A recent article in the Star Tribune reported how a man with a serious mental illness was kept in jail for several months (“Psych bed shortage leads to blowup,” July 6). He was on a provisional discharge, meaning that if he didn’t follow his treatment plan, he would be brought back to a state-operated facility. He stopped taking his medications and ended up in jail — for months — and was not admitted to a state-operated facility.
Some people, particularly sheriffs, point to the closing of the state institutions as the problem and cite the need for more hospital beds — particularly state-operated ones — as the solution (“Patients need hospitals, don’t deserve jail cells,” Opinion Exchange, July 1). Solutions that only get people out of the jails won’t take care of the broader and underlying problems. We know what happened the last time there was an attempt to solve the issue of people with mental illnesses languishing in jails — things got worse. Before we look to invest millions of new state dollars, we need to take a closer look at the problem and the effective solutions.
In the 1960s, President John Kennedy urged the closing of state institutions, stating that “many such hospitals and homes have been shamefully understaffed, overcrowded, unpleasant institutions from which death too often provided the only firm hope of release.” One of the last bills he signed was to create community mental health centers — envisioned as one-stop shops.
Most of the state hospital beds in Minnesota and around the country closed by 1980. In 1963 in Minnesota, 9,000 people with mental illnesses lived in institutions. By 1978, that number had decreased to 1,500, and it has continued to decline over the years. Institutions weren’t great places back then, and there was a good reason they closed. It was the next step that faced hurdles and was never completed — building a mental-health system.
The mental-health community faced enormous struggles due to discriminatory policies under Medicaid, Medicare and private insurance, along with discriminatory attitudes in communities that do no not want programs in their neighborhoods. It’s hard to build a mental-health system without funding and without a place to locate it. Despite these challenges, progress has been made. There are more community services than ever before.
The situation we are facing today is troubling and confusing. There have always been people with mental illnesses in jails and prisons. This isn’t anything new — just ask the founding members of NAMI (the National Alliance on Mental Illness) more than 40 years ago who had loved ones with serious mental illnesses in the criminal-justice system. More police have been trained to de-escalate and help people in a mental-health crisis. There are mobile mental-health crisis teams. So why are more people with mental illnesses ending up in the criminal-justice system?
Before the so-called “48-hour” law that requires people who are committed while in jail to be moved within 48 hours to a state-operated facility, only 52 people were admitted from jails. After passage, that number doubled in two years and tripled in four years. Now, most of the people in a state-operated facility are from the jails, greatly delaying treatment for anyone coming from a community hospital. Why has this number increased so greatly? Is basic mental-health treatment — medication and therapy — not being provided to keep people from decompensating while in the jail?
Community hospitals have also noted a significant increase in the number of people coming to emergency rooms with a mental-health crisis — particularly for children. People are boarding in ERs for days waiting for a bed. Why are more people having a mental-health crisis?
There are more community services than ever before — intensive treatment teams, in-home services for children and adults, mobile crisis teams, community crisis homes, residential facilities and more. In fact, there have never been as many community services as we have now. Yet, waiting lists and wait times to access community mental health services are on the rise. It’s not unusual to have to wait three months to see a psychiatrist and weeks or months to see a therapist. Why aren’t community services able to meet the needs of people with a mental illness in a timely fashion?
For many years, NAMI Minnesota has advocated delving deeper into what led to a crisis. What happened in people’s lives six months before going into jail or the ER? Did they lose their housing? Did they lose their insurance, or did their insurance deny care? Did they experience a traumatic event? Were they impacted by a substance-use disorder on top of their mental illness? We don’t have access to that type of data, but the Department of Human Services does; insurance companies do; providers do. We need data from these critical sources in order to develop effective solutions.
An old report cites Minnesota as having the lowest number of beds per capita but doesn’t include the more than 1,000 community hospital beds, residential beds, corporate foster home (group home) beds or long-term supportive-housing beds. The report counted only state-operated beds, which is not an adequate measure of our system’s capacity. The real question is which type of beds do people really need? Building a system that focuses only on hospital-level care will not solve the vexing problems in our system, because people spend a majority of their lives in the community — not in the hospital.
We need to find ways to provide more-intensive long-term services to people with serious mental illnesses in the community. We have relied on corporate foster-care homes too much — many serve only four people in a home, making it difficult to hire people with a strong mental-health background. People with serious mental illnesses living in their own apartments cannot access the intensity of services needed due to arbitrary limits. For example, it’s difficult to combine two intensive programs, even though the combination may be needed and would be significantly less costly than being in a hospital.
Supportive-housing programs in which there are multiple apartments or all of the apartments in a building dedicated to people with mental illnesses have proved to help people be stable in the community but are being labeled as “too institutional.” Twenty apartments in a building with ample access to mental-health professionals who can provide a higher level of care is certainly better than a jail, being homeless, boarding in an ER or sitting in a state hospital.
Having more state-operated hospital beds is fraught with concerns, since their size precludes them from receiving Medicaid, and, frankly, both the Anoka-Metro Regional Treatment Center and the Minnesota Security Hospital in St. Peter have struggled to meet basic licensing and programmatic standards.
What NAMI hears from individuals and families is that people with the most serious mental illnesses do not have long-term stable intensive services. Services aren’t flexible enough to meet a person’s changing needs; the high rate of staff turnover prevents therapeutic relationships; treatment planning isn’t individualized; and people end up deeply isolated from the world around them.
We know community providers struggle to expand due to low payment rates and narrow insurance networks. We know we have a critical mental-health workforce shortage, particularly to serve diverse communities. We actually know which community-based services, treatment and programs work — they just aren’t available everywhere.
Whether due to increased awareness or a true increase in severity, the finger-pointing must stop. This is a difficult problem, and we need all stakeholders — people with mental illnesses, their families, counties, community providers and advocates — to gather the data, learn more about the causes, and understand what is happening now in order to build our mental-health system to meet people’s needs. Everyone’s needs, not just those in jail.
Sue Abderholden is executive director of NAMI Minnesota.