WATCH | Above: CarrieAnn Grayson shares her story in front of an audience in San Antonio, Texas, as part of PBS's The Telling Project, a three-act play organized by playwright Jonathan Wei, where veterans and their families are given a voice to share their experiences.
Grayson’s claim that providers often leave Grand County is fundamental to understanding the county’s infrastructural issues with mental health care.
Between 2017 and 2019, 16 mental health providers left the county.
Mike and Mary Haas, who offered psychology and counseling services in Granby, retired in 2018. Another provider in Winter Park switched career paths and closed her practice, Creative Connectivity Counseling, which consisted of her and a partner. The partner ended up moving to Steamboat Springs following the closure of the practice. Others retired, closed or relocated elsewhere.
“There’s a lot of different factors that go into why people move,” said Sue Johnson, one of two behavioral health navigators in the county.
She added that community mental health centers, such as Mind Springs, often see high turnover because new providers and recent graduates use the centers as a springboard to gain experience before moving on.
The transient nature of the community was something Johnson highlighted as a contributing factor for the exodus.
“A lot of people come up here and find that it’s great for skiing and riding and there’s beautiful summers, but the in-between seasons can be tough. Or it’s socially isolating.
“It’s tough being in a small community and it’s not for everyone.”
Even the mental health profession is not immune to the seasonal nature of Grand County.
According to data from the County Health Ranking website, a collaborative program between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, Grand County had 28 mental health care providers between 2017 and 2018, making for a mental health care provider ratio of one provider for every 550 residents.
Grand County had been ranked 30th in the state of Colorado, out of 64 total counties, six of which did not report data, for number of mental health care providers per capita.
That number has since dropped significantly, however.
Now only 12 mental health providers exist within the county, which puts the ratio closer to one provider for every 1,280 residents. The county now has a ranking of 46th in the state for its number of providers, just above Clear Creek, Lake and Park counties, among others.
The issue of retention is exacerbated by a nationwide problem with mental health provider recruitment as facilities are understaffed throughout the United States.
Mental health providers in small communities like Grand County also face unique challenges, such as running into clients outside of sessions. This can make it difficult for them to be part of the community while still following the stringent ethics that providers maintain, including confidentiality.
“It’s hard for those providers to be out and about in the community because you never know who you’re going to run into,” said Jen Fanning, executive director of the Grand County Rural Health Network, a nonprofit organization that connect citizens with health resources. “I think that’s part of the reason it’s been so hard for some of our providers to stay.”
Ultimately, this dynamic can be harmful to the provider’s ability to offer services.
As someone who has worked with all of the mental health providers in Grand County, Fanning had no one to turn to when she was experiencing postpartum depression after the birth of one of her children.
“As a health and human services provider, I can’t get anybody to see me because I work with them,” she said. “When I need care, what do I have?”
It’s different when having to be so open and vulnerable with somebody in the way that promotes healing, she explained.
The Kaiser Family Foundation, a nonprofit that focuses on health policy, estimates that only 26 percent of the national need for mental health care professionals is met.
“We definitely have a huge service need that’s reflected across the country and the state,” Johnson said. And it’s echoed on a more local level.
“Capacity is difficult for us. We have open access hours; I typically have two open slots for intake on Monday mornings. Almost every week they get filled and we have to turn people away and say come back next week.” - Ellen Cowman, Mind Springs
The shortage also affects Middle Park Health’s ability to offer mental health care.
Jason Bryan, vice president of human resources and administration for Middle Park Health, said the hospital currently believes the best approach to mental health care is to partner with the existing resources in the community and to support what’s already working.
“If we can partner with individuals, such as Mind Springs, and be a partner together then that’s where I think we can be the most effective,” Bryan said. “They have the subject matter experts and the respect of the community in that regard.”
Instead, Middle Park Health want to focus on the medical side for patients and “if we can collaborate and be effective together, then that’s where I think we could stand to be stronger,” he said.
Currently, the hospital has not come to any conclusions on how mental health care might be included in planned future expansions.
Bryan explained that, because of the nationwide shortage of mental health care providers, it makes more sense for the hospital to partner with the existing providers.
But that doesn’t address the current need for more providers to increase patient capacity.
Local efforts, however, are being made to attempt to fill the gaps.
One, the behavioral health navigator program, helps expand the capacity of medical providers to address mental health by offering a version of integrated care. Navigators see patients during their primary care visits at Middle Park Health and other medical clinics across the county.
In an attempt to address recruitment concerns, Grand County’s largest mental health provider, Mind Springs Health in Granby, offers employees the chance to apply for student loan reimbursements to help with debt incurred during their training.
The nonprofit is also bolstering its internship program so people who are still in school or training can be prepared to go right into the workforce upon getting their credentials.
“One of our strategies is to grow our own, really give somebody a solid internship experience and then hope they stay on and stay with us,” said Kathy Capps, operations manager for Mind Springs Health, which has 13 locations in 10 northwestern Colorado counties.
With a lack of mental health care facilities and systems, further pressure is put onto existing local providers.
The county has no psychiatric hospital nor a mental health respite care facility. There is no local psychiatrist within the county’s borders. Local providers are compelled to care for patients in a system that is geographically dispersed, understaffed and overworked. All too often it is law enforcement that serves as the first responders when citizens experience a mental health crisis.
The effects of such a deficient mental health care infrastructure are felt substantially.
“For me (the challenge) is capacity,” said Ellen Cowman, clinical supervisor at Mind Springs in Granby. “Capacity is difficult for us. We have open access hours; I typically have two open slots for intake on Monday mornings. Almost every week they get filled and we have to turn people away and say come back next week.”
But not if they’re in a severe crisis, such as being suicidal. At that point, an on-call crisis counselor would be called to assist.
Considering Grand County’s continued population growth, the problem with capacity worsens each year.
The logistical reality, according to Makena Line, program coordinator at Mind Springs, is that those seeking mental health treatment might not be able to get in as quickly as they’d like.
According to Mind Springs, there were 728 unique individuals who sought care through their office in 2018. The most common mental health issues they encounter at their Granby location are depression, anxiety and PTSD.
CarrieAnn Grayson’s cut-to-the-chase demeanor belies the traumas of her past. She is shorter than most, with a big personality that is playful yet pulls no punches. She has a lively and easygoing smile while her eyes are sharp, piercing almost, reminiscent of a seasoned teacher peering at a troublesome yet cherished student.
For nearly two decades, the Grand County resident has lived with the daily realities of PTSD, which, as a former U.S. Army captain, she was officially diagnosed with while still in the military.
The outspoken Texas native has since encountered misconceptions and myths, supporters and detractors and a mental health infrastructure that has not always served her needs.
Her journey over the last decade has taken her from San Antonio, Texas, to Colorado’s high country. She has experienced marked improvements and difficult setbacks, all while advocating loudly and forcefully for veterans and anyone else suffering from PTSD.
She has sought to embrace her diagnosis while also creating a life that is not defined by it.
“No one told me I had it, it was just a note in my medical chart,” Grayson said. “When I was getting out of the military I was going through a medical board and it came up as one of my diagnoses. That is how I found out I have PTSD.”
Grayson believes the military deliberately withheld her diagnosis as part of a larger effort to label soldiers with PTSD as having borderline personality disorder to reduce disability payments. Veterans with a borderline personality disorder diagnosis are not eligible to receive compensation from the military while veterans with PTSD diagnosis are.
DEFINING OUR TERMS: What we mean by 'providers'
Grand County saw a drastic reduction in the number of mental health care providers since 2017. But what exactly do we mean by “provider?”
A mental health provider is any health care professional that treats patients for mental health, be it preventative or otherwise.
Primary care physicians, however, the doctor you’d see for a routine physical or if you get injured, are not included when we say “provider.”
While they do tackle questions from patients about mental health — Sue Johnson said around 70 percent of primary care visits include some sort of mental health question — that’s not their main role.
A mental health provider includes therapists, counselors, social workers and psychiatrists, the people who specialize in dealing with mental health issues. They are most often licensed professionals.