By Catherine Komp,
Newsletter Editor
In a new three part series, Out of Sight, WUNC’s Jason deBruyn examines North Carolina’s psychiatric residential treatment facilities or PRTFs. More than 1100 children were enrolled in these facilities in 2023. Kids in the foster care system make up more than 50% of that number. Because in-state PRTFs are at capacity, more than half the kids are living in facilities far from home across state lines.
“It is honestly hard to imagine a more disenfranchised person than some of the kids that are in these facilities,” said deBruyn. “These kids, in some cases have no advocate or barely have an advocate— an overworked social worker who’s trying to look after a kid with a severe psychiatric disorder, who might be out of state. That child has basically no advocates. So that’s what got me started on this project.”
The issue had been on deBruyn’s radar for a while, but with a data fellowship from USC Annenburg’s Center for Health Journalism, he found support to start investigating the two dozen PRTFs across the state. His series exposes some of the problems at facilities, including violence against the kids enrolled; a shortage of state regulators providing oversight of the facilities; how state government has been responding; and the slow progress of investing in one of the solutions — more community-based services that could keep kids out of PRTFs.
I had the chance to chat with Jason about what went into this investigation, the public records he used and opportunities for other reporters to explore PRTFs in their own communities. Find parts one, two and three of the series. Our conversation below has been edited for length and clarity.
NC Local: As you started looking into this issue, what were some of the main questions that you wanted to find answers to?
Jason deBruyn: The first thing that I really wanted to do is wrangle down these PRTF inspection reports. One good thing about North Carolina is that the Department of Health and Human Services through the Division of Health Service Regulation does these inspections, some announced, some unannounced, and whatever they find, they make a report of it, they post that online for anybody to see. Not every state does that so we should commend North Carolina for doing that.
They are in PDF form and they are linked individually, sort of in a hard to find place on the DHSR website. This is where the data fellowship really came in handy because they taught me how to bulk download the reports and then helped me with some of Google’s AI platform Pinpoint to be able turn them into something that’s machine readable. So there’s a lot of data work, some scraping and some wrangling and some AI help, but ultimately we got all 500 reports into an Excel spreadsheet.
At that point, obviously there’s a whole lot of data work that we could do: keyword searches and looking for certain words and phrases. Getting to those inspection reports and getting that work done early really served as the backbone because then I was able to say “Okay, there’s this many violations” and sorting the different types of violations. Then using that data to underpin all of the additional reporting, we were then able to ask critical questions of DHHS and of facilities that returned our questions. When we spoke to folks at say Disability Rights NC, it wasn’t “Well, here’s a group that’s saying something it could be,” it’s backed up by what state regulators themselves have been saying in these reports.
NC Local: Looking at all this data, did you find that there were more serious violations across the board or concentrated at a smaller number of facilities?
They’re kind of across the board, with some variation of course. That was really something that ultimately stood out to me: we’re not looking at just maybe a couple of bad actors here and there. We really are seeing that these facilities as a whole across the state and probably the nation are types of facilities that need reform, that need more and better investment, that need more and better oversight.
NC Local: Your reporting said anybody can file a complaint about facilities. What did you find in terms of staff filing complaints or parents or kids? And how are they investigated?
Yes to all and DHSR says that it does take these complaints seriously, and I think that’s fair, and there are also, importantly, unannounced visits that a state regulator will do, and that’s sort of a good process to have, because ideally that would have facilities sort of always being on their toes, thinking that any day, there might be a regulator to come in to check.
But the reality is that DHSR, as all state government, is just very understaffed. There’s an 18 percent vacancy rate, which maybe that’s even larger now than from when I got that data point a couple of months ago. One of DHSR’s points was that it’s very difficult to keep regulators because they don’t really pay well. It’s a state job, so you have good benefits, but in the private sector, people can make more. If DHSR were funded at higher levels, you would have more regulators. But it doesn’t stop there, and Disability Rights NC has said this over and over: if you fund the care for these kids at higher levels as well, then that allows folks at the facilities to hire and retain better staff.
I noted in the first story that a staff member at one facility choked a 12-year-old boy and had to be physically restrained by two other staff members. One thing that struck me about this report is that the staff member came in and said he was having a bad day. Whether or not you’re having a bad day, it doesn’t give you an excuse to ever choke a 12-year-old boy. But if that facility had more and better trained staff, then when this staff member came in and said, “Hey, I’m having a bad day,” they could say, “No problem. Go home, take a mental health day. We got this backup of folks that we can bring in, somebody that’s having a good day,” and maybe that bad outcome could have been prevented.
NC Local: Are all of these facilities privately run or are some of them state run?
There’s one state run, but the rest are private.
NC Local: Are any owned by bigger out of state companies?
This was something that I would have liked to have gotten into more. There’s some reporting nationally that private equity groups are starting to buy up PRTFs or programs that offer PRTF services. And there’s some concern that it will be similar to what we saw happen with the adult care industry, nursing homes specifically, when private equity bought those facilities— care just declined. I had started to try to get into some Secretary of State records, trying to see if I could trace ownership back. Unfortunately, I just ran out of time. So maybe that’ll be a project for this Fall. But it’s something that is certainly on the radar of advocates nationally and it’s certainly a concern that ownership makes a big difference. If you’re an owner that’s concerned primarily about the bottom line, that’s going to impact the care that you provide to, again, some of the most disenfranchised kids.
NC Local: How did you go about finding families and your source in Part Two, Ariel Wolf?
Just good old fashioned shoe leather reporting. I just started talking to folks that I knew were advocates and asked them do you know anybody that spent time in a PRTF? Can you connect me? And just through asking the question over and over, I was connected with Ariel and she agreed to chat and we chatted for about three hours, and then I chatted with her mom for another two hours or so.
If I could share a point of personal pride: Ariel sent me a text this morning. “Thank you for your story. I so appreciate the emphasis on how anomalous it is to have a healthy, independent adult life and the reasons why that’s not a common outcome without the oversharing of details for shock and awe.” Which I thought was really nice of her to say; she had been interviewed by another reporter and she felt almost as if they dramatized her self harm just to be shocking, what some people might call “disability porn.”
The point is not the specifics of the self harm, the point is that there’s this very real mental disorder that affects her and certainly many other people, and they’re not getting the right treatment for it but they should be.
NC Local: The experiences of Ariel that you share are really layered and complex. Her quote at the end of Part 2 captures a lot of this: “I am alive today because my parents loved me enough to keep me warehoused for several years on end in PRTFs. They didn’t help me. I have a lot of trauma as a result of it, but I’m alive, and I love my life.”
Yeah, that quote, that’s going to stay with me, I think for the rest of my life. How can it be that it’s both an incredibly traumatic experience, but it’s also the reason that you’re alive. That’s so foreign to me, but in many ways that encapsulates the problem, right? Because there are not enough home and community-based services, the best option for these families is to warehouse a child for four years so that they don’t attempt suicide. How is that the best outcome? How is that our only option?
NC Local: You also spoke with a UNC researcher who studied PRTFs and found that almost half of the kids sent to them don’t really need to be there.
Right. So they have a diagnosis of what’s called Disruptive Behavior Disorder, which is in the DSM. It’s an officially diagnosed behavior, but UNC School of Social Work researcher Paul Lanier and many other people say it is something that can be treated outside of an institution. It’s not schizophrenia, it’s not bipolar. It’s not to the level of needing this inpatient care. It’s something that can be treated with a qualified psychiatrist or psychologist or better counselors in the school system.
In many ways, part of the problem is that too many providers still think of mental health care as different from physical health. But they need to be thought of in the same way. If there were better trained providers, particularly in rural areas that could help a kid with disruptive behavior disorder when they’re 6, 7, 8, 9, 10, 11, 12, that might then be treated and under control and handled better, in the same way that a Type 1 diabetes diagnosis would be. But that takes investment, that’s not free. It takes personnel and it takes paying them enough so that they will go to rural parts of the state where it’s hard to attract people.
NC Local: Have incentives like that been proposed by anyone as part of the solution?
I can already hear Kelly Crosbie at DHHS in my ear saying, “Talk about some of the things we are doing.” And yes, they are doing things. Medicaid has been expanded. That’s great. Many people would say a decade too late, fine, but now it is expanded. That’s a big help.
And there was this significant investment that the legislature provided last year, this $835 million to improve behavioral health. That’s real money that does increase payment rates to Medicaid mental health providers. This is great. It is far from enough money to be a solution to the whole problem.
There’s some very cautious optimism with a heavy emphasis on the cautious part because if we just expand Medicaid once and leave the rates at this one time increased rate, that’s not going to be good enough. If there’s continued investment, then maybe we can see some improvement. So there are things that are happening. Pilot programs are working. And now that there’s a little bit more money, that can be expanded to some more counties. But we’re still a long ways away from having these successful pilot programs implemented in all 100 counties, we’re just not there.
NC Local: How responsive were the owners and/or directors of these facilities?
Not, you might not be surprised to learn. Credit to Alexander Youth Network and Dr. Van Catterall. He’s the only person that responded of all the providers and so he’s quoted in the story. We reached out to all of the providers of these treatment facilities, sent multiple emails and calls to these networks of providers and got only one response. Dr. Catterall said many of the same things that the folks at DHHS said, which is that this does take funding. This takes money. This takes investment in people so that these facilities can be staffed with well-trained people and enough of them so that there’s a good staff to client ratio.
NC Local: Did you get to tour any of them?
No, I would have very much liked to, if nothing else, just to grab audio for some of my reporting, but nope, that was not on the table. And that’s not just news reporters. In many cases, parents cannot even go inside the facility. There are special visitation rooms, which again gets back to what folks with Disability Rights describe as this carceral setting where they have their rooms where they stay, and then they have this visitation area, and that’s the only place that parents are allowed to go.
NC Local: These psychiatric residential facilities are located across the state. Are there some good local angles that other reporters could be looking into?
Absolutely. Especially if you want to take on only one or two facilities, you don’t really need to have a big data background to be able to read two dozen reports. You could read those yourself and then come to a conclusion about this one particular facility that maybe is in your backyard. So that would be a great place to start and I said this before, but again, kudos to DHHS for posting these online.
Another good followup for me is just to see what private equity groups or what these ownership structures are like. But another big one is to see how these funds are being spent. Importantly, as I was talking about the rates increasing for providers, rates for PRTFs are not increasing. And so the hope would be encouraging networks of mental health providers to find ways of caring for kids not in these institutions.
And, in a positive sign, the overall population is coming down. Now, folks at Disability Rights would say it’s coming down far too slowly. But it is coming down and so maybe that can continue. And maybe there’s a facility or two where the population is coming down, maybe at a faster clip than the state as a whole. So that might be something to look at. And to see if pilot programs are being implemented in some of your local counties and is that having an impact on how many kids are ultimately placed in the PRTF? I think there are plenty of angles for follow up.
NC Local: Your series was supported by a data fellowship with the USC Annenberg Center for Health Journalism. What kind of support did the fellowship provide?
My mentor was Andrew Tran, who is the data reporter for the Washington Post and a data whiz. I knew that Google Pinpoint existed, the AI tool that’s available to journalists, but didn’t really know anything about it. Andrew had done a whole project with it and he was able to help me step-by-step with how you can bulk download from PDFs. I’m pretty good at Excel, but I’m not very good at the programming language R, but he was really patient with me and helped teach me the code and really helped me write all the code that I needed. So he was incredibly helpful on that data wrangling part, which again was crucial. The data from the inspection reports underpin the whole series.
NC Local: Is there something I haven’t asked you that you’d like to share?
Just to reiterate that we as a society need to move to a place where we treat mental health with the same urgency and same seriousness that we treat physical health. A person does not choose to have diabetes. A person does not choose to have bipolar. These are not problem children that misbehave. These are people with diagnosable psychiatric mood disorders and they need to be treated by the healthcare system as such.
Interested in looking into Psychiatric Residential Treatment Facilities in your community? Jason is happy to share data and offer guidance. Get in touch with him at jdebruyn@wunc.org.
Find resources and past coverage about PRTFs in this round-up from Disability Rights NC.
