Illustration by Marissa Goldman

What It's Like to Live in a Mental Healthcare Desert

One state that needs resources the most has the least.

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Apr 7 2017, 3:10pm

Illustration by Marissa Goldman

Missy McLean's first hint that something had gone horrifically wrong on her brother's Labor Day weekend in Las Vegas was a panicked phone call from the friend who was supposed to be with him.

"She told us that he was having a full-blown manic episode and she couldn't control him, so she left, she came back home," says McLean, a 35-year-old communications specialist from Toronto, Canada (where her brother lived, too). "She just abandoned him in a foreign country, in a city where he knew nobody."

The friend also unwittingly left McLean's brother—whose name Missy is withholding—in the worst possible location for suffering a bipolar-induced breakdown. In 2013, the year McLean's brother went missing, Las Vegas was in the grip of a full-blown mental health crisis. Without enough beds in the Rawson-Neal Psychiatric Hospital in Las Vegas and other psych facilities around the state, hospital ERs were jammed with people suffering from mental illness—an average of 139 a day. If a bed didn't open up by the time the clock ran out on the mandatory three-day psych hold hospitals used to keep them, many people were turned away, back to the streets, and often wound up either in jail or back in the ER a day or two later. But some disappeared forever, or turned up as a Jane or John Doe in the morgue—and that's what Missy McLean most feared for her brother.

Two days after his friend fled, McLean's brother was picked up by police for causing a disturbance in a hotel on the Las Vegas strip. He was jailed, but officers soon realized he wasn't just another drunk on a bender, and dumped him at a nearby ER. McLean, who started speed-dialing every Sin City precinct and hospital the minute she heard he'd come unhinged, finally got word of his whereabouts.

But she didn't know if he would still be there by the time the family arrived to take him home. "I asked the nurse if he had a social worker overseeing his case and she told me they don't do that anymore. I don't know much about the US healthcare system, but as I was trying to navigate it in the middle of a health crisis, it became really evident how dire the conditions are in Nevada, and how poorly the people are treated down there," says the married mother of two. "I was desperate to get my brother out of there."

Nevada is a mental healthcare desert—a state where access to professionals who treat mental illness is startlingly low—and it's one of many in the US. Research from 2014 shows that at least ten states, including Mississippi, Utah, and Tennessee, consistently face a similar scarcity of resources for those struggling with depression, anxiety, and addiction, among other conditions. People who fall into the low-income category or who live in rural, isolated areas are the hardest hit. In some states there's only one mental health professional per 1,000 residents. That's psychiatrists, psychologists, social workers, counselors, and psychiatric nurses combined.

Image: Mental Health America

Technology seems to be driving much of the isolation and unhappiness in this country, as we sit alone at home instead of connecting with real live humans, or subject ourselves to bullying over social media. But it also seems to be facilitating some of the most successful interventions: Call centers in mental healthcare deserts have started using texting and other telehealth approaches to keeping people safe.

In some states there's only one mental health professional per 1,000 residents. That's psychiatrists, psychologists, social workers, counselors and psychiatric nurses combined.

Across the US, more than 40 million people are struggling with some kind of psychological concern—more than the population of Florida and New York combined, according to Mental Health America, an advocacy group that tracks treatment and care accessibility nationwide. Research shows that more than half of adults in need—56 percent—don't receive treatment, and youth mental health problems are on the rise. Six out of ten young people with major depression can't or won't get care.

Four years after McLean's brother's incident, little has improved in Nevada. It remains the worst state for mental healthcare access in the US—despite its high prevalence of mental illness and its off-the-chart suicide stats. It ranks fourth-highest for suicide in the nation overall, and among people 65 and older, the suicide rate is double the national average—33 per 100,000, compared with 17 per 100,000 nationally. Younger people don't fare much better; self-inflicted wounds are the second-leading cause of death in Nevada for 15- to 24-year-olds. And despite its fairly low gun ownership, firearms are used in 53 percent of the state's suicides—twice the national average.

At the Nevada Crisis Call Center, director Anna Duffy is well acquainted with the dearth of services available to most Americans outside of large cities on the east and west coasts. She and her volunteers—roughly two dozen seniors and a few college students—handle Nevada's general crisis line, set up decades ago as an effort to control the state's burgeoning mental health demands.

They also pick up overflow calls from the National Suicide Hotline. Last year they answered more than 65,000 calls—and every year they seem to get more, Duffy says. Then there are the consoles that receive crisis texts, sent mainly from teens and twenty-somethings. The volunteers use keyboards to type responses, sometimes handling up to three conversations at a time. 

Duffy says that for young people in particular, the anonymity of technology is comforting. "You can't hear the emotions come through and they like that—we can't tell if someone's voice is breaking for instance and they're crying, or if their cadence shows they are getting upset," she says. "This is what they've grown up with and it's more comfortable for them."

Conversely, it also helps Duffy and her cadre of mostly senior volunteers disguise their ages.
"Most of our texters are under 20," she says. "They want to think we are too. It helps maintain the illusion that they're talking to a peer."

The first goal for volunteers is to listen and help avert the current crisis—not sign on as a caller's regular therapist, even though that is often want what callers really need.

It also helps that the first rule for volunteers at the Nevada Crisis Call Center is that there is no single way to offer empathy—in other words, there's no script to follow. "You have to use what comes naturally to you," Duffy says, and that includes texts. "The first thing we want to do is establish a rapport, and you can't do that if you're reading off a piece of paper."

Volunteers get two full days of weekend training, including Applied Suicide Intervention Skills Training, or ASIST. But they are cautioned against trying to counsel or solve callers' problems. The first goal, always, is to listen and help avert the current crisis—not sign on as a caller's regular therapist, even though that is often want what callers really need.

"The whole premise of ASIST is 'How do we keep you safe for now? Do you have pills? A knife or a gun?' Volunteers are trained in active listening, to be alert for cues. For example, does a caller say they've written a will, or found an adoptive home for their pet? Things like that are a cue that they might be serious about suicide and are putting affairs in order," Duffy says. In an emergency, call center volunteers can dispatch a local 911 call to an address, no matter where it is in the country. But most of the time, the Nevada Crisis Call Center is all about keeping people talking and formulating a plan of action to get through the crisis. Some callers who struggle with suicidal ideation even call back on a regular basis.

"Many are mentally ill and find it hard to maintain friendships," Duffy says. Recognizing their need, even if they are not in crisis, the center allows regular callers to chat up to ten minutes once or twice a week, depending on their state of mind.

It's not so easy via text. In fact, the text conversations volunteers have from the call center illustrate the double-edged sword that technology brings: In theory, and in some ways in reality, tech brings people closer—connecting a rural patient to a city therapist, for example. But in other ways, it's the very same texting and social media that has catalyzed people's mental struggles, particularly among today's young people, who can feel isolated and even terrorized by bullying on social media.

In Arizona, a state ranked in 50th place in terms of mental illness prevalence and lack of access to care, technology is filling many gaps for rural populations, says Kristina Sabetta, who works with Mental Health of America Arizona. Thanks to Arizona's generous Medicaid benefits, those who qualify for the low-income program get swift and frequent treatment, Sabetta says. But middle-class residents who earn too much to receive Medicaid yet can't afford private insurance fall through the cracks, she notes. Ditto for the rural residents who can't afford to pay for internet service. And there's almost no help for the incarcerated. "We are sixth in the country for our incarceration rate," Sabetta says. "And our mentally ill aren't getting what they need in jail."

In addition, mental health among Arizona youth has worsened significantly in recent years—a side effect of cyber-bullying and the omniscient reach of social media in teens' lives, she says. "We don't pay enough attention to our education system out here," says Sabetta, who advocates for better training of teachers to recognize warning signs of depression or other mental illness among students.

But there's no denying technology is a boon among Arizona's less-populated areas. "In this state we have a huge rural community. Our Medicaid funders have been pretty good about opening up technologies, making sure people do have access to the internet so that they can access care, like tele-health and psychological counseling," Sabetta says.

Mental Health of America is also pushing online screening for common psychological disorders via its web portal—and through kiosks placed at local Walmarts across the south, where there are many mental healthcare deserts. Users can take a simple test to find out how likely they are to be at risk for depression, bipolar disorder or other common mental ailments, Sabetta says.

The ultimate goal is to get into local schools as soon as possible and start giving mental health screenings. The hope is to prevent students from getting to the point where they feel like taking their life is the only option. "The problem is social media nowadays is everywhere, and kids get almost no relief from it," Sabetta says. "A cyberbully can reach right into their bedroom while they are lying in bed at night, and leave a kid feeling like there's no sanctuary at all."

That's why Sabetta's group routinely sends out positive text messages to young people who come in contact with her organization's social media. "We sent them positive, uplifting messages on a regular basis. We try to do a lot of education through our social media, we want them to get a hopeful post from us," she says. "We're getting to those platforms to tell them they are beautiful, they are loved."

It's a small token of the kind of regular, one-on-one counseling distressed teens and adults should receive, but better than nothing, both Duffy and Sabetta agree.

In the end, it was technology that saved Missy McLean's brother from falling off the face of the earth.

In the end, it was technology that saved Missy McLean's brother from falling off the face of the earth in Las Vegas during his manic bipolar episode four years ago—but not in the form of counseling. Just as McLean had feared, the Las Vegas hospital released her brother before a family friend could fly there from Toronto to pick him up.

"They said they gave him a bus ticket home. I was like, 'A bus ticket to where?'" McLean says. Thankfully, the family was able to follow her brother's movements through his debit purchases, and over the course of 48 hours after he was discharged, McLean and the family friend in Las Vegas tracked his every move.

"I did not sleep for 48 hours. I was watching that account like a hawk and I'd say to the friend, 'Okay, he's on this place on the strip now, go there. No wait, now he's here,'" says McLean, adding that, "there could not be a worse place" for a person suffering a bipolar breakdown than a gambling town.

She caught a break when a particularly empathetic restaurant employee at Caesar's Palace picked up the phone when she called to ask if her brother was there after a charge popped on the debit card.

"He was so kind, he helped me so much, and hooked me up with the hotel security, who eventually spotted my brother," McLean says. The family friend was finally able to get her brother back to Toronto.

Four years later, McLean's brother is now in his 30s and attending college. He spent 22 days in an inpatient facility for treatment upon his return, and has a caseworker and doctors who care for him on a regular basis.

"Our system in Canada is not perfect, but I think of what could have happened to him every day and give thanks," she says. "We could have lost him forever, and instead he is here with us and getting care and we don't have to worry about the costs ticking over every second of every day. We are so very lucky."

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