DOWELLTOWN, Tenn. — Five-year-old Bryson Hines stands in the bedroom he shares with his sister and pounds repeatedly on the closed door, sending echoes through the brick ranch house in rural Dowelltown.
He’s on a timeout.
In the kitchen, his mom, Tasha Burrage, lights a cigarette and exhales in a mixture of stress and release.
Her spirited, and at times aggressive, blond-haired boy was born in a Tennessee June a couple of years after she graduated from high school. Two years later, she had a daughter.
The 25-year-old mother lived in housing projects in rural DeKalb County then, in recovery for addiction, she says. She was dealing with bipolar disorder and post-traumatic stress disorder brought on by childhood abuse, yet she was unable to get the mental health care she needed.
She didn’t have insurance and had just sold her beat-up ’99 Mazda Protege with its busted transmission to the junkyard, leaving her without transportation.
Life could have continued that way, but when she lost custody of her two kids after a violent night with a previous boyfriend, Burrage finally found a way to get support.
“I didn’t like being away from them,” she says, “but it helped me do what I needed most. I went back to counseling … .”
It is estimated that more than 1 million Tennesseans ages 18 and older have a mental health or substance use disorder. Many are uninsured.
Studies have shown that the risk for serious mental illness is generally higher in cities, but those living in rural areas can face greater barriers to diagnosis and treatment due to lack of services and access to transportation.
Experts say the state has one of the best first-response systems in the country, serving every Tennessee county, but before and after a mental health emergency finding help can be a challenge.
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Addressing the stigma associated with mental health care and confronting barriers to services are top priorities for care providers.
So, too, is addressing the continued connection — legitimate or perceived — between mental health crises and the violence reported in heartbreaking news stories across the country like the Waffle House shooting in Nashville.
To get there, experts believe there must be a more thorough understanding of dire needs in two divergent settings — cities and small country towns — and a closer look at the specific actions needed to ensure people who need mental health care do not fall through the cracks.
Urban environments are more likely to see large disparities in socio-economic status, higher rates of crime and violence, and the presence of marginalized populations with high-risk behaviors.
People who need mental health services may congregate in big cities, knowing there are more solutions available.
In truth, a bigger city doesn’t mean more hospital beds are ready or more counselors are available.
Tennessee is a state with a shortage of mental health care providers, particularly in high-population counties such as Davidson and Shelby.
In fact, nearly every county in the state is underserved, according to the U.S. Department of Health and Human Services.
The Tennessee Department of Mental Health and Substance Abuse Services operates four regional mental health institutes and contracts with three private psychiatric hospitals to provide inpatient services, with 11,983 total admissions in 2017.
But it’s not enough.
And it doesn’t address the daily need for outpatient services, for which a backlog can create unruly waitlists.
Providers in private practice may have a monthslong wait and often don’t accept private insurance.
“When talking about mental health treatment, it can take so much courage just to get them in the door,” says Amanda Bracht, senior vice president of clinical services at Mental Health Cooperative. “And then, to tell them to come back in a month to get time in front of a psychiatrist — that can seem like forever, especially when dealing with severe mental illness.”
For Ernest Porter, it took 38 years, a stroke and a three-month coma to find the services he needed. The help came through nonprofit care provider Centerstone.
The Nashville native played linebacker at Maplewood High School and earned a football scholarship to Western Kentucky. But he never made it. Drugs got him first.
For more than a decade during his active cocaine addiction, he held a steady job. He had a wife he loved. He had children.
Then, he lost it all.
Porter thought often about what he sacrificed. Many times, he said he was finished.
Six years ago, it nearly ended another way. He started to feel dizzy in his apartment.
He grabbed the side of his bed and started to fall. It was a stroke.
“When I hit the floor, everything went black,” Porter remembers now, “and I didn’t see light again for three months.”
When he woke up, he made a promise to God that for the rest of his life he wouldn’t smoke, drink or do drugs.
A friend recommended he visit Centerstone for support. In cases of long waitlists in big cities, it is often nonprofit community mental health centers that get people care faster.
Now he has symptoms of depression with his history of substance use. He visits Centerstone several times a month for primary care doctor appointments and to see a counselor.
“I didn’t really feel that I needed the help,” he says, “but I am sure I probably did, and I still do.”
He doesn’t drive. Instead, he gets to his appointments using the metro bus service or the free medical transportation offered through TennCare insurance. Most days, with an advance reservation, he can get a ride to care in just an hour.
Out in rural Tennessee, those options are more rare.
Over the years, there have been times when Burrage got on a TennCare transportation van at 6 a.m. and didn’t return home until 4 p.m. — just to get to one counseling appointment an hour away in Cookeville.
She lives in Dowelltown now, staying with her children at the home of her new boyfriend’s mother.
They don’t drive and depend on a close friend and his beat-up white Pathfinder to get to the grocery store or the doctor.
They are in the process of receiving intensive in-home services, seeking stability as part of a Department of Children’s Services-funded pilot program with Youth Villages to help children avoid foster care. It doesn’t require insurance or cost to the family.
Three times a week, they get a special visitor.
The kids cling to Lacey Lewis, a Youth Villages family intervention specialist, cozying up on her lap and eagerly accepting the candy she brings as a treat for good behavior.
Youth Villages is helping facilitate a psychological assessment for Bryson, in part to determine if he has autism.
But the wait for his assessment has been weeks long. There aren’t enough providers in the area.
Every county in Tennessee is covered by a crisis response team for those who are experiencing a mental health emergency.
The 24-hour-a-day service funded by the state Department of Mental Health offers telephone services provided by trained crisis specialists, face-to-face or telehealth assessment, stabilization of symptoms and referral for additional support.
“In mental health, you have to triage immediate life-threatening issues,” Bracht says. “But people aren’t getting the more preventative side taken care of.”
Fewer mental health providers offer services in rural areas, making preventative visits tricky to schedule and trickier to get to. When Burrage lost her kids, she started seeing the same counselor in Cookeville as her parents.
She went to one mental health center in Cookeville, then another in McMinnville when her case was moved. When it got moved again, she quit out of frustration.
In-home services like those the Burrage family receives offer an alternative to long drives and uncertain care while avoiding the stigma of being seen in the parking lot of a psychiatrist. It is a positive approach and solution, experts say, but finding therapists and social workers willing to live in small counties can be difficult.
Lewis estimates she drives up to 500 miles each week to visit families across rural Middle Tennessee.
“Our goal is to help them and support them and encourage them and get them to the spot where they feel they are the change — because they are,” says Christina Williams, clinical supervisor at Youth Villages. “But there’s no quick fix. The reality is a lot of times we come in and parents need additional services and families don’t have the right resources that allow them to be good parents.”
And even when they do seek help, paying for care is a challenge that cuts across the urban-rural divide.
Estimates show between 49,126 and 65,857 uninsured adults in Tennessee have a severe mental illness, according to an analysis of 2014 federal data by Vanderbilt School of Medicine’s Department of Health Policy.
The Behavioral Health Safety Net of TN program can provide help for the uninsured who have a diagnosed serious mental illness.
But people with mental illness continue to be incarcerated at high rates, an outgrowth of mental health policies and practices that don’t address illnesses until they become extreme.
Crisis intervention teams, or CITs, work to reduce the unnecessary jailing of people. Memphis has become a leader in this training nationwide, teaching law enforcement officers to deal with emergency mental health situations.
And some states, such as Tennessee, are moving to increase the number of beds and overall crisis services — to help keep a mentally ill person from spiraling out of control.
The Tennessee Department of Mental Health and Substance Abuse Services’ total budget for the current fiscal year is $380,236,100, including $23.5 million for new programs with focus on juvenile justice and substance abuse services. Three new behavioral health facilities are planned for Nashville in the next two years, adding approximately 160 beds.
The Davidson County sheriff’s department is building a 64-bed behavioral care center to serve as an alternative to jail for mentally ill residents who must be taken into custody.
Saint Thomas Health is planning a 76-bed behavioral health treatment center to open in Nashville in early 2020, with the aim to relieve crowding at Davidson County emergency rooms, where patients with mental disorders may wait more than a day for psychiatric treatment.
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And a 20-bed “psychiatric emergency room” is planned to open in the fall at the Mental Health Cooperative campus in MetroCenter.
“It’s kind of Nashville playing catch-up with the growing population of our city and surrounding counties,” Bracht says. “I think it will definitely have a positive impact. Will it completely solve the problem of patients boarding in emergency rooms? It depends on how effective they are.”
The effectiveness of these solutions will be highly dependent on good outpatient follow-up. If patients are treated and released after a crisis has passed without a plan for continual care, “they will continue to cycle back into our crisis program,” Bracht says.
But even more beds may not help people like Porter.
On one of the top floors of his senior living high-rise, Porter welcomes guests.
The building smells of stale smoke. The elevators are claustrophobic and sometimes out of order. But Porter’s apartment is clean and comfortable, with a fan and two air-conditioning units keeping him cool on a warm July day.
It is a significant upgrade from his prior living conditions — and an important move for Porter’s mental health.
Before this, Porter lived in a single room at a hotel converted into efficiency apartments. Bedbugs and roaches scurried about. Many of his neighbors had felony records.
Living in a high-crime area meant his environment was stressful and chaotic.
He wanted to move, but he owed a former landlord a large sum of back rent. Despite chronic illnesses, having several appointments a week, and a limited budget, he saved.
With his debts paid, and through working with his case manager at Centerstone, Porter moved. As a result, his health has improved.
Porter still faces challenges. He needs a motorized wheelchair to get around. He has some memory loss from his stroke.
But he can sleep at night, and he has support.
“I never had any mental health care before,” he says. “As a matter of fact, I didn’t think I needed it. But evidently, somebody thought that I did. And the thing is, I am willing to accept whatever it takes for me to gain or to come back to the state of mind that’s healthy.”
Reach Jessica Bliss at firstname.lastname@example.org or 615-259-8253 and on Twitter @jlbliss.
Call 855-CRISIS-1 (855-274-7471) and you will be routed to a trained crisis specialist in your area.
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