On My Mind: A safe harbor in a storm

Imagine a young Islander whom I will call Becca. She was stationed in Afghanistan, saw her buddies killed, one right next to her. On returning to the Vineyard, she struggled with nightmares and flashbacks. She felt numb and cut off from her feelings. Sometimes hours passed with no awareness of how she had spent that time. She was always on guard, slept minimally, and sometimes couldn’t stop hearing in her head the noises of combat and the voices of dead comrades. She comforted herself with Percocet and later heroin, which offered temporary relief but soon became a problem when she realized she couldn’t stop. She managed to hold down a low-level job, but all her earnings went to support her habit. Becca and her childhood sweetheart found themselves fighting incessantly, and eventually, Becca’s boyfriend became physically abusive.

And then the pandemic happened, increasing Becca’s sense of isolation. She lost her job, and was stuck at home with a boyfriend who grew increasingly threatening. It became harder to find the drugs she was dependent upon, and she began drinking heavily to quell her constant anxiety. Desperate, she sought help: She found a therapist, and asked her primary care doctor for medication to treat her insomnia and depression. Both of these interventions helped a little, but they didn’t address her substance use, severe post-traumatic stress disorder, or the domestic violence she lived with.

Becca is a fictional example to illustrate how the consequences of serious mental illness permeate every aspect of human functioning: physical health, family relationships, financial stability, employment, housing and legal status, and so much more. Disruption in any of these areas can thwart the best talk therapies and medications, and make symptoms even worse. Mental illness can rarely be cured by a pill alone, or by sitting once or twice a week with a psychotherapist, even when other life factors are well aligned — which they rarely are when people are suffering from severe mental illness.

America’s Community Mental Health Centers (CMHCs) were designed in the late 1950s and early 1960s to address the complex causes and pervasive consequences of mental illness by offering a wide range of programs and services designed to help people holistically. Founded in 1961, Martha’s Vineyard Community Services (MVCS) was one of America’s first rural CMHCs. Over the past 60 years, it has changed the fabric of Island life for the better by fulfilling the promise of comprehensively meeting the needs of our mentally ill and otherwise struggling neighbors, regardless of their ability to pay for services.

If Becca, at the bottom of her despair, had called MVCS’s Island Counseling Center’s (ICC) 24/7 crisis hotline, she would have been seen quickly at the Island Intervention Center, co-located in the organization’s behavioral health wing. After assessing her needs, the center would have offered her a recovery coach who could help her negotiate sobriety, and the option of joining the New Paths Recovery Program, an intensive outpatient program for people struggling with substance use. She would have seen a psychiatrist or nurse practitioner to help her deal with her psychiatric symptoms, and been offered medication-assisted treatment to help with her opioid dependence. The center’s staff would have referred her to Connect to End Violence, a program for the victims of violence, to help her find safety from her abusive relationship, and to the Veterans Outreach Program and Support Group to help her feel less alone with her suffering from traumatic wartime experiences.

Becca’s multipronged treatment plan — that only CMHCs can comprehensively prescribe and coordinate — represents only a slice of all that MVCS has to offer. Community mental health centers also offer services to family members of people who struggle with mental illness or substance use, age-related debilitation, and medical disabilities. In a community mental health center, the entire staff gets to know clients and their families. Even the receptionist and office manager are crucial members of the team. Work in community mental health is nothing if not relational: What our patients need most is to know that they are seen, heard, known, valued, cared about, and that they can trust and entrust themselves, their bodies, their lives, and their care to the CMHC. This is what makes CMCHs effective. A clinic cannot accomplish this without people with the local knowledge, presence, and reputations that are all critical to relational trust.

My father, also a community psychiatrist, started a Community Mental Health Center on Staten Island, where I grew up, around the same time that Milton Mazer, a psychiatrist from New York City, was recruited to start ICC (which later morphed into its parent organization, MVCS). I remember the excitement and sense of mission of the diverse staff and neighbors who came together to make Staten Island Mental Health a reality. When I came to ICC, and later became its medical director, an important component of what attracted me was being part of the mission that I watched transform my childhood community. It has been immensely gratifying to be part of the ICC team who work with tireless devotion to help Islanders in need.

Throughout the pandemic, the team has worked almost seamlessly to provide telemedicine services and the full array of clinical activities. They have continued to provide 24/7 consultations to the hospital emergency room. A team of four supervisors have consulted every day for over a year, including weekends, to ensure clients needing crisis and/or urgent care services are linked to the services they need. The ICC clinicians have maintained and even increased their caseloads — all while they too are experiencing the devastating effects of the pandemic. Programs for people with substance use disorder have never missed a single session. Daybreak, a clubhouse for people with chronic mental illnesses, has operated via Zoom or in person throughout the pandemic, and the staff volunteered to continue food distribution to this group as well. Connect to End Violence still serves those experiencing domestic violence, and the rape crisis center has been fully operational. Veterans Services continued providing group, individual, and family counseling. An arrangement was made in collaboration with the sheriff’s department and the public school system to transport our Island veterans to the Cape for their coronavirus vaccinations, and food distribution is continuing to be provided to numerous veterans and their families.

Historically, staff who work in CMHCs earn less than they would in the private sector or in hospitals, finding their principal sense of value and reward in the joy of helping people who are in need, the pleasure of feeling part of a team, and feeling that one’s training and ideas allow for creative solutions to complex problems. What’s more, there is the excitement of building programs together and a feeling of being respected, appreciated, and heard. Human beings are, after all, tribal animals, and being part of a community of clinicians and clients feels good and is good for our own mental health.

It is the norm that Community Mental Health Centers rely on local fundraising to finance essential needs that Medicaid and other insurance revenue don’t. Historically, MVCS has been successful in raising the extra funds it needs. Now, with needs greater than ever, we all need to do what we can — from inside and outside the organization — to continue to make operations run as efficiently as possible and keep attracting the extra support that enables this critically important Island institution to be strong and effective.

Currently, ICC is in desperate need of more clinicians to serve a growing unmet need. With the move toward doing more work via telemedicine, there may be opportunities to hire more clinicians who work remotely from afar. But these people need to know the community, the Island, and its culture. They need trusting and mutually supportive relationships with the agencies and people who provide the full range of comprehensive services that people with severe mental health challenges need — in addition to talk therapy and/or medication. Island clinicians need to know each other so they can all convey to their patients that there is a whole institution that is holding them, caring about them, always ready to support them. This kind of institutional holding, which is so effective in supporting people with severe mental health and substance use challenges, is known as “institutional transference,” a well-established therapeutic result of a cohesive clinical team with deep community roots. For many people with severe mental illness, and especially for those with a history of trauma, trusting others — anyone, including their therapists — may be one of the most difficult challenges they face. Trusting a caring institution and team can feel safer. This is one central reason that CMHCs have been so successful.

Working at ICC has given me a deep appreciation for the wisdom, strength, and generosity of our community, and an understanding of what we can accomplish when we work together as a team of neighbors helping neighbors. We must continue to find the resources and solutions that enable MVCS to carry out its mission of helping those in need to accept themselves, to know that they’re not alone, and to find hope and healing.

Dr. Charles Silberstein is a psychiatrist at Martha’s Vineyard Hospital and Island Counseling Center, where he is the medical director. He is board-certified in general, addiction, and geriatric psychiatry. He writes regularly about issues Islanders have with mental health.

Laura Roosevelt is a poet and journalist who writes regularly for Arts & Ideas magazine and Edible Vineyard. She currently curates the MV Times “Poets Corner.”