Six years ago Laura Cook was diagnosed in Boise as bipolar. Shortly thereafter she lost her daughter to the state, her job at McDonald's and then her home. Since then, this 34-year-old mother has bounced between friends' homes, the emergency room at St. Alphonsus, Franklin House, Intermountain Hospital and homeless shelters like City Light and Sanctuary—where she's been most of the last year.
Occasionally Laura has an eruption, with a temper tantrum, as she did on a recent Sunday night at Sanctuary. Jayne Sorrells, director of Sanctuary, is a leading advocate for Boise's homeless who worries now that there simply aren't facilities that care for homeless people who have mental illness.
"We're not set up to care for people with extreme mental health issues," she said of Sanctuary. "With Franklin House gone, I don't know what we'll do."
Many homeless people in the Boise area and across Idaho who suffer a mental health crisis face serious obstacles accessing care.
"I run across people who can't access either psych meds or the counseling they need," said Heidi Hart, program director at Terry Reilly Health Services, the Idaho nonprofit health services provider. "They don't have the money, and there aren't places where they can go."
Hart said one patient told her she called the Department of Health and Welfare's Region 4 and was told they were too full and weren't taking new patients. She then called Family Practice Residency at St. Al's where the recorded message said they weren't accepting mental health patients. "So then she showed up at a Terry Reilly walk-in clinic," Hart said. "She saw the physician's assistant or nurse practitioner. But they aren't trained to provide that care."
Hart said the Terry Reilly clinic has waiting lists "pages and pages long" of people looking for psychological counseling, especially in Nampa. In addition to counseling, the clinic provides primary health care, prescriptions and case management.
Sylvia, who asked that BW change her name out of concern for her safety, is another Boise resident who's been homeless and mentally ill. She's been diagnosed as bipolar and suffers from post traumatic stress syndrome.
But Sylvia—unlike Laura—has also been addicted to drugs, and she has done real time in the Ada County jail.
Sylvia Navigates a Rough Road
Sylvia tells a dramatic story. When she was 7 years old, she was kidnapped from her grandfather's restaurant. She was raped, then released, but her attacker kept her Raggedy Ann doll. Later, the man gave the doll to her grandfather, who didn't understand how it had come to him. Sylvia blamed herself for the whole thing.
She began drinking and by age 10 was using marijuana and cocaine. At 11 she began prostituting. Pot, coke, heroin, meth—she said she's been strung out on all of them.
Now 42 years old, Sylvia has 11 children. Working with Affinity, which provides mental health services at two local shelters, and with her strong belief in God, Sylvia is determined to stay off drugs, control her anger and be a mother to her kids.
"I had a relapse in 2006," she said. "I went back to jail. I had told my probation officer that if I relapsed, take me back to jail. I wanted to live. I hate my addiction so bad. I would have committed suicide. I love my family very much. I want to be a mom, not a gang-banging hootchie drug dealer."
Back in jail, Sylvia found a list of programs to help addicts. "I wrote to a lot of them," she said, "but only City Lights wrote back."
City Light is a women's shelter in Boise, the counterpart to River of Life, a larger homeless shelter for men. Both are operated by the Boise Rescue Mission.
"About 80 percent of substance abusers who engage in treatment have a co-occurring mental health disorder," said Michael Dickson, director of the chemical dependency program at Personal Development, Affinity's sister organization that provides treatment for chemical dependency. Mental health disorders include schizophrenia, bipolar disorder, post traumatic stress disorder, depression and borderline personality disorder Dickson said.
"What's unique about Affinity's contract with the Rescue Mission," continued Dickson, "is that it's the first time treatment for the dual-diagnosed is being provided to Boise's homeless."
But this type of treatment is only available, for now, at Rescue Mission facilities, which do not accommodate couples—with or without children—and which encourage religious participation.
"Affinity would be happy to provide its services to any shelter, whether or not it has a religious mission," explained Leslie Kelley-Majors, the coordinator of Affinity services at the two Boise Rescue Mission shelters. "Our programs are absent of religion."
No longer homeless, Sylvia now lives with a friend but continues using Affinity services, and she credits Kelley-Majors for helping save her life. In addition to coordinating Affinity services at the Mission shelters, Kelley-Majors is a facilitator of its classes in trauma recovery, anger management and co-occurring disorders, all of which Sylvia has completed, and she oversees the "psychosocial rehabilitation" that Affinity provides. "I think I've called Leslie about 100 times," said Sylvia. "I know this is how I can recover."
Kelley-Majors explained that psychosocial rehabilitation is one-on-one. "On any given day, a PSR worker could work with an individual on how their family triggers their anxiety by not observing their boundaries, and how to deal with it appropriately through use of assertive communication rather than violence ... We could work on how to access community resources [like advocacy groups] rather than letting depression escalate due to a housing dispute. We could work on how to understand medications and manage them appropriately to ensure psychiatric stability."
Sylvia's been improving. "Now I can talk with my mom, and I tell her things that she didn't know about," Sylvia said. "I thought she knew about things [like the rape], but she didn't. Now it's over. It's done. It wasn't my fault."
"But I still get really nervous talking with guys," Sylvia said. "I don't trust them at all." Sylvia only agreed to be interviewed for this story after arranging to have her 19-year-old daughter with her.
A crisis of access, a crisis of care
Nationwide, "there are things that happen in the mental health care system you couldn't imagine happening in the so-called 'health system'—as if the parts of the body are disconnected," said Dr. Ken Duckworth, a former commissioner of mental health in Massachusetts who now serves as medical director for the National Alliance on Mental Illness.
"I can tell you there's no parallel thing happening in American cardiology. People are not languishing or being neglected in cardiology wards across America."
Things certainly are no better in Idaho. Idaho scored an overall grade of "D" in the national NAMI report released last week, up from "F" a few years ago.
"We're one of the most underfunded states for persons with severe and persistent mental illness," said Charles Novak, a Boise psychiatrist who works in two local hospitals. "Our state spends millions at our two state hospitals, but we can't get people into those hospitals who are voluntary. Those who are voluntary are the most likely to respond to treatment because they want it—but they can't get in."
Local mental health providers acknowledge that the system often pushes people directly into emergency rooms.
"Mental health has never been a priority in the nation, much less in Idaho," said Michael Estess, a local psychiatrist who in his 36 years of practice has served as medical director for Health and Welfare's Region 4, various institutions and the Ada County Jail. "The trick is to prevent people from going to our emergency rooms," continued Estess. "ER is not the best place to take care of social problems."
And the problem isn't just lack of funds. Last year, a study overseen by the Idaho Legislature's Health Care Task Force reported that "Idaho's mental health and substance abuse systems are severely fragmented, with a significant lack of clarity and consensus regarding the roles and responsibilities of various system stakeholders."
The Detox Center: overdue and still a year away
After years of talk, local governments have partnered with the state to build a Substance Abuse and Mental Health Crisis Center—a facility where emergency sobering, detoxification and mental health services will be provided to Treasure Valley residents in need.
A spokesman for Boise Mayor Dave Bieter expressed confidence the center will become a reality early next year, although groundbreaking planned for next month may be pushed back to May.
The facility, often referred to as the "detox center," is expected to reduce the number of expensive visits to hospital emergency rooms. It should also help fill the void in mental health services left by the closing of Franklin House. Prior to its closing due to state funding cuts, Franklin House logged an average of 600 admissions each year for people with mental illness crises.
Meanwhile, how are local mental health crises being handled?
The answer depends, in part, on whether you have a residence. The state is "looking to replace the [Franklin House] capacity by utilizing a team to provide services to clients in their place of residence ... trying to maintain people with the highest degree of independence," explained Scott Tiffany, mental health bureau chief at the Idaho Department of Health and Welfare.
Tiffany acknowledged that 10 to 12 percent of Franklin House residents were homeless. For them, "perhaps we can purchase temporary housing—for example, hotel rooms. But some may end up in hospitals."
Neither Laura nor Sylvia look forward to another emergency room visit.
As Sylvia says, recovery is "a one minute at a time situation."
Or, as her daughter rephrases: "Recovery is a never-ending battle."