The state is taking a new look at its requirements for mental health crisis centers in light of Fresno County’s predicament: The area’s only psychiatric crisis center for children and adolescents does not — because of circumstances it cannot change — meet state regulations.
Like a dark version of the children’s book classic “If You Give a Mouse A Cookie,” the crisis center’s precarious standing with the state and the possible fallout is a seemingly endless loop.
The state requires pyschiatric crisis centers to be adjacent to a psychiatric hospital for children and adolescents. There is no such hospital in Fresno County. If the understaffed clinic closes, children and adolescents would be sent to emergency departments at local hospitals.
The county closed its adult crisis center in 2009 because of a lack of funding, and area hospitals are already overwhelmed with adults with mental illness. If the children’s crisis center closes, children and youth would face wait times of more than 24 hours. Without timely intervention, they would be more likely to need hospitalization. But there is no youth psychiatric hospital.
It’s a quagmire the state is trying not to exacerbate.
“The ultimate end goal is to give the regulations more flexibility while protecting safety,” said Jennifer Turner, a Department of Mental Health spokesperson. “The state does not want to cause more harm.”
From Bad to Worse
Mental health services in Fresno County have long been in disarray. Even families with money can’t find providers. Tales abound of parents driving delusional, suicidal or panicked children three hours for treatment in Los Angeles or San Francisco. The closest children’s mental hospital is in Bakersfield.
A community safety net is close to nonexistent, according to county officials. The area has one of the deepest shortages of psychiatrists in California — 6.9 per 1,000 residents, compared with a 16.9 average for the state.
“The biggest mental health facility in Fresno County is our jails,” said Fresno County supervisor Henry Perea. “As for the emergency rooms, they’re packed. A person having a mental health crisis sometimes waits days for care. The bottom line is it’s bad.”
The youth crisis center in question is a place where police and paramedics can take youth in need of mental health care for a 72-hour involuntary holding period known as a 51-50, a section of the California Welfare and Institutions code. Even if the state does decide Fresno’s child crisis center is not in compliance, the center still might be allowed to treat children and teens with mental health problems, but it would not be able to receive 51-50 patients.
The original reasoning for the regulation that a clinic be adjacent to a hospital was simple. Some patients brought in on holds might prove a threat to themselves, staff or other patients at a small clinic and need to be transferred immediately to a mental hospital.
That threat might be even higher at the Fresno crisis center because it’s short-staffed. The county will need to add two mental health clinicians and one licensed vocational nurse to meet state guidelines.
“We’re looking at what we can modify. The state is not taking any hard stances and is listening to the county’s limitations. But we have to find more flexibility while still ensuring safety,” said Turner.
A Last Line of Defense
More than 100 children and adolescents are brought to Fresno’s crisis center each month — the majority by police.
The center can hold up to 12 patients at a time. There is a day room, as well as seclusion rooms for children and youth who need isolation. Those who show no improvement in the first 24 hours are sent to mental hospitals.
“I can tell you that 88% of the kids do not go to the hospital,” said Donna Taylor, director of behavioral health for Fresno County.
“We can adjust medications. Sometimes we can help by just giving them a calm place,” she said.
“When kids are in crisis, when they’re suicidal, when there’s explosive behavior, sometimes we can de-escalate that child by putting them in a quiet room and giving them a little hope.”
According to Taylor, the clinic is an integral part of a community trying to work around the area’s lack of a psychiatric hospital for children and youth.
Taylor said, “Law enforcement, group homes, child protective services, all know that when there’s a crisis — whether it’s in the middle of the night, a weekend — they can bring a child to the crisis center. Without it, where are they going to go? There will be a lot of children from our community hospitalized outside the area.”
Taylor said this would cost the emergency departments, the ambulance systems, hospitals, and — most of all — local families.
“I just had an adolescent with a first psychotic break. The family was beside themselves. Treatment often involves educating the families. But in our area there are a lot of people who can’t afford to visit a child hospitalized three hours away. Sometimes they can’t even afford to pick them up.”
Taylor said the area’s last resort is to lobby for the crisis center to remain open and, when possible, keep children from needing hospitalization because there is little hope the area will have a children’s mental hospital any time soon.
“For five years we’ve tried everything to get an inpatient mental health unit for children — but there’s no organization willing to take the financial risk,” Taylor said.
Bigger Implications
About $1.5 million of the crisis center’s $2 million budget comes from money the county receives from the state sales tax and vehicle fees — revenue that has dropped dramatically during the economic slump.
Perea, the county supervisor, said the crisis center’s fate is part of a broader struggle in how counties are going to provide public health services in a fiscally stricken state.
“There’s less money. Everybody understands that,” said Perea. “But when local governments are being asked to do much more on so much less, the state has to lighten some regulations.
“There’s a little bit of danger in that, but there’s more danger in not streamlining. The answer on this clinic goes way beyond just this one part of the system. It goes to how we’re going to deliver services in California.”