On December 10, 2020, 79-year-old Dumfries resident Kurtis Kay Frevert was having a mental episode outside his home. He was armed. Police were called to the scene by his wife, and they brought with them a co-responder, a social worker trained to de-escalate these kinds of situations. It was part of a brand-new program in Prince William County, one that, since its founding that month, has supported dozens of 911 calls by calming the situation to avoid arrest or directing the subject to emergency hospitalization.
But the December 10 call was not one of those instances. In front of his house, Frevert pointed his gun at the police. He said, “Shoot me.” The officers did, killing him, a tragic instance of what’s often colloquially known as “suicide by cop.” The mental healthcare the man needed had come too late, another account added to a rising number of reports of mental health incidents amid the pandemic.
Yet on July 9, 2021, Virginia Behavioral Health Commissioner Alison Land announced that, due to overcrowding and understaffing, five of the eight state psychiatric hospitals in Virginia were closing to new admissions. Only three would remain open, leaving those who are struggling with mental health outside their coverage area to find their own safe haven, potentially at a private hospital. The decision sent shockwaves through Virginia’s public health system, creating a minor media fiasco. Within days, the decision was reversed, and by July 28, Gov. Ralph Northam had directed $485 million from the American Rescue Plan to support the embattled hospitals.
Experts say it’s just a patch, and once the temporary funds run out, mental health institutions will once again be in danger of shutting their doors. And beyond that immediate issue of funding, the question raised by Frevert remains: How can Virginia ensure that not only those within the hospitals are safe, but those outside as well?
The pandemic has exacerbated the issue of mental health across the country. Reports of substance abuse, anxiety, insomnia, domestic abuse, and suicidal thoughts have skyrocketed. And while those who are already institutionalized are often dealing with deeper challenges than the ones presented by the pandemic, stress can increase the number of episodes for those able to live independently.
Another problem for hospitals: The stress on social workers, for whom teleworking is rarely an option, makes them particularly likely to join the Great Resignation trend. With fewer staff, a stressful situation becomes even more difficult to manage. In the two weeks before the hospitals’ closure, 108 staff members resigned from the Virginia Department of Behavioral Health and Developmental Services. Staff and patients across the department had suffered 63 “serious” injuries in the week prior to the announcement, and assault accounts have filled local news reports before and since. In one instance, a patient in restraints was allegedly repeatedly assaulted by another patient due to lack of staff oversight. In another, a patient allegedly repeatedly punched and slammed a 58-year-old nurse’s head against the wall, resulting in the patient’s arrest and the nurse undergoing emergency surgery. In November, a patient with a criminal record of assault escaped while being transferred from his hospital (though law enforcement did not state this was due to inadequate staffing at the time).
Even though Northern Virginia Mental Health Institute was one of the three hospitals that remained open, its director, Amy Smiley, described to Northern Virginia outdated, cramped conditions, where some of the most unhealthy patients must be gathered together instead of kept separated, creating a “pressure cooker” situation in which tensions build to the point of violence.
“[The] reality is that a lot of people and hospitals all over the state were being assaulted and were just put in very dangerous situations,” says state Sen. Creigh Deeds, a former Democratic nominee for governor and a mental health advocate.
Even before the pandemic, Virginia was struggling with its mental health system—a problem sources agree would have come to a head with or without COVID-19.
It’s an issue Deeds knows deeply. In 2013, his son was struggling with mental illness, and Deeds, recognizing that he needed help, attempted to take him to an institution. That facility, overcrowded, turned him away. The next day, his son attacked him, stabbing him repeatedly before taking his own life.
Deeds led an effort to pass a unique “bed of last resort” law in response, requiring psychiatric hospitals to accept patients in an emergency. But the law has had unintended consequences, revealing just how lacking in space and funding the Virginia mental healthcare system is. The law caused a spike in admissions for hospitals, with some suddenly reaching over 100 percent capacity, where formerly the “safe” percentage was set at 85 percent and often kept lower.
“Anything above 85 percent capacity puts both patients and staff at risk,” Deeds says. “But here’s the other side of it: When the hospitals were shut down, the problem didn’t go away—it just got pushed down on law enforcement and emergency rooms and local [community service groups].”
That’s in part because Virginia’s mental health institutions were not designed for emergency episodes. When a patient is institutionalized, they’re committed to long-term recovery. The law, as it’s being applied in the absence of other solutions, is changing the function of these institutions.
That’s why the funding from the American Rescue Plan, used only to maintain the current workforce as it is, is only a temporary solution, according to Angela Harvell, Virginia deputy behavioral health commissioner. The Virginia Department of Behavioral Health and Developmental Services used the funds as bonuses to maintain current staff and hire temporary contractors to replace the ones they’ve lost, but the funding is set to run out. And as stress simply increases in an ever-fluctuating pandemic, Smiley and Harvell are not optimistic about the prospect of growing that workforce to levels they say were already insufficient. Recently, they’ve spent months trying to recruit a single applicant for a staff position that might have previously attracted 20 applicants.
“That’s not something that has happened before,” Smiley says.
This isn’t an everyday matter of recruitment. The dangerous work conditions appear to have consequences beyond the shuttering of hospitals and threat to staff: Patient deaths within psychiatric hospitals have increased since the bed-of-last-resort law went into effect in 2014, according to a report by the Disability Law Center of Virginia in 2019. Deaths within the first 90 days of admission never went above 23 percent prior to the law being passed. That number more than doubled in the year after the law went into effect (from 15.6 percent to 36.2 percent), and it hasn’t dipped below 30 percent since, which led the Center to call for an immediate investigation into the cause.
The root of the problem—as is often the case—goes back to money. Mental health can be a hidden, poorly understood, and stigmatized health issue, and Virginia is particularly disposed to let those kinds of problems go neglected.
“There’s just been a chronic underfunding. Virginia is a low-tax, low-service state. Historically, we’ve done things on the cheap,” Deeds says, pointing out that mental health is not a new problem. “The need for these services has been around since the beginning. One hundred years ago, there were tens of thousands of people in mental health facilities around Virginia. But we didn’t mind institutionalizing people. We didn’t mind lobotomizing people.”
It isn’t until the problem is made stark by a pandemic and the widespread shuttering of state hospitals that money (like Northam’s allotment from the American Rescue Plan) arrives.
“I think [the closure] did help increase awareness,” Harvell says.
In Prince William County, where Dumfries is located, supervisor Andrea O. Bailey is seeking to build a better space. She was inspired by the case of Frevert and others who lost their lives in a mental health crisis, as well as the time she has spent visiting homeless encampments throughout the county, where veterans struggling with mental illness often gather for the VA services out of Quantico, as others struggle with opioid addiction. Seeing the effects day to day, she realized mental illness is deeply bound up with inequity in Prince William, the most diverse county in Virginia.
“There were individuals talking to themselves, drifting in and out of it as I spoke with them,” Bailey says. “There is a great need in our county.”
That’s why she’s building a community crisis center, a kind of intermediate point between institutionalization and standard therapeutic services, modeled on a crisis center located in Fairfax County. Instead of heading to an institution for a long-term stay away from their families, those who only need a temporary stay in a rare crisis event will be able to enter the crisis center in Prince William, which will have multiple beds and access to psychiatric support. They can then choose whether to go on to seek a stay in a psychiatric hospital or return to the support of their family.
So far, through her advocacy, she’s raised millions from public and private sources and hopes to complete the center in 2023.
But not every community will have an Andrea O. Bailey or the resources of Fairfax County. And in a situation like Frevert’s, a crisis center may have been too late.
That’s why Deeds thinks it’s a matter not only of space, but also of services. And an infrastructure that could go a long way toward providing psychiatric services in the community already exists. Virginia requires that each county has what’s called a community service board, or CSB. The CSB program seeks to provide preemptive care, such as therapy and suicide prevention, for those suffering from mental health disorders. The model can be successful at helping patients short of being institutionalized, according to Deeds.
The problem is that CSBs are unevenly funded, primarily drawing from local contributions, and each county is largely left to its own devices as to the services it ultimately provides.
“Community service boards are as disparate as night from day. Fairfax County’s Community Service Board has all the bells and whistles. They’re really well funded, and they do a great job on a number of levels. Some of—most of—the other community service boards aren’t nearly as well funded. And so we have a lot of challenges,” Deeds says. “The comparison you can make is of schools. For example, you can point to Fairfax County schools as some of the best schools in the state, and most of that’s because of local funding.”
Deeds has been working on legislation to standardize the network of CSBs since 2014, providing funding to each in return for establishing new performance standards and services across the board. His hope is that by bringing mental healthcare into the community, counties across the state will get access to preemptive care that will lessen the need to turn to institutionalization.
“Ultimately, we’re gonna have to invest in community services because [if] you keep people out of crisis in the first place, you keep them out of [the] hospital,” he says.
Deeds knows that both CSBs and psychiatric hospitals need more funding. Bailey is working in cooperation with her local CSB, which she refers to as the “Divine 9.” And Harvell views all of their independent efforts as moving toward one goal.
“It all ultimately goes back to the health of the patients,” she says.
But it will take a sustained push to make the desired reforms and motivate legislators to act beyond another patch. Deeds points to the fact that the CSB model in Virginia could serve as a model for other states, if they’re successful.
“The pandemic made things worse. We just had a series of circumstances that is—it’s almost like quicksand. We’re stepping in quicksand. The more you struggled, the more you got stuck. We’re going to get out. I’m determined we’re going to get out,” Deeds says. “It’s not like we are operating in a vacuum—other states are having similar problems. We’re creating a system where people that are struggling…have access to the services they need. And if we keep that as our goal, we can build a system that is a model for the rest of the country.”