Regional innovations – Fresno: How to rebuild a mental health system in crisis

150 150 Justin Ewers

The Fresno area has felt the crunch of closing county psyciatric facilities (Photo Credit: Omar Omar)

Doug Noll isn’t ready to declare victory. Not yet.

A recent California Stewardship Network report rightfully celebrates Noll and others for bringing together a pioneering coalition of Fresno business leaders, public officials, and nonprofit advocates to address an acute health crisis in the San Joaquin Valley brought on by a perfect storm of recession, severe budget cuts, and entrenched poverty.

The report details how Fresno leaders rallied after the closure of a county psychiatric crisis center sent a ripple effect throughout the region: With nowhere else to go, rising numbers of suicidal and psychotic patients picked up by law enforcement sent caseloads soaring in Fresno emergency rooms. Small treatment centers like the eight-bed Selma Community Hospital­ reported seeing about one mental health patient a month before the recession. By 2009, they were treating one every day. In the region’s emergency rooms, wait times for those seeking mental health treatment climbed to an average of 19 hours.

Driven together by crisis, regional leaders from hospital administrators to the sheriff and county health department formed the Fresno Mental Health Initiative—a collaborative effort to build the foundation of a radically new, fully integrated mental health, substance abuse, and criminal justice system.

Noll, though, the group’s mediator, insists the initiative’s work is only beginning. “We’re trying a new process here, but we have not succeeded yet,” he says. He ticks off a litany of challenges still facing the region, most of them driven by the widespread poverty that has made his part of the Valley the nation’s poorest congressional district: Only one out of every fifteen adults in the region graduate from college, only half of households earn more than $16,767 annually, and most residents live a full four years less than people in other parts of the country.

“There’s a desire here for something different, and we have generated a lot of energy and interest in what we’re doing,” Noll says. “But until we’ve started moving the dial on the most entrenched poverty in the nation, there’s not much to cheer about.”

Focusing the mind

What there is to celebrate in Fresno is this: Faced with a real crisis in their community, Fresno leaders have joined forces to do something about it. Together with groups like Fresno Mental Health Initiative, the California Economic Summit is working to scale up similarly innovative regional efforts, joining with dozens of regional organizations across the state to pursue a shared agenda that will create jobs, keep California competitive, and help reduce poverty in places like the San Joaquin Valley.

The recession provided a stark reminder in Fresno of just how vital this work is. The housing collapse and ensuing downturn devastated the region’s health system, causing a spike in mental illness cases and pushing the homeless population in the city close to 4,000. At the same time, budget cuts wiped out the public sector’s resources to respond. As the Stewardship Network report describes it:

Mental illness and chronic homelessness had been straining Fresno infrastructure for some time, but the issue came to a crisis point after the County’s Crisis Center was closed due to budget cuts. Mentally ill adults in crisis had nowhere to go other than to the emergency room or local jails. While the issue was affecting the community overall, no single entity had responsibility for addressing the problem. Institutions were operating in silos, with few incentives to collaborate.

The region’s health system began to struggle under this new burden. “Fresno County hospitals had dealt with mentally ill patients in their ERs for years…but never at the levels of patient volume, scope and severity of illness that we began to experience,” says Lynne Ashbeck, regional vice president of the Hospital Council of Northern and Central California, in the Stewardship Network report. “Our focus evolved from solving a specific problem to realizing work needed to be done to address system-level disconnects.”

The Fresno Mental Health Initiative emerged as a way to do just that, bringing together leaders from the Hospital Council of Northern and Central California, the Fresno Business Council, and a diverse group of community stakeholders including the county’s criminal justice and social services agencies. The goal was to engage leaders in a meaningful collaboration on the issues of mental health and addiction in the Fresno area.

“We made a call to action by saying if we can’t solve this problem today with the political capital we have in this room, we should call it off for a generation,” said Ashbeck.

Even with such a clear mission, though, the group still had its growing pains.

“You put mental health in the room with the district attorney and the sheriff and police and probation and the courts, and then you add in homeless advocates. By the time you get everyone together, you realize that one person’s speaking Greek, one speaks Aramaic, one High German, and another Sumerian,” says Noll. “It really is incredibly difficult to talk to each other.”

A new approach to collaboration

Seeking a solution, the group asked Noll, a professional mediator, to shepherd the initiative along. After reminding the initiative’s stakeholders that they shared the same objective, Noll proposed a revamped approach.

“The two ground rules we have for people who want to enter into our process: It’s totally voluntary. You come and leave whenever you want,” says Noll. “But if you come, you come with power to bind your organization. We don’t want middle managers here. Don’t send people to get information. If you can’t come with the power to make decisions, you have no business at the table. This is about getting results.”

One year later, the initiative has moved from concept to the brink of reality, agreeing on a plan to create a new Fresno Restoration Center to meet the region’s needs. The campus will offer a continuum of services for mentally ill and substance-abusing clients, from a sobriety unit to transitional residential housing, while connecting them with other community resources, as well. The group modeled their approach on a successful treatment center in San Antonio, where wraparound services have reduced the problems associated with mental illness enough to save the Texas city $25 million over three years.

For the Fresno center, the only issue now is finding the initial startup capital—a total of $250,000—necessary to put an organization in place, with a board, executive team, and detailed business plan.

“We think there is big money out there to fund this initiative, but we have to prove that we are investment-ready and worthy,” says Noll. “To change conditions in Fresno and the San Joaquin Valley, we need to change ‘normal,’ not treat symptoms. This cannot be done with isolated efforts or by one organization. It requires the leaders of major players in every sector to come together. That is what is happening in Fresno. That is what makes the work so compelling.”    

With all of the right stakeholders committed to the effort, Noll believes the initiative is ready to be nimble. “Without the help of government or foundations, we have to look to the private sector for social entrepreneurialism,” says Noll. “But the beauty of it is, from the time our initial capitalization hits the bank account, we can have our organizational structure up and running in 120 days. And from there, although it won’t be easy, we will go after the big social investment capital. With a lot of hard work from a lot of committed community leaders, we will achieve our goal of creating a system that integrates mental health, criminal justice, substance abuse, and homelessness services into one seamless operation.”

Only a few years removed from a severe crisis, that is a welcome state of affairs in Fresno. 


Justin Ewers

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