Five years after Tropical Storm Irene flooded out the state hospital in Waterbury, health care providers are still dealing with massive challenges the storm presented to the state's mental health care system.
In some parts of the state, a shortage of available psychiatric beds means local hospitals serve more patients with psychiatric disorders.
And as a recent investigation at Brattleboro Memorial Hospital showed, hospitals and law enforcement are making changes to address the issue.
The inspection, conducted by the state's Division of Licensing and Protection, followed three complaints of improper patient treatment. The inspection was done on behalf of the Centers for Medicare and Medicaid Services, and found that most of the problems occurred after a patient spent time in the emergency department because a psychiatric bed wasn't open.
Most patients who are involuntarily admitted into the state's mental health care system first show up at nearby hospital emergency rooms.
Brattleboro Memorial Hospital CEO Steve Gordon says those visits ideally last just a few hours while the patient waits to be transported to an open bed in a psychiatric facility.
"We're probably the worst place for those patients to be," Gordon says. "When they have to wait for a bed, they're not getting the kind of psychiatric care, or behavioral health care, that they could in a psychiatric facility."
In one case documented by the report, a patient remained at Brattleboro Memorial for eight nights until a bed was available at the Brattleboro Retreat.
When she was told that there wasn't a psychiatric bed available, she became violent, the inspection report shows.
The Brattleboro Police Department was called, and officers pinned the patient's head to the floor and subsequently handcuffed her to the bed.
Following the violations report, the hospital adopted new policies and procedures, and has since been cleared by the federal agency.
"We've got a problem," Gordon says. "Especially for the most critical psychiatric or behavioral health patients who require a level one bed, there's a lack of those beds. And at different points in time those patients have to wait for a bed."
And when a patient does end up waiting for a bed in the emergency department, the hospital's policies and procedures are put to the test.
The inspection report said that the staff violated the rights of mental health patients who were awaiting placement in a psychiatric facility.
Gordon says the hospital continues to work closely with the retreat and with the designated mental health care agency, because the issue isn't going away any time soon.
"It's a reality of our life right now," says Gordon. "It's a societal issue. I mean, when you have 9-year-olds that are admitted to the ER with suicidal ideation, that's what's out there in society right now, and in our community. So we've got to prepare ourselves for that. But it's, you know, a challenge."
The Department of Mental Health has tried to address the bed shortage problem, and system wide there have been improvements.
But at the Brattleboro Retreat, and at a facility at the Rutland Regional Medical Center, the number of patients seeking care is consistently higher than the number of available beds.
In the case of the patient who was forcibly restrained, the hospital was cited not for the force that was used, but for turning over the situation to law enforcement when the patient wasn't in police custody.
Brattleboro Police Chief Mike Fitzgerald says his officers acted appropriately that night.
But Fitzgerald says the events highlight what can happen when law enforcement responds to an overwhelmed mental health care system.
"The sad part about all this is the individual that's suffering from a mental health crisis is not getting the services they need," Fitzgerald says. "So, you know, we're doing the best we can, but we're still going to address behavior, and the safety is first and foremost in our minds. That person did nothing wrong, criminally. They're not a criminal and they shouldn't be in the criminal justice system. They should be in the mental health system."
The Department of Public Safety recognizes law enforcement will inevitably have to deal with patients with mental illness, and it has collaborated with the Department of Mental Health to fund a training program called Team Two.
At a recent training session, coordinator Kristin Chandler said the Team Two program helps build relationships among regional responders.
"It's one of the only forums where mental health crisis folks and law enforcement and police dispatchers can come together in the same room and go through some scenarios," Chandler says. "They learn how to better collaborate with each other in responding to mental health crises."
In 2014, mental health training became mandatory for all Vermont law enforcement officials.
The Team Two training is voluntary, and Chandler says the program offers a level of instruction beyond the mandated program.
In Vermont, a crisis can develop at a hospital in Brattleboro, at a remote cabin in Thetford without cell service or on the second floor of an apartment in Burlington. So Chandler says it's important for police and mental health counselors to get to know each other before a crisis breaks.
"There's no black and white answers," Chandler says. "There's a lot of gray. But, in order to sort of solve that gray area, it's much better to have a couple different perspectives in order to figure out what's the best approach here."
And even when those best approaches are taken, Chandler says sometimes situations don't turn out well.
She says the training can at least try to achieve a level of consistency across the state, even though resources vary among communities.