There was no white picket fence for Micaela Boice's daughter.

There was turmoil at home and acting out at school.

There were physical restraints and padded rooms; medications, new medications, then a stay at an inpatient hospital.

Boice put her faith in the system and got her daughter a counselor. She went to Southeastern Behavioral Health looking for a stable source of support for Makenzee.

Boice never found stability.

Instead, she found a revolving door of therapists as one after another moved on for personal or career reasons, leaving Makenzee starting over each time, trying to get help for her raging emotions.

“It’s like they’re a life raft, but you’re in charge of inflating it,” Boice said.

Providers such as Southeastern are supposed to be a cornerstone of mental health treatment for America's children. But in terms of spending, South Dakota's network of 11 regional mental health care centers play second fiddle to the state psychiatric hospital.

Part of an occasional series exploring adolescent mental health care in South Dakota.

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For decades, as other states shifted funding from institutions to local communities, South Dakota has been slower to transform its mental health system. While funding for community-based treatment is catching up, most state funding for mental health still flows to address emergencies at the state psychiatric hospital.

Critics say South Dakota's misplaced spending priorities hurt the quality of local treatment options and contribute to staffing turnover at regional care centers. That hurts children who rely on agencies such as Southeastern for help, said Phyllis Arends, who heads the Sioux Falls branch of the National Alliance on Mental Illness.

“I just told you everything about me, and now you’ve left,” Arends said.

Slow to change

President John F. Kennedy helped spur the nation’s break from hospitalization, an arcane treatment philosophy that corralled people with mental illnesses into asylums. Kennedy's goal when he signed the 1963 Community Mental Health Act was to cut the number of people in state psychiatric hospitals in half.

As states invested more in local centers, psych wards across the country closed. By 1993, government investment nationally in mental health finally favored community-based centers.

States on average spend more than two-thirds of their mental health budgets on community-based care. These facilities are more likely to provide care to children because they work in schools and homes. The idea is to get children outpatient care close to home, before they fall victim to a life-threatening crisis.

South Dakota is one of just eight states that spent more on hospitalization than on community centers in 2014, according to a report from the National Association of State Mental Health Program Directors.

Paul Gionfriddo, who heads the nonprofit advocacy group Mental Health America, called South Dakota’s funding model “backward.”

“If you wait until it’s too late; if you wait until people need to be put into some kind of institutional setting,” Gionfriddo said, “then you’ve waited too long to provide services.”

Comparing spending

Lawmakers increase money for community-based care each year, but the state budget still favors the psychiatric hospital in Yankton. The Human Services Center had a budget of $45 million in 2016, while local centers spent $30 million.

Vermont, with a population smaller than South Dakota’s, spent $135 million on community-based care and served nearly twice as many children.

South Dakota has made little progress in more than a decade in the number of children who get help from the state, and it’s likely thousands who qualify for treatment from the state aren’t getting it.

But comparing spending between states is difficult because each system is different, said Amy Iversen-Pollreisz, deputy secretary of the Department of Social Services. South Dakota’s state hospital, for instance, also provides geriatric care and drug addiction treatment for adults. Community-based centers in the state focus strictly on outpatient care, while other systems might offer inpatient stays, Iversen-Pollreisz said.

The money goes where it’s needed, she said.

“What we do is we monitor the demand and the need for service,” Iversen-Pollreisz said. “As we see that demand and that need increase, we do look at expanding the funding.”

Mental health, in general, gets less money in this state. The amount South Dakota spends per resident on care is about three-fourths of the national average. The state spent about $84 per capita on mental health treatment in 2014, less than North Dakota, Montana, Wyoming, Nebraska, Iowa and Minnesota.

Patients wind up needing inpatient care from the state hospital because they have problems getting care from local providers, Arends said.

“The need is for the state hospital,” she said, “because we don’t adequately fund community services.”

The state hospital gets a bigger lump sum from the state budget. In 2015, it was nearly three times what lawmakers approved for community providers, which rely more on Medicaid. Medicaid reimbursements don’t cover the full cost of care, though, said Dr. Jerry Blake, a developmental behavioral pediatrician, who retired from Sanford Health last year.

“Therefore, they can’t pay their employees as well,” Blake said.

Trust and turnover

Makenzee was shuffled between more than half a dozen counselors during her time at Southeastern.

"Every time I get a new counselor I have to start all over with my relationship," Makenzee said. "I gain their trust and they gain mine, and then we have to start over."

Southeastern counselors move on to better-paying jobs because of the way the industry works in Sioux Falls, said Kris Graham, CEO at Southeastern. Graham said she isn’t worried about the center’s turnover rate, which she said is 12 percent.

Southeastern is a training ground for aspiring mental health care workers. It hires people out of college who lack the credentials often needed to work in private practice. Once they earn their licenses, they can move on to a more lucrative career.

"If you can come away from here with your license and specialty, you are in-demand," Graham said.

But switching between counselors can interfere with treatment. Developing a rapport with a child takes time, Blake said. Trust is important for one-on-one counseling because the patient needs to be willing to share.

“You need to have at least eight visits before you get to know that person, and that person gets to know you,” Blake said.

Workforce problems aren’t unique to South Dakota care providers, Iversen-Pollreisz said.

“We certainly see those same challenges,” Iversen-Pollreisz said. “Is it at a crisis point? I would say no.”

Some progress, new programs

Iversen-Pollreisz invited families to reach out to the state Division of Mental Health if they have problems getting help from local care providers. Each center, including Southeastern, has a grievance process, she said.

“If there are systematic problems across the community mental health system we generally are aware of that,” Iversen-Pollreisz said.

State officials have taken steps to improve mental health care resources.

As part of criminal justice reforms a few years ago, lawmakers approved extra funding for substance abuse programming. Following the improvements to the adult corrections system, leaders in the state have also committed more funding to new therapy options for children and families.

The Legislature has approved about $6 million for juvenile justice reform in the last two years, including Functional Family Therapy. The evidence-based practice, offered by community providers, is designed to prevent teens and young adults from winding up in the criminal justice system.

Makenzee went through the new program, which treats both the child and family in group therapy sessions.

But weeks after it ended, Southeastern told Boice her daughter wasn't benefiting from counseling.

She worries about the future. She's done with Southeastern, but hopes to find Makenzee a new counselor, Boice said.

"She’s just at an age where kids start getting sad," Boice said. "They start getting angrier. They feel like nobody’s on their side. You start seeing them disappearing."

Finding help

Help is available to children and families who are affected by mental illness. Here are some South Dakota resources:

Helpline Center

1000 N. West Ave., Suite 310

605-339-4357 or 2-1-1 in Sioux Falls

Text zip code to 898211

help@helplinecenter.org

http://www.helplinecenter.org

Avera Behavioral Health

4400 West 69th Street

800-691-4336

NAMI Sioux Falls

605-610-7226

info@namisiouxfalls.org

http://namisiouxfalls.org