Mental health: How Alabama is responding

In her "come full circle" career, Lynn Beshear believes everything she has accomplished has led her to oversee the state's mental health system.

It comes from her time working in the Intensive Care Nursery at Duke University Medical Center, to her latest 17-year stint as executive director of Envision 2020 – where mental health was on the forefront of her agenda the past few years – and everything in between.

And in the community, it is her leadership, her visions and her goals.

As Beshear sits in her office at 100 North Union St., within sight of a side door to the Capitol Building she has special access to, the newly appointed commissioner of the Alabama Department of Mental Health focuses on partnerships, planning and prevention.

Crisis center could save hundreds of thousands in medical, jail costs

"I want to make this department relevant," she said. "I think most people feel like it's just 'there' and it really doesn't relate to their lives. And what's ironic, is that it's the Alabama Department of Mental Health, but there's 100 percent focus on mental illness.

"There's never going to be enough money, and we need to back up and say 'What do we need to do starting at birth, or maybe before, for people to be mentally healthy?' The best-intentioned people in the world, from the best families imaginable, are still going to get schizophrenia, and bipolar disease, and major depression. Because these are diseases. These are not character flaws."

The State of Mental Health

Beshear wants to make the department relevant up and down the chain. She wants to always remember that her first job every day is to "protect our consumers. To make sure they are taken care of.

"My other top priority is to make sure we can take care of the workforce. Because if our workforce is not mentally and physically healthy, they're not going to deliver the level of care that needs to be delivered."

The biggest problem Beshear said the state faces has to do with accommodations and living environments for people with developmental disabilities. The focus now in caring for them is moving away from what is called congregant living and to instead incorporate people into the regular workforce as much as possible.

Grant to bring together mental health advocates, professionals

Beshear, while she served as executive director of Envision 2020, worked to initiate and support several mental health programs throughout the region, including:

* Sequential Intercept Mapping: an interactive tool for developing partnerships that is being used by communities to assess those opportunities at each of five "intercept points." The mapping exercise aims to identify potential opportunities for diversion, or alternative justice and behavioral health interventions for persons with mental illness and co-occurring disorders, within each of the five intercepts.

Beshear said it would be an idea to "bring that to the juvenile justice system and to take it state wide in the adult system. That whole process, just to get the map, brings everyone together."

* CIT training: Crisis Intervention Training programs equip officers with the knowledge of how to recognize signs of mental illness and provide techniques to de-escalate potentially dangerous situations. Through the training, they are more likely to move mental health consumers into treatment instead of jail, thus getting them on the road to recovery and reducing the chances they will be arrested in the future.

* Mental Health First Aid: training class offered to help take the fear and hesitation out of starting conversations about mental health and substance abuse problems by teaching people how to identify, understand and respond to a variety of mental health situations.

"We need to treat them like diseases," Beshear said. "But there's a lot of serious emotional disorders that would ... never happen if we dealt with child abuse and access to education and access to other supports that people need to be mentally healthy."

Community voices

Ben Arthur, 60, was diagnosed with schizophrenia in 1977, and has worked with the state off and on as a volunteer for several years in different capacities.

"One of the issues I think needs to take place is people need to get sober before they make a diagnosis on a mental illness," he said. "Because there are so many people with dual diagnosis ... substance abuse issues as well as a mental illness. They often do what they can to alleviate the pain."

One issue Beshear wants to address in the state is the mental evaluations for people who are arrested and sometimes who have to wait a long time to be evaluated because of their mental status.

"That impacts what happens to them in the court system," she said. "They’ll end up being in jails for an extended period of time. They’re not all in jail – sometimes they are released depending on the nature of the situation. It’s very complicated and it’s going to take a lot of cooperation between the judges, the court system and the department of mental health."

Herb Maloney, diagnosed with schizophrenia more than four decades ago at age 23, said there needs to be a crisis intervention unit.

"Everything with mental health is for financial reasons," he said. "They have to do something about the prison system because they are going to get under court order if they are not careful, for overcrowding."

Both Maloney and Arthur agree there needs to be more public empathy for those with a mental diagnosis.

"When they open group homes, I imagine a lot of people say that it's fine that you're going to have them, but not in my neighborhood," Maloney said. "People don't understand mental illness ... that most people with a mental illness are not going to do anything.

"They see the shooters in Colorado, and different places. Most of these shooters have not gotten in to get an appointment, or they have, and have been given medicine, and they don't take it."

Arthur said to help change public opinion, he would reassure people "that most mentally ill people are the most thoughtful human beings you'd ever want to meet. And the ones that get the headlines have made it rough on the rest of us."

Looking beyond Montgomery, beyond Alabama

The Restoration Center in San Antonio is a one-stop shop where the mentally ill can be treated with psychiatric care, counseling and rehabilitation. It is a place the River Region has worked on bringing to Montgomery.

Mental illness costs the U.S. $113 billion annually, and U.S. jails and prisons are the largest providers of mental health care in America.

"If we have a crisis center, that's fabulous," Beshear said. "But we have to have the housing."

The center is a plan that has been ongoing for years. And a plan city leaders have believed will keep the mentally ill out of jails and in treatment where they can become stabilized and from where they can return to the community and their homes. 

There have been roadblocks to developing the center — namely financial ones — that have hindered the progress.

Restoration Center: San Antonio's answer to mental health

"We have got to have this urgent care center," Henry Parker, executive director of the Montgomery Mental Health Authority, has said. "We have to take the pressure off the hospitals. We have to have good psychiatric care. We have to get them stabilized and back where they belong."

On the flip side, Beshear said there also needs to be prenatal care.

"It all begins before birth," she said. "If you have a mother who does not get prenatal care, or who is opioid-addicted or an alcoholic, you are going to have a baby at risk from birth. The way you deal with it, you start today preparing that workforce."

The opioid crisis

While the governor's office reported that of Alabama’s 736 reported drug overdose deaths in 2015, a total of 282 – 38 percent – were caused by opioids, Gov. Kay Ivey in August signed Executive Order 708, creating the Alabama Opioid Overdose and Addiction Council.

While the declaration would give the federal government expanded powers and additional resources to prevent and treat overdoses, the executive director of the Council on Substance Abuse-NCADD said that, along with education, more treatment options and recovery support are needed.

"I think one of the challenges that we are trying to gauge, is the fact that the prescription opioids ... unless you are caught where there is a crime or an accident of that nature, it can pretty much go unnoticed," COSA's Shereda Finch has said. "Especially when people receive prescriptions from their doctor."

This is what Shelby County is working toward through its COMPACT 2020 program, which has three organizational divisions:

Education, prevention and intervention; a Community Liaison Team; and a Drug Enforcement Task Force. Launched in July 2016, it is aimed at heroin and opioid drugs. And, it targets teenagers, said Alan Miller, a Shelby County assistant district attorney who oversees the program.

"The teenage population is incredibly hard to police," he said. "The teens were going unnoticed by and large.

"When a teen is involved with drugs, we go straight to the parents and meet with them. And then, we connect them with people who can help them. Because that's not us."

The community is buying into the idea, Miller said. 

"We need to do a much better job engaging this problem as a community," he said. "The families that we've met with always feel isolated and alone, and they are ashamed to the stigma attached to substance abuse.

"What we would like to see is a community network of support, so when people leave our office, they can call someone in their community to get support."

Peer to Peer

If there is one thing Beshear wants in the state, it is a peer program, in which those living with a mental illness can lean on someone who has been on their path.

Within the mental health department is the office of consumer relations, which oversees the state's peer to peer specialist program. Mike Autrey is director of the department, and who has been diagnosed with both major depression and obsessive compulsive disorder (OCD).

Because of his diagnosis, he lived on disability for 10 years.

The department offers a peer certified specialist program for people with a mental illness and who are in recovery. The program provides training so they can learn to use their recovery story to help others with mental illness who are not as far in their recovery.

There is also a program for substance abuse.

“Traditional treatment treats your symptoms, and you need that,” Autrey said. “But you get to a point that you find a medication that’s working and you’re feeling better. And then what? All I had to do was sit at home all day and started thinking about my situation and getting worse.

“This training helps people move beyond the symptoms of the illness but also the effects of the illness – the unemployment, poverty, lack of hope. Because when you’re in treatment for a long time, it’s like any other thing. If you lose everyday living skills, you lose your ability to carry on conversations. You lose hope.”

Peer support, he said, is about helping people realize that there is life in recovery from mental illness.

His recovery began when he met Joel Slack, the first director of the office of consumer relations – during a time Autrey volunteered at the department – and who founded RESPECT Institute, a program which offers participants recovering from a mental illness training in how to present their story before an audience.

Slack, who facilitates the RESPECT Institute in Georgia, originally developed the program at the request of Fulton State Hospital in Missouri.

“That is a very healing thing,” Beshear. “I want to find out how to bring the "respect institute" to Alabama.”

Autrey said stories within the mental health department are shared as a way to motivate others.

“People can and do get jobs and work and what the peer specialist is trying to do is get the individual they are working with to devise a plan and move beyond where they are and then start to move forward.

“They don’t come up with the plan,” he said of the peer specialist. “But the consumer comes up with it.”

Touching base with Ohio

Montgomery County commissioners in Montgomery, Autauga, Elmore and Lowndes counties in January 2016 signed a resolution in support of a new national initiative called Stepping Up, which works to reduce the number of people with mental illnesses in the nation's jails.

The Stepping Up Initiative was launched in May 2015 as a partnership of The Council of State Governments (CSG) Justice Center, The National Association of Counties and The American Psychiatric Association Foundation.

The initiative is designed to rally national, state, and local leaders around the goal of reducing the number of people with mental illnesses and substance use disorders in jail.

"I'd like to see Alabama as a 'Stepping Up' state," Beshear said. "I've been in touch with Ohio on how they did that."

Ohio Department of Mental Health and Addiction Services director Tracy Plouck serves on the board of directors for the Council of State Governments Justice Center, and was an early champion of the nationwide initiative.

She told the Montgomery Advertiser this week the Ohio initiative is in its second formal year and of the state's 88 counties, 33 have county commissioner resolutions passed to make improvements at the intersections of mental illness and the jails.

Plouck said counties have the opportunity to focus in different areas including treatment and services upon an inmate's release from jail.

Ohio is one of a handful of states, including Texas and California, that has been on the cutting edge of efforts to advance local initiatives to shift the state’s reliance on jails and prisons as the primary mental health providers towards a system that diverts people with mental illness to community based treatment options, according to the National Alliance on Mental Illness Ohio.

At the end of the day

Beshear feels she is on a steep learning field, but is starting to feel ownership.

"I feel like I'm in a position now to move forward with the work we were trying to do in the River Region and establish it as a model, which was our intention all along," she said. "I feel comfortable that I can learn this, and I'm feeling really happy that I have such great staff, and that the work is ongoing.

"It gives me an opportunity to learn what I have to learn and to take my message to various boards. It's very complicated, but I'm not giving up."

Opioids in Alabama

A total of 736 people in Alabama died in 2015 from drug overdoses, including overdoses of opioids, such as heroin, fentanyl and prescription narcotics, as well as other drugs such as cocaine and methamphetamine, according to the Centers for Disease Control and Prevention (CDC).

Of Alabama’s 736 reported drug overdose deaths in 2015, a total of 282 - 38 percent - were caused by opioids, according to a Kaiser Family Foundation review of CDC data.