On the Road to the Prevention Summit: Cowlitz County

May 06, 2008

A wan sun and a pale blue sky greet visitors and Cowlitz County mental health advocates and community members on a brisk spring morning in Longview, Washington. It's sunny, but cold. The Prevention Summit is a month away, and it's time to talk about making mental health work.

In the run-up to the Prevention Summit, public meetings like this have been taking place across Washington State. Citizens and government workers gather to express their concerns and sense of priorities about how to make a system with ever-dwindling resources work better.

In Cowlitz County, prevention is a topic near and dear to them. They still talk about a government study on public health issues produced here some 20 years ago. Its now legendary preface tells a parable about cliff bluffs on the ocean and rocks below, and a choice between whether to spend money on building a fence up top, or on enhancing the emergency services that collected casualties at the bottom.

It's the classic policy dilemma between prevention and cure. Like all of us, in Cowlitz County they are still struggling one way or another with that choice, particularly when it comes to addressing mental health needs.

Talking Prevention Policy in Cowlitz County

By 9 a.m., more than 40 people have filled practically all the seats provided in a large conference room in a modern building on the county fairgrounds. No one is shy about starting. The first order of business: children. Handouts are distributed that detail the nature and impact of Adverse Childhood Experiences (ACEs), how poverty and community values mitigate and complicate the picture.

There is grim and universal acknowledgment of the problem of fetal alcohol syndrome. "The womb is the most dangerous place on earth," says one person. "Trauma is to mental health like smoking is to cancer," says another.

Another handout describes the benefits of home visitation programs, such as the Nurse-Family Partnership. Cowlitz County already has a reputation for the quality and innovation of its foster-care programs.

Someone talks about the zero-sum aspect of prevention and cure. "How do you shift resources to a front-end preventive system without leaving those in need behind?" asks one person. ("You don't," another answers.)

Someone brings up integrated care, which calls for healthcare to be a single, comprehensive experience. It's a popular subject in Cowlitz County, where a strategic alliance called Cowlitz Comprehensive Healthcare advocates strongly for it. The alliance includes the Cowlitz County Guidance Association, Cowlitz Family Health Center, and the Drug Abuse Prevention Center.

A pediatrician advocates for the importance of the medical home model, defined by the American Academy of Pediatrics as "a model of delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care."

Now someone raises the needs of Native Americans, who "are clearly disproportionally represented among mental illnesses."

Again and again, the idea of "silos" comes up – the closed doors within a system that recur at virtually every logical access point. People turned away for making too much money; for making too little. People turned away because they live – or work – at the wrong address. People losing hope as the difficulty of finding help becomes overwhelming. With the details of one particularly knotty effort to deliver services, someone makes the point that "the biggest silos in this state are called counties."

Now coordinated care models and their problems are up for discussion. Two problems are typically encountered: the logistics of bringing together professionals, and the necessity of adequate training for everyone involved.

Everyone agrees on the need for more training – for everyone, but especially for those making "initial contact" with children.

Now the issues come fast and thick: Preschool practices. Pitching trauma-informed care in schools. Meeting mental health system requirements for collaboration under current staggering caseloads. Long-term care facilities increasingly providing shelter to younger and younger people, a strain to the system. But rejecting these people, especially after they have already been placed in the facilities, will profoundly interfere with their recovery.

The issue of stigma comes up, of course – it usually does in any discussion of public mental health needs. Before anyone knows it, it's 11 and the meeting is over. The notes have been taken, the ideas and strategies collected for ways to improve prevention-oriented approaches to mental health. Much more work remains to be done, of course, in the lead-up to the Prevention Summit and then after. But the morning has produced a good exchange of ideas, and momentum for everyone participating. It feels like things are headed in a good direction. People linger to speak with one another as they drift slowly outside, where it's still a sunny spring morning, but warmer now.

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