Vermont State Hospital (VSH), to care for the most acute cases.

After being decertified in 2003, VSH lost access to Medicaid funding, making the hospital a significant financial burden for the state. Conservatives had been trying to close the hospital for years, but they had been unsuccessful, due in large part to opposition from the Vermont State Employees Association (VSEA).

Back in 2007, VSEA argued that the plan was "nothing more than an attempt by the Administration to wash their hands of the mental health system through privatization."

It wasn't until Hurricane Irene flooded VSH in 2011 that the political balance of power shifted. Shumlin used the disaster as an opportunity to close the hospital and further privatize the system. Instead of a large state-run facility, the administration would create a decentralized system of smaller psychiatric units run by run by non-governmental service providers like Howard Center.

Shifting to designated agencies had the double advantage of regaining access to Medicaid funds and removing roughly 200 workers from the pool of state employees represented by the VSEA. The Ethan Allen Institute, a conservative think tank in Vermont, advocated for closing the hospital in part because it would "diminish the VSEA's breadth and reach, i.e. membership base and dues."

Since the financial crisis began, the VSEA had been a strong source of opposition to budget cuts. As a result, the administration tried to minimize cuts to public agencies. By contracting with designated agencies the government was able to bypass the VSEA altogether, making mental health services a prime target for the budget axe.

Shumlin framed the new, decentralized system as a more ethical and cost-effective alternative to institutionalization. The only problem was that he never had any intention of providing the financial resources needed to make this vision a reality. What he was really doing was packaging neoliberal policies as leftwing reforms.

Designated agencies were, in theory, going to provide enough community support that the need for psychiatric beds would be minimal but the reality has been very different. Since the closing of VSH, there has been a chronic shortage of psychiatric beds throughout the state. Many of the people in need of psychiatric placement wind up in the ER.

EMERGENCY ROOMS typically do not have the staffing or resources necessary to treat psychiatric patients, as a result, they basically function as a holding facility while the patient waits for a psychiatric bed to become available.

Emergency hospitalization is both astronomically expensive and almost completely ineffective, making it one of the worst methods of treatment. "The ER wasn't designed to house patients," explained Dr. Jesse Ritvo, a psychiatrist at Central Vermont Community Hospital, in a report by the Vermont Medical Society. "It was built for triage medicine. It is stressful for me and horrible for the psychiatric patient and it shouldn't be happening."

This is not to say that we should go back to institutionalizing those in need of psychiatric care. VSH had a long history of offering poor care, at times abusing and neglecting patients.

A system that allows people to remain in their community while still accessing necessary services is of course a preferable alternative to institutionalization. But without adequate resources and infrastructure, closing the state psychiatric facility has simply meant fewer options for people in crisis.

The Shumlin administration would have us believe the government's hands are tied and that its austerity budgets are simply a response to the "fiscal realities" created by the financial crisis.

While it's certainly true that state revenues at their current levels are too low to fund social services, this has almost nothing to do with the financial crisis and almost everything to do with the neoliberal restructuring of Vermont's economy under Shumlin.

Since 2008, Vermont has had one of the fastest growing economies in the Northeast but tax breaks and various economic incentives have meant that almost all of the wealth has gone to those at the top. Despite a strong economic recovery, tax revenues have still not reached their pre-2008 levels.

It's been encouraging to see agency administrators becoming more public in their criticism of the government, but their fear of alienating democratic allies in the state house--combined with an inherent aversion to an organized workforce--will always be a barrier to supporting the strategy and tactics capable of winning reforms.

Without the inclination or ability to confront the state, DAs are ultimately in the self-defeating position of working against the development of the very social forces that could win these demands. This is the reason that Howard Center's former Director, Todd Centybear, could champion the demand for more funding and higher wages and then hire a union-busting law firm out of Boston to handle contract negotiations with the agency's direct care service providers.

Given the proper funding and infrastructure, community-based care would have a big step forward in the quality of mental health care in Vermont. Such a system would allow vulnerable populations access to necessary services while remaining embedded within their network of social supports.

There is no reason this vision can't become a reality. But our strategy must not rely on playing nice but building our power.