Presented by Alaska Mental Health Trust Authority

Part 5 of 6

Ellen doesn’t know quite where her son is right now.

That’s not entirely true -- she’s pretty sure he’s still somewhere on the other side of the world. That’s where Justin was the last time she heard from him.

“He’s homeless in an epidemic, in a country where the president doesn’t believe in COVID,” Ellen said. (Names have been changed and details withheld to protect the family’s privacy.)

It’s a frightening situation for any parent to be in. But for Ellen, it is no longer surprising.

Justin’s mental health troubles started when he was still in high school. After graduation, he started to develop a pattern of taking off for the winter, when his mood disorder is at its peak, and flying somewhere warm.

“He would get some money and he would travel to Hawaii and be homeless in Hilo, he would be homeless in Fresno,” Ellen said.

When he gets tired of being away, he will call and talk his parents into flying him back to Anchorage, where things generally get worse. At his parents’ home, he is manic, violent and destructive, a pattern that dates back to his late teens.

“We had to have our first restraining order, and he had to live on his own somewhere, and I think that was when he ended up at Covenant House for the first time,” Ellen said.

Now an adult, Justin’s history has, in some ways, painted him into a corner. On the advice of police who responded to their calls for help, Ellen and her husband have twice filed for protective orders, starting a court record that has haunted Justin into adulthood.

“He wanted to join the military,” Ellen said. “They looked at his record, saw a restraining order filed by his parents, and said ‘No, thank you.’”

Justin is one of the many Alaskans who experience collateral consequences from criminal charges that follow them for years, making it harder to secure housing, work and benefits.

“He has no work history, but he has a restraining order from his parents -- that tells a story right there,” Ellen said.

Then there are the misdemeanor charges -- destruction of property, drunk and disorderly, obstructing traffic, resisting arrest -- most of them stemming from the night he got drunk and decided to challenge a police officer to a fight. It took three or four officers to get him down.

“The judge at the time said, ‘I don’t know what’s going on with you, sir, but you better figure it out,’” Ellen said.

But “figure it out” isn’t an effective plan of care for a person struggling with a behavioral health disorder. Justin doesn’t want to be medicated -- he says it’s not “holistic” or “organic,” Ellen said -- and ultimately he ended up homeless in Anchorage, sleeping by day and walking around at night to avoid predators. He tried spiritual teachers and churches, and when they didn’t have the answers he was seeking, he went looking for them overseas. This winter, he got on a plane in search of the “pure, real” practice of Christianity that he believes needs to attain to be cleansed of his illness. The last time his mom heard from him, he was living on the beach in a crowded city on another continent.

“He’s homeless somewhere out there, and he’s had all of three dollars to his name for the past two weeks that we know of,” Ellen said.

‘Housing first,’ meet ‘treatment first’

If you drew a Venn diagram of behavioral health disorders, poverty, joblessness and housing instability, Justin is just one of the many Alaskans who would show up in the large, overlapping center.

“I think the data that we have is fairly similar to other cities,” said Dr. Dick Mandsager, a senior fellow at the Rasmuson Foundation who is currently serving as an executive on loan to the Anchorage Homeless Leadership Council. “(Among) the folks who experience chronic homelessness, 60-plus percent of the individuals have mental illness and/or substance abuse, often dual diagnoses.”

Alaska Behavioral Health clients on a community outing in Anchorage. When clients are connected to services such as supportive housing, they learn daily living skills and build community connections, reducing the chances of another crisis, and building the support and skills to manage a crisis should it occur. Photo Credit: Alaska Behavioral Health

People who experience debilitating behavioral health symptoms often aren’t able to function well in the workplace, which leads to unemployment. Unemployment leads to housing instability. And homelessness and all of its associated effects make it harder for people to recover. The cycle means you can’t really solve one problem without solving the rest.

“It’s not just one lane,” said Christine Alvarez, chief clinical officer for adult services at Alaska Behavioral Health. “It has to be comprehensive.”

Both Mandsager and Alvarez pointed to Maslow’s hierarchy of needs, the theory that a person’s basic physiological needs -- things like food and shelter -- must be satisfied before they have the capacity to pursue less immediate needs.

“If you don’t have your basic needs met, if you don’t have (clean water) to drink or you’re not warm or you don’t have food, if you don’t feel safe … how are you going to engage in feelings of belongingness or love or accomplishment?” Alvarez asked. “You really need to have those needs met.”

Nationally and in Alaska, there has been a movement toward getting people housed as an initial step on the path to recovery, and while that’s a start, it’s important to remember it’s really just one step, according to Mandsager.

“I’m a believer in the policy of this country of the last 25 years that ‘housing first’ is key, but that doesn’t mean ‘housing only,’” he said. The combination of housing and treatment offers a better chance of long-term sobriety and stability.

People tend to wrongly mischaracterize behavioral health as a choice, he added.

“We don’t criticize people who relapse on their diet to help manage their Type 2 diabetes or go off their blood pressure medications or whatever, but boy, do we judge people who relapse on their substance abuse,” Mandsager said. “One upside about the opioid crisis of the last 20 years is more middle-class Americans have realized this can happen to any of us.”

Mandsager added that he sees the “treatment first” approach to behavioral health in the Crisis Now framework currently being developed by the Alaska Mental Health Trust Authority as a “profound and way overdue” component of addressing homelessness and health in Alaska. Developed in Phoenix, Arizona, Crisis Now adds new critical services for behavioral health crisis response, including a 24-hour crisis line, mobile crisis team, short-term stabilization centers and peer support.

“I’m really hopeful,” Mandsager said. “I think the data that I’ve seen from Phoenix has just been immensely persuasive to me.”

And there’s support for this kind of initiative in the community, he added. Homeless Leadership Council research suggests that Anchorage residents overwhelmingly approve of investing in mental health and substance use treatment.

“I think this is a necessary first step,” Mandsager said. Ultimately, the state still needs to build out a more robust system for behavioral health, he added, but implementing Crisis Now is a move in the right direction.

Opening more doors

For Renee Rafferty, regional director of behavioral health for Providence Alaska, the professional became personal one day when a man experiencing a behavioral health crisis wandered into her house.

Yes, it was scary. But after overcoming her initial fear, she started to worry more about the trespasser than herself.

“I remember thinking ‘There is nowhere for him to go other than to be in harm’s way for himself and the community,’” Rafferty said. “It felt heartbreaking that the only option for him was to go to jail. With Crisis Now, at least there’ll be a system in place to say we are going to create more opportunities.”

One of the challenges that frequently arises in Alaska, even in Anchorage, is that there are not a lot of treatment options for someone who needs help for both a substance use disorder and a mental health issue.

“Someone that’s suffering from severe and persistent mental illness as well as substance use disorder is going to be very challenged in this state,” Rafferty said. “It’s going to be hard for you to get the right services at the right time. The Crisis Now stability model allows for no ‘wrong door,’ so both substance use and mental health can be treated at the same time.”

The model also incorporates peer support, something that Cook Inlet Tribal Council has found to be successful in its outpatient and residential substance abuse treatment programs.

“The peer model is really brilliant,” said CITC Senior Clinical Director, Recovery Services Jenae MacNaughton. “It’s somebody who has walked in their shoes. A professional coming in has to stay at a very cold distance sometimes.”

Peer support specialists are workers who have been successful in recovery or management of a behavioral health disorder. They combine their personal experience with professional training to serve as advocates and navigators for behavioral health program participants.

CITC Recovery Services employs 14 peer counselors working across its entire continuum of care. They bring a different kind of experience to the recovery environment, MacNaughton said -- one that makes a significant difference for participants.

“Peers are boundary-less with what services they can do, with the intent to warmly bring individuals into treatment and warmly walk them through that pathway,” MacNaughton said.

Peers provide a level of trust that may be harder to achieve with a clinician, she added.

“Building that trust, warming them up to ‘Hey, I’ve been there, look at me,’ and telling their story, versus somebody in charge saying ‘Hey, you need treatment’ … it’s like having a lifeline, a buddy,” she said. “It’s having that point of reference. It’s really beautiful. Recovery has a social piece, and we’ve got to be able to have that connection.”

A new approach to fostering recovery -- and fighting stigma

If there’s one more thing that homelessness, poverty and behavioral health disorders have in common, it’s stigmatization. In the case of behavioral health, often the stigma is due to the fact that a person’s condition can be invisible.

“It can be organic,” MacNaughton said. “It can be something that happens due to a fall or a traffic accident. Mental illness is so internal that we have no idea. Anxiety affects so many people, and we would never see it.”

Homelessness, on the other hand, is stigmatized because it is so visible. Alvarez said she hears it in conversation all the time.

“What they have said is ‘We don’t want to see them, we don’t want them on our streets, we don’t want them in our city,’” Alvarez said. “I think my conversation, instead of saying ‘We don’t want to see them,’ is ‘How can we help them?’ They are equally valuable members of the community.”

Ironically, she added, pushing the problem out of view just tends to make it worse.

“When individuals are marginalized, it increases stress, and then they tend to have more health issues,” Alvarez said. “It’s all kind of interconnected.”

An approach like Crisis Now, which brings intervention out into the community and provides multiple levels of support, has the potential to help ease that stigma.

“Our current crisis response relies too heavily on police, the criminal justice system, and the ER,” Alvarez said. “What Crisis Now brings is a behavioral health crisis system of care that provides someone to talk to, someone to respond, and a place to go for those in crisis. By having the right system of care in place, individuals have an opportunity for intervention and services at less intensive levels of care.”

One of the elements of Crisis Now that Alvarez likes is the idea of a crisis call center functioning as “care traffic control,” so individuals in crisis are connected to services they need at the right time without ever losing contact.

“We are trying to find solutions, but individually we don’t have sufficient bandwidth to address those needs,” she said. “If we come together in the community and make sure we aren’t duplicating efforts … that’s where everyone in crisis can have a safe landing.”

Crisis Now involves dozens of organizations in Anchorage, Fairbanks and the Mat-Su working together to bring the new services -- a crisis line, mobile crisis team, peer support and a 23-hour stabilization center -- to life.

“Collaboration allows for a coordinated system that people are far less likely to fall through,” Rafferty said. And the effort to launch the Crisis Now framework “has created collaboration that I’ve never seen. This stakeholder group can start to move mountains around the challenges facing our state,” she added.

Credit: Alaska Mental Health Trust

It’s a level of cooperation that is unusual -- and, she said, much needed.

“The crisis care that we are delivering right now has been built in a very fractured way,” Rafferty said. “Everybody’s trying to do their best, but patients are having trouble having their needs met.”

That perpetuates the cycle, she added: “People can’t receive outpatient care easily, so they go into crisis.”

That’s exactly what Ellen watched Justin experience, and what she hopes Crisis Now will help prevent in the future.

“I’m thrilled,” Ellen said. “(The stabilization center) would have been a safe cooling-off area where professional folks who are not dealing with incoming trauma would be able to perhaps talk to him about options available to him, and maybe have access to resources that we just didn’t know about.”

Instead of an escalating crisis mediated by the police, Justin might have been able to stabilize enough to find his way into housing -- something that would have made a huge difference for him.

“A safe place to not freeze to death? Absolutely,” Ellen said. “Where he could feel like he could sleep safely, not sleep with one eye open? Absolutely.”

Ultimately, advocates say, helping the Justins of the world get back on their feet can help change the community for everyone -- without sweeping the problem under the rug.

“It’ll impact us on the visible homelessness side, on the panhandling side, for folks that have a lack of trail safety,” Mandsager said. “It clearly will also allow families to have more stable lives to support their kids in school. It will enable individuals to heal so that their ability to hold jobs will be enhanced. That helps the community.”

Read the rest of the series: Part 1 - Part 2 - Part 3 - Part 4 - Part 6

The Alaska Mental Health Trust Authority is a state corporation that administers the Alaska Mental Health Trust to improve the lives of beneficiaries. Beneficiaries of the Trust include Alaskans who experience mental illness, developmental disabilities, chronic alcohol or drug addiction, Alzheimer’s disease and related dementia, or traumatic brain injuries. Learn more at AlaskaMentalHealthTrust.org.

This story was produced by the sponsored content department of the Anchorage Daily News in collaboration with the Alaska Mental Health Trust Authority. The ADN newsroom was not involved in its production.