Jean O’Connor-Snyder intern Logan Fenhouse reports on access to mental healthcare in her civic dispatch from Walker County.

According to the National Alliance on Mental Illness, almost one in five of American adults will suffer from a mental illness of some form within the next year. In Walker County alone, that means nearly 13,000 of the almost 65,000 residents here will experience mental health problems. For a tight-knit small town like Jasper, this means that practically everyone knows someone, or are themselves, facing mental illness.

However, Walker County lacks adequate mental health resources to serve this population. Under the standards set by the Health Resources and Services Administration (HRSA), Walker County has been designated a mental health Health Professional Shortage Area (HPSA) since 1978. This issue has even caught the attention of community leaders.

A community needs-assessment meeting for Walker County identified two key issues as the most critical: mental health and substance abuse. Even though mental health is becoming increasingly prioritized, there is much more to be done to improve associated outcomes in this community. Because of this predicament, I set out to learn more about this community’s attitudes towards mental health, knowledge of resources available, and opportunities to promote community response to this issue.

Through a series of informal interviews with members of the Walker County community, I was able to gauge prevailing attitudes, public opinion, and stigma surrounding mental illness and substance use disorder in this area. For the most part, mental health is not widely understood in a positive or comprehensive manner.

For instance, when I explained this Solutions Journalism piece to Jasper residents at Hope House soup kitchen in hopes that they would share stories of their own, one member treated mental illness as if it were a joke. “Do I look like I have a mental illness to you?”, he responded facetiously, prompting chuckles from others. When one in five individuals struggles with mental illness, possibly even someone sitting next to him, this was no laughing matter.

Of course, I recognized his intention to make light of a heavy topic, but I couldn’t help but wonder about the root of this line of thinking. Did this group not realize that mental illness doesn’t always have apparent symptoms, but instead can be an invisible illness enshrouded in stigma?

Even in 2019, talking about mental health clearly makes others uncomfortable, highlighting stigma’s role in discussing the issue. Although this encounter revealed a lack of understanding of this topic, it also demonstrated the need for more education and conversation surrounding mental illness.

But not all of my exchanges with community members were like the one with the soup kitchen group. Others expressed concern and showed thoughtfulness on the situation in Walker County. “I can’t help but wonder if the two are related,” commented another weekly patron of Hope House, when talking about the opioid epidemic and mental illness. This woman saw the importance in addressing mental health and believed it to be a serious concern in Jasper.

Paul Kennedy, the president of the Walker Area Community Foundation, feels similarly. To him, mental illness is “the root cause of everything that is dysfunctional” and he believes that until we acknowledge it fully and treat it as a medical condition, nothing will get better. He can see public attitudes towards mental illness shifting towards those of sensitivity and compassion but believes there is much more conversation to be had.

Another Hope House patron shared the pain associated with his mental illness with me. He told me that even though others can clearly see his struggle, “they just ignore it.” It was heartbreaking to hear about his struggle to become well, but his determination to seek change was inspiring.

Caregivers in clinical settings view mental health in a similar light. Interestingly, each provider believes the opioid epidemic in Walker County has a strong connection to mental illness. When asked about mental health, Paige Britton, a peer support specialist at Capstone Rural Health Center, compared addiction to diabetes. She believes that they work the same way, albeit with different substances. Consequently, Paige believes addiction and mental health should be treated in the same manner.

Dr. Brandi Bolling, the tele-psychiatrist at Capstone, asserts that in general, people tend to care about mental health when someone they know is affected. So, she sees public views on mental health as being stagnant. Moving forward, we can address this concern by prioritizing education and decreasing the stigma of mental illness. 

Several providers at Capstone found it important to look at conditions that may lead to mental illness and substance use disorder. Lindsey Jones and Kevin Grooms, both nurse practitioners, believe that while there is a genetic component, addiction tends to be a learned behavior, while mental illness is likely the result of trauma.

For addiction specifically, there is a cycle of generational addiction when children learn their parents’ behavior. This series of events can also contribute to trauma, further exacerbating the cycle of substance abuse disorder with mental illness. It seems that improving this community’s knowledge around mental illness and addiction, and finding ways to provide equal opportunity for all to recover, is the only solution.

After learning more about views on mental health in Walker County, I was especially interested in knowledge about community mental healthcare resources. Naturally, those working in healthcare were the most informed, whereas others knew considerably less. In fact, one prominent community leader I met with struggled to name even one resource to help those struggling with mental illness.

This reveals an information gap between the medical field and the general public. Further, it raises questions about whether that gap results from stigma or a lack of information. On the upside, this interaction highlighted the eagerness of community leaders to prioritize mental health. When addressing an issue that affects one in five, and may even disproportionately affect underserved populations more severely, it’s apparent that more efforts are necessary to adequately address the problem.

Even when community members are informed about what mental illness is and where people can go for help, physically seeing a mental health provider still remains a struggle. Another woman I spoke with at Hope House identified access to mental health resources as the biggest barrier to care. She believed that those facing substance use disorder have many more opportunities for treatment than those with mental illness alone.

Rachel Puckett, program manager for the opioid use disorder grant, found similar issues in lack of treatment options. Choice, she urged, is necessary for those seeking treatment of mental illness. To Rachel, it’s important patients have good relationships with mental health providers, and in an area like small-town Jasper, with only a few, heavily-used mental health resources, it’s difficult to find someone who matches patient needs.

Access is also an impediment to treatment for those involved in youth behavioral services. Several mental healthcare providers mentioned waits of several weeks or months before children can see counselors or social workers. There is a great need for more mental healthcare providers in Walker County.

Fortunately, community leaders like Elyse Peters are trying to combat this issue by implementing a training program in schools. This model aims to build capacity in schools by raising awareness on what trauma is, how it affects behavior, and what resources exist to help those struggling.

In this model, youth in need of behavioral health services get help. And perhaps more importantly, communities better educated to understand mental illness can support and direct them to appropriate resources.

Of course, to fully address Walker County’s mental health caregiver shortage, more providers are needed. This is where Capstone Rural Health Center comes into play.

After receiving a grant through the Capstone College of Nursing, a complex integrated behavioral health model has successfully been introduced at Capstone’s three community clinics. Dr. Josh Eyer, one of the key grant writers and professor at the UA’s College of Nursing, explained this model during a meeting in Tuscaloosa.

The integrated behavioral health model involves receiving primary and mental health care under the same roof, with collaboration between providers, so patients can be cared for holistically. Specifically, this grant funds a remote tele-psychiatrist, two social workers, and technical assistance.

Capstone also has several other social workers and mental health professionals on staff, all with the goal of helping to address the mental health crisis in Walker County. 

While providing more resources to help those faced with mental illness is important, unfortunately, the cost of these services often determines whether a patient receives care. Many mental health centers in Walker County require patients have health insurance, and even then, charge a co-pay each appointment. Some providers refuse Medicaid patients, and many counseling and psychiatry services are too expensive for those with lower incomes or on disability. And sometimes, the financial burden of receiving treatment can be too much.

Given the choice between buying groceries or seeking treatment, “many individuals will choose to feed their families,” commented Lindsey Jones, clinical director at Capstone Rural Health Center. Luckily, Capstone may model the solution to this problem. As a Federally Qualified Health Clinic (FQHC), all those in need of care are seen here, insured or not. Capstone accepts insurance from those who have it, and the uninsured are charged a small fee based on their ability to pay. Medicaid and Medicare patients are welcomed here, and quality care to all is vital to the mission of Capstone.

The tele-psychiatry program in particular is a valuable addition to Walker County. Patients can see Dr. Bolling, a triple board-certified physician and psychiatrist face-to-face, through secure telecommunications technology from the convenience of Capstone’s Parrish clinic. Patients can use this crucial service for counseling and prescription needs. Plus, it makes it possible for patients to get the help they need, especially when it’s not possible or cost-efficient to make the two-hour roundtrip drive to Birmingham. 

Despite the good it’s doing, this program is financially unsustainable due to lack of stable funding. For now, the tele-psychiatry program paid by the Integrated Behavioral Health grant, but when that funding runs out in 2020, only insured or out-of-pocket patients may be able to afford Dr. Bolling’s services.

In a cruel irony, Medicare will not cover Capstone’s telehealth services. This is because Parrish, despite having fewer than 1,000 residents, is not sufficiently rural to satisfy HRSA requirements. Further, because Alabama Medicaid only pays for the facility fee for behavioral health services, Dr. Bolling would not be paid for her services.

Even self-pay would become unsustainable: fees per patient are not nearly enough to cover the hefty fees associated with tele-psychiatry.  With governmental policies the way they are now, few individuals can access desperately the care they so desperately need in communities like Walker County.

This brings us full circle: attitudes, resources, and ability to access mental health services signal that Walker County is ripe for change. Issues of stigma and discomfort with its normalization remain, but many in this community want to address the mental health crisis here.

With difficult conversations to change perceptions surrounding mental healthcare and more education on what mental illness looks like and how to help, mental health can be seen as just another medical condition, not a source of shame. More resources are imperative to provide services to assist the 13,000 individuals who likely will experience mental illness this year.

Above all, we need to convince elected leaders to prioritize mental health. Policy changes to lessen Medicare’s restrictions on tele-health reimbursement, and to better compensate Medicaid beneficiaries for behavioral health services, are of the utmost importance. With time and dedication, mental health can be seen and treated as an essential component of overall health in Walker County.

-Logan Fenhouse, University of Alabama New College

Jasper, Alabama

The photo of Logan was taken by Ms. Nicole Smith for the four-piece series on the 2019 Walker County Interns featured in the Daily Mountain Eagle.