Mental Health Care Digging Out of the Rubble

This is the third in an ongoing Source series on health care in the Virgin Islands.

For decades, mental health care in the Virgin Islands could most generously be described as “inadequate.” Now, it appears to be “in flux.”

Spurred by federal interventions following the September 2017 hurricanes, a cadre of V.I. government officials, medical professionals, and advocates have been quietly working in the background for the past year and a half, and their efforts are about to pay off in the form of a major – albeit somewhat temporary – upgrade to staff.

Though less certain, a significant upgrade to facilities is also envisioned. That depends in a large part on whether the territory gets the necessary funding through a federal grant request.

Longstanding shortcomings

The Eldra Schulterbrandt Residential Facility on St. Thomas. (Government House photo)

Before the storms hit, the V.I. Health Department operated four clinics throughout the territory, providing such outpatient services as counseling, group sessions and medication monitoring. There was only one place – the Eldra Schulterbrandt facility on St. Thomas – for long-term residential care housing 32 people from all three islands, and all experts agreed it was not nearly enough.

There was no place for patients who committed criminal offenses, including those judged not guilty by reason of insanity, except jail on St. Thomas or prison on St. Croix, neither of which has a forensic unit, a section devoted to housing and caring for such inmates. Consequently, the Bureau of Corrections has been in violation of federal mandates for decades.

Crisis intervention care was available at the hospital on St. Thomas, where a patient who was judged as posing a danger to him or herself or to others could be held for up to 72 hours and be evaluated and treated. The hospital on St. Croix struggled to provide the same service but it was unavailable for long stretches.

The local government was paying millions of dollars a year to house patients off-island, dividing up the costs among three departments depending on the individuals: troubled adolescents fell under Human Services, severe-needs inmates were covered by BOC and other adult patients were the responsibility of the Health Department.

Then things got worse.

The hurricanes rendered both hospitals, the Schulterbrandt facility and the outpatient clinic on St. Thomas unusable for many months. Many health professionals left the territory, exacerbating an already short supply . Meanwhile, the need increased, as residents tried to cope with the stress of the hurricanes and the aftermath of protracted recovery.
Silver lining

The situation got so bad it drew attention from the federal government and from some national organizations.

Most notably, the Substance Abuse and Mental Health Services Administration – an arm of the U.S. Department of Health and Human Services – organized a meeting of local stakeholders in March 2018. It included representatives from various V.I. departments and agencies as well as non-profits that provide mental health and substance abuse services.

Out of that meeting grew the Behavioral Health Coalition, with a steering committee that is as low-key as it is high-powered. Members include former Delegate to Congress Dr. Donna Christensen, attorney Archie Jennings of the Disability Rights Center, Rita Dudley Grant of Island Therapy Solutions, Nicole Syms, assistant commissioner of Health and acting director of its Behavioral Health and Substance Abuse division, and Berlina Wallace-Berube of Beautiful Dreamers Mental Health Services (and former director of the division.)

The steering committee has continued to meet by phone weekly up to the present. In December, it developed a list of immediate, intermediate and long-term recommendations for Gov. Albert Bryan’s transition team, and it clearly has the administration’s attention.

In March, Bryan declared a “State of Emergency” for mental health. Like a previous order by his predecessor, former Gov. Kenneth Mapp, it waives the law that prevents Health from rehiring retired psychiatrists. It also allows for mental health providers in the U.S. Public Health Services Commissioned Corps and other federal programs to be deployed in the territory.

The administration also has reactivated a standing entity, the Behavioral Health Planning and Advisory Council, which includes some members of the steering committee. It’s already had two meetings, Syms said.

An immediate goal is improving crisis intervention.

“We don’t even have psychiatric beds” on St. Croix, Grant said, a situation she described as scary. She’s had patients who were potentially dangerous but could not be confined because there was nowhere for them to go. Once the modular units at the Juan F. Luis Hospital are functioning, there will be seven beds for crisis care.

But that is months away. Currently, the only holding facility is a corner of the Juan F. Luis Hospital emergency room – if it’s not being used. Christensen said the hope is to free up a couple of rooms and maybe three beds in the meantime.

On St. Thomas, at the Schneider Regional Medical Center, 10 beds are designated for crisis intervention, but because of staffing shortages, normally seven is the maximum number of psychiatric patients at any one time, she said.

The facilities for outpatient care are doing better. Repairs were made to the Barbel Plaza facility on St. Thomas; the two clinics on St. Croix and one on St. John are operating.

But there’s another problem.

Figures released by Health officials indicate that in recent years the number of people being served at the clinics fluctuated around 700 or 800 territory-wide.

“I’d say those numbers have doubled since the storms,” Syms said.

A Community Needs Assessment report released in February suggested that about 42 percent of students and 57 percent of adults who were surveyed by researchers were at risk for post-traumatic stress disorder linked to the hurricanes. This situation even drew the attention of National Public Radio which released a story about it last week.

The findings were no surprise to Grant, who said that when people are severely impacted by life-altering events, “the capacity to manage everyday stress is lessened.”

She said she sees many clients who are having difficulty coping now. Sometimes, it’s a matter of a build-up from a series of events. In some cases, the trauma even seems to have started with Hurricane Hugo in 1989 and/or Hurricane Marilyn in 1995.

Grant said there has also been a spike in the segment of the homeless population with behavioral issues.

Momentum building for reform
With help from various federal agencies and from the non-profit group Black Psychiatrists of America, there are a number of plans in the works to improve mental health care.

Those include restructuring the division of Behavioral Health and Substance Abuse to give it one director and then two assistant directors, one for behavioral health and the other for substance abuse, Syms said. A director has been identified and should be in place by mid-May. The department has advertised for assistant directors and candidates are currently being vetted.

As part of an emergency response grant, the territory is requesting 25 additional professional staff, including counselors, psychologists, nurse practitioners, social workers and therapists, she said.

Staff provided by the federal government will be contracted for a year, so during that year the department will need to get permanent replacements on board, Syms said.

Another grant request includes a contract under which Black Psychiatrists of America would provide up to five psychiatrists to the territory on a rotating basis. Each group of five psychiatrists would work in the territory one week at a time, providing on-site service four days and tele-medicine services one day. That would dramatically increase services; Syms said Health currently has just one full-time psychiatrist on St. Thomas, one part-time psychiatrist on St. Croix, and none on St. John.

The division is also emphasizing education and training, she said. A major initiative is conducting workshops for teachers, social workers and police officers who may encounter persons with behavioral difficulties, training them in recognizing problems and in de-escalating potentially dangerous situations.

Additionally, “we’re working on a plan for training for counseling after a disaster,” Syms said. After Hurricanes Irma and Maria, the Substance Abuse and Mental Health Services Administration and the U.S. Department of Human Services sent teams to the territory to provide counseling; with training, local staff should be ready to provide that service.

Improvements to mental health infrastructure are less immediate – and less assured – than plans for personnel, but there is serious discussion about establishing a forensic unit and a residential care facility on St. Croix.

Currently, Syms said, there are 26 residential mental health clients being housed off-island. That costs Health between $6.5 million and $7 million a year. (Add in the cost of stateside care for children and adolescents who are the responsibility of Human Services and the cost is $20 million. According to a recently filed motion in ongoing litigation over the treatment of V.I. inmates, the government was contracting to pay $2.4 million annually to house 14 chronically mentally ill prisoners to a stateside facility.)

Even at just the $6.5 million figure, there is clear financial incentive for establishing another residential facility in the territory. It is also an accepted tenet that most patients fair better if they are near family and in familiar surroundings.

To the ACLU (American Civil Liberties Union) lawyer who filed the motion early this month to put the Bureau of Corrections in receivership, the plan for a second, St. Croix-based mental health residential care facility is “a pipe dream.” It is the same plan the government presented 15 years ago.

But Syms sees progress. The Legislature, which long ago provided a 9.9 acre site in Anna’s Hope, has now appropriated $2 million towards construction.

Total cost will be between $15 million and $30 million, Syms said, but she is hopeful that a federal grant will make up the difference in the not-too-distant future.

“We have hundreds of people seeking residential care,” she said. “We want it to be a revenue-generating facility,” serving not only the territory but people from other Caribbean islands.

The Anna’s Hope facility would be bigger than the Schulterbrandt facility (which sits on 2.9 acres) and would provide a wider range of services. It would serve not only permanent residents but could also be a “step-down” or sort of halfway home for people who receive treatment but who are able to work and otherwise function in the community.

It might also include a forensics section. Syms said zoning laws prohibit that use at the Schulterbrandt facility because it is not set far enough away from nearby residential properties. The larger site for the proposed Anna’s Hope facility makes a forensics unit there more feasible.

There is also the possibility of establishing a forensics unit at some now unused buildings at the Golden Grove prison on St. Croix, Syms and Christensen said.

That, too, hinges on funding.

Advocates are optimistic despite the long history of neglect that has characterized the V.I. mental health system.

“People are starting to pay attention to it,” Grant said. She served on a panel at a recent town hall meeting and talked about mental health to a packed house.

“What gave me a lot of hope is the amount of attention being paid by the community,” she said. “I think now is the time.”