What if you could improve mental health in our nation while saving millions of dollars? This seemingly improbable scenario might be entirely possible. The key, say believers, is starting early with children — diagnosing and treating mental illness before it gets a significant foothold.
Strategies include embedding counselors in schools, catching young people with schizophrenia just before or after they experience their first psychotic break and dealing with childhood trauma before it grows into a monster that leads to hospitalization, prison or homelessness.
It’s a bit like braking a roller coaster car before it barrels down the track’s steepest pitch or plucking a floating stick from a lazy creek before it heads downstream to increasingly turbulent waters. Not only does early intervention prevent future human suffering, but the savings could be significant.
“Investing in keeping people physically and emotional healthy is always more cost effective than treating chronic health conditions,” said Kevin Campbell, the CEO of both the Eastern Oregon Coordinated Care Organization and Greater Oregon Behavioral Health, Inc.
Two programs in Umatilla County are headed down this proactive, prevention-oriented path. The programs, known by their acronyms REACH and EASA, are getting noticed and being replicated around the nation.
Embedding counselors in schools
Norman Valdez is the kind of guy that makes you feel you are the only person on earth at the moment. When kids are in Valdez’s orb, they likely feel comfortable and valued.
Valdez spends his days at three different schools — McNary Heights Elementary School and Clara Brownell Middle School in Umatilla and Hermiston’s Rocky Heights Elementary School. Not a school district employee, he works for Lifeways, which provides mental health services in Umatilla County. Valdez is one of 10 skills trainers embedded in Umatilla, Hermiston, Stanfield, Echo, Pendleton, Athena-Weston, Ukiah and Milton-Freewater schools as part of the REACH (Resilience Education and Community Health) program.
The easygoing Valdez helps kids explore ways to cultivate good mental health. Most of the students referred to the program, at least before spending time in one of Valdez’s groups, had trouble focusing in the classroom. Many deal with the toxic stress of poverty, abuse or some other adversity.
Toxic stress, Valdez said, actually changes brains, causing a child to become stuck in the fight-or-flight mode. Executive functions don’t develop fully because the brain doesn’t develop the proper connections. The child may lash out, unable to think logically.
“Trauma isn’t necessarily that one big thing,” Valdez said. “It can be a series of little things.”
Research shows a connection between adverse childhood experiences (ACEs) and future health effects such as depression, heart disease and diabetes. Studies on the harmful effects of ACEs suggest that persistent poverty, abuse, loss and other trauma can lead to lower cognition, engaging in risky adult behaviors, prison time and even premature death.
“The question is not what’s wrong with you, but what happened to you,” Valdez said. “That helps flip the script and change the narrative from ‘Your behaviors are uncontrollable’ to ‘What happened to you?’”
Toxic trauma can bring on problematic behaviors. The student may act impulsively, have trouble sitting still or melt down when frustrated or angry. Traditional discipline doesn’t usually help.
“Reward systems and punishment don’t work when you’re in a state of just trying to survive,” said Valdez’s boss, REACH Coordinator Jovanna Centre. “Things just escalate.”
The idea is to address trauma early in the game to help children establish necessary brain connections and develop in a healthy way. The Umatilla County effort is funded by Greater Oregon Behavioral Health, Inc., and the Eastern Oregon Coordinated Care Organization. The state’s 16 CCOs, charged with providing care for Oregon’s poorest citizens on the Oregon Health Plan, are encouraged to lean heavily on prevention and innovation. In this case, the Eastern Oregon CCO opted to provide free counseling and skills training to the wider school population to prevent expensive mental and physical illness down the road.
Valdez started a recent day at Clara Brownell Middle School by checking his email and then going on a walkabout to collect seven students from their classrooms. He led the group — the first of seven groups that day — to his room. He couldn’t allow a reporter to witness for privacy reasons, but agreed to describe a typical session.
The students settle in seats arranged in a U-shaped pattern. They read the quote Valdez has written on the whiteboard. On this day, the quote comes from psychologist Abraham Maslow — “If the only tool you have is a hammer, you tend to see every problem as a nail.” The quote is relevant. Valdez regularly helps his students develop their collection of behavioral tools.
Valdez checks in with each student with a low-pressure, “Tell me how it’s going.” Their replies range from the mundane to the serious. He places his full attention on the person speaking and expects everyone else to stay respectfully silent.
An ice breaker follows. Valdez sometimes grabs a soft, miniature soccer ball with thought-provoking questions printed on each panel and tosses it to someone in the group. Whichever question their thumb touches is the one the student answers. Questions run the gamut. When does teasing go too far? What is love? Why might someone feel scared? The answer sometimes evolves into group discussions. When they finish a topic, the student tosses the ball to another.
Valdez guides the teens through role-playing exercises. They might play-act what they would say to a friend who has gone behind their back and lied about them. The group explores various topics such as anger management, conflict resolution, anxiety, friendship building and bullying prevention.
Valdez said the therapy eases kids from survival mode and helps them explore different ways of navigating their lives. Valdez doesn’t coddle them.
“Kids need structure and expectations. They need to be held accountable for their behaviors,” he said. “They want to feel like someone actually cares.”
Catching psychosis early
At age 19, Michael Haines was blissfully unaware that a frightening change lurked right around the corner. The former high school cross country runner was living the typical college student life, attending classes at Clatsop Community College in Astoria, hanging out with friends, playing ultimate Frisbee and working part-time at a grocery store.
Then he started hearing voices.
Haines started having trouble focusing. With the onset of hallucinations and delusions, he fell down the rabbit hole called psychosis. Thinking back on it now, Haines said the voices seemed absolutely real.
“Some voices were people I knew,” he said. “Sometimes they weren’t.”
Haines got baffled looks when he confronted the people directly. He felt a muddle of confusion and anxiety.
“To me everything was reality,” he said. “That’s part of psychosis — to you, what you’re experiencing is the truth.”
It was a time of isolation for Haines.
“I felt alone in my struggles,” he recalls. “I felt like no one could understand.”
Today, Haines is a healthy 26-year-old student living in Eugene with college and career plans that are firmly on track. He credits his transformation to an early intervention program called Early Assessment and Support Alliance, or EASA, to which he was referred after ending up in the emergency room during a psychotic break.
EASA started in Oregon in 2001 and is spreading far and wide. The state now funds the program in multiple counties as a way to ward off costly medical treatments and lost productivity. The idea is to address psychosis early with two years of intensive services that include counseling, education, medication (if desired) and family support. The service is totally free to clients who are screened and accepted into the program, whether they have insurance or not.
“The mission of EASA is to help them regain a normal life path,” said Elizabeth Conkey, a mental health therapist at Lifeways and clinician for Umatilla County’s EASA program. “Just because things are kind of bizarre and scary doesn’t mean they can’t go on and do whatever they planned before this episode. We help them know what is going on inside their head.”
Occasionally, someone will cling to their delusions. Someone, for example, may see auras that he or she believes give them information about people. A pink aura may signify a good person and black, a bad one.
“It becomes the new normal,” Conkey said.
Psychosis, which affects three percent of us, usually strikes in the teens and twenties. Taming psychotic disorders such as schizophrenia isn’t simply medication management, said Conkey’s boss, Micaela Cathey, who is Lifeways’ outpatient program manager in Pendleton. They learn to decode their delusions. They receive counseling and talk to peers who have experienced psychosis. They get help finding their way back to school and work. They may choose to take antipsychotic medication or not.
“They helped me use logic to get through my delusions,” Haines said. “I used reality testing to figure out if what I was experiencing was real.”
Conkey said the program has had good results. With their newfound resilience and toolbox of coping skills, many. EASA also keeps people out of the hospital, Conkey said, referring to an EASA Center for Excellence study of 943 EASA participants from 2008 to 2013.
“Before intake, 42 percent of participants had been hospitalized,” she said. “Twenty-four months after being engaged in EASA, only three percent had been hospitalized (again).”
Haines is headed toward a career in behavioral health as he works on his bachelor’s degree and, later, his master’s. He serves as a peer support specialist with the EASA program run by PeaceHealth in Eugene. Haines, who hasn’t experienced another major psychotic break since his first, is living a meaningful life.
“It really turned my life around,” Haines said. “I think things would be a lot different today if not for the EASA program.”