To the world at large, Santa Barbara is the American Riviera where happy rich folks frolic on fabulous estates and there is no sorrow or trouble. As Borat would say: “Not!” While there is much privilege, there is also marital strife, depression, suicide, eating disorders, acting-out teenagers, and, increasingly, the streets of Santa Barbara are home to many untreated mentally ill homeless people.
In our city’s benign and generous environment, you would think there would be plenty of help for anyone with ailments of the mind. But, as it is with so many things, the options available depend on where you hang on the economic ladder. Gary Linker, a therapist and executive director of New Beginnings Counseling Center, breaks it down this way: “If you have money, you can get Mercedes service. If you have insurance, you can get Honda service at least. There are many good therapists on insurance panels, but it is hit-or-miss. If you can only afford $40-$80 for therapy, you are really looking around.”
Most people in the mental health field whom I spoke with agreed there are plenty of private-practice therapists available for people with the means to pay for it. Fees range widely from $75-$250 (see next week’s Healthspan column for more about this), but where do people go for mental health services when their cash flow is more limited? Community counseling centers traditionally fill this need and Santa Barbara has several excellent ones.
Only five years old, New Beginnings Counseling Center is dedicated to never turning anyone away, according to Linker. They have an established sliding scale for individual psychotherapy from $25-$75, but, according to Linker, “even those who can only pay $1 are taken care of.” New Beginnings has been expanding its services to include psychologically oriented life skills training to homeless and low-income persons.
The Community Counseling Center, which has been around for 23 years, has a similar mission. It also provides counseling services on a sliding scale — $16-$75 — basing the individual’s fee on their income and how many people they are supporting. According to director Patricia Cooper, approximately 35 percent of the center’s clients are Hispanic and it is well staffed with bilingual counselors. Like New Beginnings, the center does its best to provide clients with comprehensive services that include counseling, educational classes in communication, and parenting skills, as well as a support group for Hispanic parents called Poeticas de Familias.
Another excellent community counseling clinic is the Hosford Clinic at UCSB, which isn’t just for students anymore. Like the other community-based counseling clinics, Hosford offers a sliding scale ranging from $15-$85; it also provides therapy by more experienced licensed staff members from $50-$150. The clinic is not set up to provide emergency services but it does have a consulting psychiatrist available for medication.
Recently Hosford added the Psychology Assessment Center (PAC). PAC can provide psychological assessment services for all kinds of disorders that affect psychological, emotional, academic, and occupational functioning, including ADHD, learning disabilities, neurocognitive disorders, traumatic brain injury, and thought and personality disorders. A full battery costs $500 and a sliding scale is available.
All these centers rely almost exclusively on student therapists who are supervised by licensed therapists. This system is effective in that it provides more coverage for the population in need of services, but it does restrict the scope of practice.
Debra Manchester set out to deal with that issue when she cofounded the Family Therapy Institute of Santa Barbara (FTI) in 1980. Her idea was to combine a nonprofit model with a good business one, so that higher-fee clients would supplement the lower-fee clients. Manchester was convinced it was “theoretically possible to run a counseling agency with a staff so good we could play Robin Hood.” FTI puts this into effect with a staff that is comprised of more than half licensed therapists, and yet maintains a generous sliding scale from $30-$130. One thing that distinguishes FTI is its dedication to treating all cases “in context,” working with families, partners, and other social relationships in almost all cases.
Manchester also made the point that it is a very different story for those who want and seek therapy as compared to the more emergent mental health situations, including the severely mentally ill. “It’s a revolving door; a lot of crazy things have happened as we have tried to accommodate. Santa Barbara is making its efforts,” she said.
Often, “non-elective” cases erupt and need an emergency response. In Santa Barbara, the first line of defense is the Cottage Hospital Emergency Room. There is a licensed therapist on duty 24/7 with a psychiatrist on call.
If you call 9-1-1, it can get complicated. In the good ol’ days, we had a PET (Psychiatric Evaluation Team) composed of psychologists who were part of the response team called during emergencies. This system has been changed to a MAT (Mental Health Assessment Team). This is often run by paramedics with less training in psychiatric evaluation. They are oriented toward involuntary commitment that has a very strict standard — it requires the approval of the on-call county psychiatrist and is rarely done. Often, people in crisis are told to call County Mental Health and enter into that system which, by most reports, can be dicey.
There are some positive developments in our public mental health system. The county has opened a crisis clinic called CARES (Crisis and Recovery Emergency Services). The original intention was to be a 24-hour emergency walk-in service for Medi-Cal patients and those with no insurance, but budget cuts have restricted it to a Monday through Friday, 8 a.m. to 5 p.m. schedule. This is the county’s attempt to make services accessible before hospitalization is required.
Santa Barbara no longer has a suicide hotline. However, the 211 Crisis Hotline is up and running and can deal with all kinds of emergencies, from domestic violence to suicide. The county also has a Family Stabilization Team, which goes out to homes and works with eruptions in families or between parents and children. The CARES program also provides a 24-hour crisis hotline (884-6850).
Much of the mental health services provided to people with little or no means is provided through Medi-Cal. Medication help is usually provided along with case management but according to various sources, the real problem arises because many of these people are in need of counseling as well but there is little ability to provide it.
There is a further problem in the system in that many patients who come in for help don’t have serious enough mental health issues to qualify. They are therefore turned back to their primary care physicians. These doctors are often overwhelmed. “They are too sick for us to manage,” is a complaint often heard.
Mental Health Reality
In California, generally, mental health services in the public sector have been under-funded. Ever since Ronald Reagan closed the mental hospitals, things have gone south. Community health centers were intended to pick up the slack, but funding and energy have left that camp. The excellent Santa Barbara Neighborhood Clinics, for example, have no mental health services available, although they are looking into it. According to Executive Director Dr. Cynthia Bowers, “Because of the lack of mental health services in the community, our primary care providers, by default, also become mental health providers.” This is a problem, as Bowers estimates at least one in 10 of the adult patients who come to the Neighborhood Clinics suffer from some form of mental illness.
The mental health professionals with whom I spoke — most of whom wished to remain anonymous — agreed serious problems exist. “Most people in the mental health field would say it’s a nightmare,” one said. Another put it simply: “We have a mental health system that is broken. [In Santa Barbara County] we have been traditionally under-funded, which makes our system worse than other counties.
George Kaufmann, former president of the board of the Mental Health Association of Santa Barbara County, knows about these problems — not only as a community activist but also as a father of a mentally ill son. Kaufmann described his son, who was diagnosed with schizophrenia, as “typical of a young person with this illness: no insight into his condition, refuses treatment, addicted to drugs, went missing, and was homeless.”
The family previously lived in Michigan, where there were excellent services, and in that system, Kaufman’s son attained a “remarkable recovery.” But all that changed when the family moved to Santa Barbara. Due to the high cost of real estate, housing was a problem. The only way he could get his son higher on the housing list so he could live independently was to move him out, in effect, making him homeless once again. “The reason I have stayed involved in this area is that I was shocked that services were so poor even though there was lots of money available,” Kaufmann said. “In California we have a ‘make-do’ culture … because mental health treatment is actually an option here, unlike other states. Ever since deinstitutionalization, everybody has become resigned to making do with suboptimal services.” And what about Santa Barbara County in particular? Like everyone else I talked to who had criticisms of our public mental health services and policy, Kaufmann didn’t want his statements to be an indictment of the county. “With its resources, it is doing a good job.” As an example, he cited the county’s emergency mental health services. “Everyone agreed these needed our most immediate attention and, to their credit, they created CARES even before funding was fully in place.”
I asked Dr. James Broderick, director of the county’s Alcohol, Drug, and Mental Health Services, about the mixed reviews his department has been receiving. “Some of the criticisms I’m sure are valid,” he said during a phone conversation. “Our county staff has caseloads of 50 to 60 cases, and we are doing a good job with the resources we have. People need to see we are in the process of changing the system.”
For example, Broderick said the county is doing a tremendous amount for the mentally ill homeless, getting them off the streets and into treatment. Along with working to provide housing for this population, the county is involved in an innovative program called Restorative Policing, wherein teams of mental health workers and policepersons go out to the streets to more effectively deal with the homeless. “The public system is a safety net and the primary responsibility for the seriously mentally ill falls to us,” Broderick continued. “All the expectations are on the public sector but where is the private sector? For example, we are supposed to have parity [insurance companies paying for mental health services at the same rate as physical health services] but this is not enforced.”
According to one high-ranking mental health professional in the private sector who wished to remain anonymous, “There doesn’t seem to be much leadership around this locally. Let’s face it, this isn’t a sexy issue. Yet it is surprising this is happening in a place like Santa Barbara, a place that is politically progressive and wealthy. You would think it would be different here.”
Community Counseling Centers
Family Therapy Institute of Santa Barbara, ftisb.org Hosford Clinic, education.ucsb.edu/ccsp/hosford.html Hosford Psychology Assessment Center, education.ucsb.edu/netshare/ssmith/pac.html New Beginnings Counseling Center, newbeginningscounselingcenter.org Family Service Agency, fsacares.org Community Counseling and Education Center, ccecsb.org
Cottage Hospital 24-Hour Emergency: Pueblo and Bath sts.; 682-7111 211 Crisis Hotline: Dial 2-1-1 CARES 24-Hour Crisis Hotline: 884-6850
Private Practice Referrals
Licensed Psychologists: Santa Barbara County Psychological Association, sbpsychologists.org Licensed Marriage and Family Therapists: Santa Barbara CAMFT, santabarbaratherapy.org Santa Barbara Healthsource, sbhealthsource.org/site/directory/16.html