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A WA town's proactive approach to mental health care starts on the street
Seattle Times - 9/4/2022
Sep. 4—MOUNT VERNON — Driving down a featureless street in Mount Vernon, Erin von Fempe spots someone she recognizes. A man in his 30s with a brown beard and red flannel shirt tied around his head is walking down the sidewalk in the opposite direction.
"Rats," she says, yanking the wheel to spin her SUV. "Fortunately, I brought my Southern California driving skills to a small town."
Von Fempe, a social worker with flax-colored hair and round, gold glasses, spent her career in Long Beach, California, before moving north seven years ago. With traffic whirring by, she pulls over long enough for the man, Gerald, to climb in. She felt lucky to have spotted him. There were several months when it was hard for von Fempe to find Gerald, who has been in and out of shelters and encampments since they met three years ago.
Von Fempe is an employee of the Mount Vernon Police Department with access to law enforcement resources, but carries no gun or Police Department trappings aside from a radio. She's on a daily crusade to preserve the humanity of those jettisoned by society: people like Gerald who churn in and out of homelessness, mental health and substance use facilities, emergency rooms and jails.
She buys people meals, signs them up for housing, shelter or health care, and looks for job opportunities, creating critical connective tissue between several siloed systems of care. Limited resources, patient privacy laws and other barriers often make it difficult to pave a seamless path across these systems.
"I only see people who are falling out of the systems," she says.
The problems of Mount Vernon, population 35,000, are mirrored in communities large and small across Washington. Still, von Fempe and a handful of other influential people in the Skagit County town are transfixed by the idea that their labor and creative ideas may actually make a difference. Her work, and that of many others across Skagit, help illustrate the potential of a collaborative approach to mental health crises — one that, in an ideal world, would involve intensive coordination between social workers, behavioral health agencies, law enforcement and the courts.
Mount Vernon's police chief, Chris Cammock, is a skeptic of recent moves limiting law enforcement's role in mental health crises. He's adding at least three people to the department's social work staff to give von Fempe reinforcements.
Von Fempe, who was hired in 2016, is a proof of concept that spurred that expansion. She's perpetually generating new ideas for how to help Gerald and the dozens of others she's come to know.
At the deli counter at Haggen, a local grocery chain, Gerald orders two containers of chow mein. The grocery worker knows him — they briefly reminisce about growing up together — then von Fempe pays the bill. In the parking lot, Gerald bends to pick up half a discarded cigarette before they take off for a hotel where von Fempe recently helped him secure a free room.
On the drive, Gerald moves seamlessly between sincere complaints about his chronic back pain and fragmented phrases that sound poetic, if detached from reality. After they part ways, von Fempe explains about the spirits that bother Gerald. And she describes his skepticism whenever she nudges him to see mental health or substance use professionals.
Most days von Fempe drives up and down roads that follow the Skagit River, scanning for people who need help. She goes alone. Her work is proactive, not in response to a crisis. And, especially when the weather is mild, she'll usually run into folks she knows.
Above her desk, cluttered with coffee thermoses and file folders, she has taped a reminder. "Rather than knowing what kind of illness a person has, it's better to know what kind of person has this illness."
Instead of forcing people to sign consent forms or agree to specific services, she asks what's meaningful to them. Gerald, for instance, wants his back pain to go away. Another man with substance use problems loves being in the woods, so von Fempe looked for ways he could help clean local trails in exchange for a stipend. "There's less resources here," than where she worked in California, she admits. "But I have found that a community like this can band together and work toward the same cause."
Her tone darkens when asked what she's up against.
She pulls out a sheet of paper with a drawing that looks like an intestinal tract. Along its curves are notes about one local woman's interactions with police, mental health agencies, jail and transition homes. The stats are grim: The woman has had at least 190 police run-ins.
"I think [von Fempe] drew it when she was really angry," quips her boss, Chief Cammock.
Von Fempe laughs, then demurs. She's angry, she says, "a lot of [the] time."
About 15 miles northeast of town in Sedro-Woolley, steps from the grounds of the long-closed Northern State Hospital, Skagit County Superior Court Commissioner James Dolan walks into a squat psychiatric building.
Dolan is at Telecare North Sound Evaluation and Treatment center, a private inpatient facility that happens to be run by von Fempe's husband, and where, on any given day, about 16 people are receiving involuntary psychiatric care.
It's also the location of a small courtroom where Dolan holds so-called Involuntary Treatment Act hearings several times each week.
On this foggy morning in March, a man named Christopher is up for release from inpatient care. Seated across a conference table from Dolan, he tells the commissioner he's been here 14 days and he wants to get out.
In Washington, like many states, people at risk of hurting themselves or others — or those incapable of making choices about their own basic care — can be held against their will for psychiatric treatment.
Since their rights are at stake, they're afforded a legal hearing. It's not a criminal proceeding, but attorneys are involved. The person being detained is assigned a public defender whose job is to argue for whatever their client says they want. If a hospital believes a patient needs inpatient treatment, a public prosecutor makes a case on behalf of the hospital — in Christopher's case, Telecare North Sound — petitioning to keep the person in care.
Dolan's court is collegial, even casual. There's a sense that everyone here — the attorneys, the hospital staff, and Dolan — wants the best for the clients.
Telecare's first witness is Christopher's mother. Christopher had at least 39 emergency room visits in the past year — including several times when the hospital thought he could benefit from inpatient care. He's homeless, has a history of substance use and is experiencing symptoms typical of schizophrenia and mood disorders, his mom says. She insists he needs continued treatment.
"Most of all," she continues, "I would like a plan for when he leaves there."
After others' testimony, Dolan decides Christopher must stay.
But it's not unusual for Dolan to discharge patients into homelessness, he says, a reality he finds "incredibly frustrating." Having mental illness or substance use concerns don't guarantee someone will become homeless — and not all people living outside have behavioral health issues — but such social, psychological and behavioral problems can overlap.
It's a small enough community that Dolan has grown used to seeing people from his courtroom stabilize and then tumble back through the system over and over. Some return to substance use or fall off their psychiatric prescriptions, struggle to find work or can't secure housing. Dolan can't legally hold someone against their will just because they don't have a home.
It's difficult to measure the scope of this problem — Dolan doesn't keep track of each person's housing status — but a 2017 report offers a window into its depths. About 48% of people leaving intensive inpatient or long-term residential substance use care have nowhere to live once they leave, and only 1% have a job, according to the report, which looked at Skagit residents who left such centers.
"Not only are they leaving treatment with limited 'recovery capital,' they are also returning to a community with limited recovery support services to help them secure housing and employment," it concluded.
"It is a complicated system," said Denna Vandersloot, who authored the report and is co-director of the Northwest Addiction Technology Transfer Center. "There are so many different pieces of it and people responsible for different pieces of it. So how do you actually get all of those pieces working together?"
The pressure-cooked system is facing new stressors. Most notably, the demand for mental health care is up at a time when mental health agencies struggle to fill staff vacancies. "We lost a decent chunk of providers [who are] leaving the field altogether," said Jennifer Leonard, a behavioral health regional director for Sea Mar Community Health Centers who oversees outpatient services in Skagit. During the pandemic, she said, some behavioral health agencies stopped taking new clients or closed their doors temporarily to all patients.
Two adult outpatient programs at Compass Health, another large behavioral health agency that serves Skagit, have temporarily stopped taking new clients in the county. And across the agency's outpatient programs in Skagit, enrollment is down about 29% since December 2019, Compass CEO Tom Sebastian said in a statement.
Compass offers a treatment option for people with severe or persistent behavioral health problems, called Program of Assertive Community Treatment, or PACT, and that program has continually enrolled patients throughout the pandemic, said Tawna Thomas, who oversees Skagit's PACT team. But the team is limited to serving 50 clients at any given time.
A lack of services has made it increasingly hard to transition people leaving inpatient care into necessary outpatient services like therapy, Dolan says. "So now," he says, "those people just leave."
When he's driving in town and sees someone in need, he says, he'll occasionally call the person he knows can help: von Fempe.
"Life would be different"
John Denver's "Take Me Home, Country Roads" plays softly in the Skagit Valley Food Co-op as von Fempe zips past wine racks and the checkout counter in search of a woman, Melissa Kellogg, who needs housing. Von Fempe is stood up, she says, about 50% of the time she's meant to meet someone.
Then: "You're here! Yay!" she exclaims when she spots Kellogg. Kellogg orders a cinnamon roll and coffee. Then they get to work.
Kellogg, 42, has had a long string of tough days. Her mom passed away. She has several mental health diagnoses and is having trouble getting her medications. She lost her driver's license. She's spent time in jail. And she's been sleeping outside for at least a year and a half.
"If you had the opportunity to stay in a motel, how do you think your life would be different?" von Fempe asks.
Kellogg's eyes well up and she instantly lists her goals: to get more services, to volunteer, to go to college and advocate for domestic violence victims. von Fempe dials the number for someone she knows at Catholic Community Services who helps coordinate a new hotel program that's set aside 20 rooms for people living outside; because of her role at the Police Department, she has the ability to bypass red tape that often comes with trying to secure housing or shelter. It's the same hotel program she used to get Gerald a place to stay.
"Two o'clock, we'll help you move in," she says.
Kellogg, in disbelief: "Really?" Her tears finally spill. In a matter of hours a big police van arrives to bring her belongings to the hotel. It's all moved so fast — this is how von Fempe likes it — but in the scheme of things, Kellogg has a long way to go.
When she's asked to make presentations on the work she does, von Fempe sometimes gets stigmatizing retorts like, "It's their choice. They're choosing to live outside. They're choosing to use drugs."
"But I'm hearing it less," she says. "At least in our community."
Her role reflects a somewhat new and important iteration of social work referred to as the co-responder model, one that's building political momentum through statewide groups such as the Co-Responder Outreach Alliance; co-response generally refers to partnerships between mental health professionals and first responders like police and firefighters.
Kim Hendrickson, chair of CROA, said co-responder programs are especially important in rural areas where resources are slim, like Mount Vernon. They're often born of frustration, Hendrickson said, among "both police and fire [departments] just realizing that the people that most need help aren't being connected to care."
Von Fempe has witnessed other practical shifts in her community. An informal network of volunteers has started bringing food to people without shelter, she says, and other agencies have hired outreach workers. A permanent supportive housing building for at least 70 residents is under construction. And over the past few months, von Fempe has become increasingly hopeful about a new plan from county leaders called the North Star Project. It is expected to look critically at all the ways the housing crisis and behavioral health system can be improved.
Still, von Fempe can't help focusing on what needs fixing. For starters: It can take at least a year of abstinence before a person's brain activity recovers from drug use — but abstinence is hard and Medicaid limits coverage for inpatient substance use treatment.
Skagit County has the lowest apartment vacancy rate statewide at about 0.9% — and one of the highest rent prices per square foot.
It often takes months from the time someone is assessed for mental health services here and when they actually get an appointment or medication. And wins can quickly turn to defeats: Both Gerald and Kellogg were eventually kicked out of the hotel program — which has strict visitor and drug use rules — and are again living outside.
Von Fempe's list is overwhelming. Too big for any single person to shoulder.
"Everybody is traumatized," she says. "The clients and the mental health workers. Because it's so hard. So I hope it can change."
Toward the end of a long workday, she drives to Burger King, orders a burger and fries, and delivers the meal to a woman who is sitting on a street corner and sleeps outside. The woman likely has anosognosia, von Fempe says, which means she's unaware she has a mental illness. One winter, von Fempe found the woman sitting in the snow.
Aside from an occasional meal, the woman otherwise refuses services.
One day, von Fempe hopes, she might say yes to an offer of something more.
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