When the mentally ill have nowhere to go, they go to jail

By Benjamin J. Gohs, Editor

It’s mid-afternoon on a Wednesday in Charlevoix.

The county sheriff is interviewing with the Boyne City Gazette regarding the strain a lack of local in-patient mental health facilities is putting on his office, when he gets a text.

“It’s my jail administrator,” Charlevoix County Sheriff Don Schneider said concerning a patient some of his staff were escorting. “We took one down today to Kalamazoo and now they have to take him to the psychiatric center two hours away from there.”

Schneider said this kind of thing happens several times each month.

“If we’re transporting them, we need two officers. It takes two hours to drive to War Memorial and two hours back—and that’s after they found a bed,” he said. “That doesn’t take into account the time we sit on them in the ER for hours and hours looking for a bed.”

Schneider added, “Thousands and thousands of dollars a year in wages are spent on this.”

The problem?
The closest hospitals with available psychiatric beds are hours away from Charlevoix … and they don’t always have room to spare.
So, patients are often taken into protective custody at the Charlevoix County Jail until an appropriate facility can take them.

Nowhere else to go
Local medical facilities like Charlevoix Area Hospital may not be official inpatient psychiatric care providers but they do help where they can.

“We are mandated to provide medical care for people with medical issues. Sometimes the mental health issues exacerbate to a degree that medical intervention is required,” said Charlevoix Area Hospital Director of Social Services Kris Hoeksema. “Oftentimes, we are the only place that is available to provide a safe place for the patient.”

The strain on resources felt by Sheriff Schneider is shared by health care providers.

“Our facility is not set up to manage violent patients,” said Hoeksema. “Most often, these patients remain in the ED (emergency department) as this is the safest environment we can provide. This is a problem when a patient needs to be isolated and requires 1:1 supervision; which we often do not have the staffing for.”

Hoeksema agreed with Schneider’s assertion that staffing issues can be a “huge problem” when dealing with a person with severe mental illness.

“Having to provide constant supervision is an ongoing problem that has required us to request help not only from law enforcement but requiring us to also call in extra staff or to bring in an outside agency to provide the supervision if our staffing is unavailable,” she said.

Public psychiatric beds
According to the Treatment Advocacy Center, there should be a minimum of 50 beds per 100,000 people in the population.

“(This) is considered necessary to provide minimally adequate treatment for individuals with severe mental illness,” says the center. “Like every state, Michigan fails to meet this minimum standard.”

In 2005, there were 1,006 beds available across Michigan.

By 2010, that number had been cut by nearly half, at 530 beds.

This 47 percent reduction in mental health facility space means there are 5.4 beds for every 100,000 residents.

The bottom line

Triston Cole

Triston Cole

“The bottom line is, trying to find beds for these people to the point where, probably about a month ago, we had an individual we had to take down to the hospital. He was here from Monday to Thursday because they could not find him a bed—I went ballistic,” Schneider said. “I called Representative Cole and raised Cain and they found him a bed in Kalamazoo. I said, ‘You couldn’t find a bed in Northern Michigan?”

The night before that, Schneider said, he received a call with a pickup order for another individual in Kalamazoo who was supposed to go to Traverse City.

“These are long trips for us that tie up man hours—a lot of man hours,” he said. “And, many times, they can’t find a bed.”

The facility wasn’t ready for the patient so Schneider had to take him into protective custody and hold him because there was nowhere else for him to go.

“Sometimes it seems like the left hand doesn’t know what the right hand is doing and the jails are getting dumped on,” he said. “If you break your leg, do you go to jail? No, you go to a hospital. So, why do you want to send someone with mental illness to jail?”

Schneider added, “I’m not saying some of these people haven’t done something wrong but they’re doing wrong in direct relation to mental illness.

We’re not psychiatrists or psychologists who can fix these people. All we are is a holding facility.”

Mental health officials
Dr. Andrew Sahara Ph.D, Director of Clinical Services at the North Country Community Mental Health office in Petoskey, said his organization tries to provide services to as many people as they can.

“We go to the jail and evaluate at the request of the sheriffs,” Sahara said. “It’s not uncommon, when someone is charged, arrested and booked, for them to be anxious and depressed. So, the jail has an appropriate screen for mental health vulnerability.”

When patients exhibit signs of needing mental health attention, doctors must decide whether to put the patients under 24-hour watch in the jail or have them transferred to an inpatient psychiatric facility.

“More often than not, when people have settled in and had time to talk with their attorney and family, they say they just said things (like threatening suicide) because they were inebriated in one way or another or they said it because they were scared,” said Sahara.

By the numbers
According to the mental health statistic information clearinghouse Treatment Advocacy Center, 7.6 million adults in Michigan suffer from severe mental illness.

Of those, 84,000 are afflicted with schizophrenia, and there are 168,000 with severe bipolar disorder. (treatmentadvocacycenter.org)

Local resources
While there are no local inpatient psychiatric facilities, there are local mental health resources.

Sahara said his mental health professionals work to help people in several major ways.

One approach is pre-booking diversions, which basically deals with keeping the mentally ill out of jail if all they did was commit a minor nuisance crime that was obviously a result of their mental illness.

Community mental health workers may also visit people while they are jailed to ensure they receive therapy and medications they need.

Also, mental health officials often will work with the courts to make therapy and medication mandatory pieces of probation requirements.

While most patients who need inpatient care are referred to private hospitals around the state, Sahara said there is one state hospital in Kalamazoo where patients with severe and persistent mental illness can be sent for care.

Sahara said the long distance to psychiatric hospitals is an issue but he said it is an issue for all rural populations.

“In this state, right now, we seem to be experiencing a lack of hospital beds for the mental health patients,” he said. “The reason I’m saying that is there are delays in finding someone a bed… In the last year, we have been having more trouble finding beds. Some nights, we’re told beds are filled and we’re calling all over the place.”

Sahara added, “You really want to get a person to services as soon as possible.”

Sahara said the concern, other than not having a bed for a patient, is that sending them far away from friends and family can be detrimental to the patient.

“There is a lot of data out there that says recovery from mental illness is enhanced by family and a support network,” he said.

The average psychiatric hospitalization runs anywhere from five to nine days, in Sahara’s experience.

Does anybody care?
Back in late-September, the Charlevoix County Board of Commissioners unanimously passed a resolution in support of the nationwide “Stepping Up” initiative, an effort to reduce the number of incarcerated people with mental illness.

“This is not a local problem. This is not a state problem. This is a national problem,” said Schneider. “Talk to any sheriff and he’ll tell you the same.”
As far as Schneider can tell, the issue all boils down to money.

“They (hospitals) have a difficult time getting reimbursed and it’s manpower intensive when they have someone suffering from mental health issues. So, they dump them in jail where we can keep them locked up like animals,” he said. “We need a regional hospital for psychiatric patients. I don’t care if it’s in Traverse City or Gaylord or Petoskey but we need a psychiatric hospital where we can take patients.”

According to the board’s resolution, the prevalence of people in jail with serious mental illness is as much as six times higher than the rest of the population.

“I talked to Lt. Governor (Brian) Calley in October, and told him the system is broken and I told him we need beds and he said he is going to look into outpatient care facilities … but that is not going to fix the problem,” said Schneider. “We need care facilities to get people stabilized so they can function.”

He added, “Everybody says it’s a problem but you can’t get anybody to do anything about it.”

More than merely babysitting

According to Charlevoix Area Hospital Chief Nursing Officer Bernadette Cole, RN, law enforcement officers do a much greater service than merely babysitting mentally ill patients.

“The goal of the hospital is to manage the medical aspects of the patient’s mental illness,” she said. “We also have an obligation to protect our staff, other patients and our visitors—therefore, (we) need assistance from law enforcement, since that is their expertise.”

Mental illness is no crime
According to the Treatment Advocacy Center, in 2005, Michigan had 67,132 inmates.

Of those prisoners, 10,741 of them were severely mentally ill.

Contrast that figure with the total psychiatric inpatient population of 2,496 in 2004.

“Like every state in the nation, Michigan incarcerates more individuals with severe mental illness than it hospitalizes,” says the center.

And, while overcrowding in jails and prisons seems to be an issue in more urban areas, Schneider said he has plenty of space. But, he added, that space is supposed to be for criminals, not mental patients.

“We have to put them in segregation cells because, most of the time, it’s a suicidal situation and we’ve got to watch them very carefully so they don’t take their lives in this jail,” Schneider said. “For us, it’s labor intensive to watch a few when we’ve got a lot more folks to take care of in here.”

A critical need
Schneider said, for some people, there seems to be a revolving door in the system.

“Most of the time, it’s a suicidal situation. For example, they wind up here. We call the hospital. If they haven’t done anything criminal, they go from here to the ER. The doctor evaluates them and then community mental health gets called in to interview them to determine whether they need to be hospitalized. Then, they get kicked loose back into the public,” Schneider said. “This summer, a guy went to the hospital a couple times in a week’s time and each time they said, ‘You’re OK to go home.’ He ended up taking his life in Boyne City because he was not getting help.”

Reaching out
Schneider said a meeting on the matter was supposed to be held back in August with he, Nick Lyon the head of the newly formed Michigan Department of Health and Human Services—who was appointed on April 10 of this year—and State Rep. Triston Cole (R-Mancelona) but that it had been canceled.

“At this point, the meeting is in limbo,” Schneider said. “I have a call in to Representative Cole to get an idea as to when he will be available.”

Cole told the Boyne City Gazette the meeting was canceled at the request of Lyon, who wanted time to familiarize himself with the job before working on this issue.

“We have not dropped the ball on that. But, this legislative cycle, the priorities have been roads—and that was just accomplished—and that literally was sucking the oxygen out of the room more than anything else,” said Cole…. “The financial strain on communities because of a lack of mental health services in Northern Michigan is absolutely a priority for me.”

Cole said he is also working with the department of health and human services on issues concerning women and children, so he remains in contact with the new director.

Limits on care
Another issue faced by mental health workers is that local taxpayer funded mental health facilities are limited to treating the persistently mentally ill, seriously emotionally disturbed children and developmentally disabled individuals.

“We don’t really have resources or a mandate to treat mild or moderate cases,” said Sahara, who added that this particular issue is getting better through relationships between community mental health facilities and rural health centers, which lease mental health workers who offer treatment to low-income patients with mild and moderate issues in places like Harbor Springs, Cheboygan and Indian River.

Sahara wouldn’t go so far as to say a psychiatric hospital was needed in this region but he did say he would welcome any additional resources.

“We try to work cooperatively with sheriffs. I think we are all struggling with finite resources,” he said. “Our resource streams allow us to do certain things and not others.”

Sahara added, “Any resources that are more localized would be welcome but, given the state of the economy, I don’t know how likely that is.”

Challenges of rural care
Hoeksema said some people have left the area for more urban settings simply because they could not get the psychiatric care they needed.

“Our community, being so rural, has unique problems that tend to compound the issues of accessible and adequate mental health services,” she said. “Our service providers’ capacity to see patients are limited, and intensive treatment options for those struggling with mental illness are extremely hard to access. When a person is so compromised emotionally that they come to our emergency department, they are clearly in desperate need of intervention.”

Hoeksema added, “It is difficult when we cannot provide the appropriate services or even to help them access those services.”

According to Hoeksema, Charlevoix Area Hospital has a good working relationship with North Country Community Mental Health.

“They are working diligently within their means to help provide for these people in need,” she said. “They graciously come to our hospital and assist with screening and accessing treatment facilities. This is not a service that is mandated but a good example of a small community utilizing all of their resources as efficiently as possible to better serve the needs in our area.”

Still a priority
Cole said he plans to meet with mental health officials early in 2016 to discuss the best strategy for dealing with issues like those facing Sheriff Schneider.

“I’m not saying it is off the table but, as far as having a new hospital up here, that is going to be a challenge,” Cole said. “As we start talking with the various departments—hospitals, mental health officials, sheriffs—that will be a logical time to discuss the best way to serve rural areas … and what needs to be done at the legislature to make that happen.”

He added, “It’s a big issue, and probably bigger than most people realize.

One of Cole’s guiding principles is to always assess how to most responsibly use taxpayer dollars and, when possible, reduce the burden on taxpayers.

He said addressing mental health issues of Michiganders before they lead to incarceration may cost less in the long run than warehousing them in prisons later on.

“We need to help those folks achieve their maximum potential … and that ultimately creates a safer society,” said Cole, who added that even commonsense and bipartisan pieces of legislation can take a long time to be passed due to the nature of the legislative process.

Is there a solution?
Schneider suggested concerned citizens contact their governmental representatives.

Hoeksema said advocacy groups are pushing legislators to respond to the mental healthcare issue but she said more could be done.

“Invest dollars in our mental health system to provide more preventative services with results, hopefully, decreasing the costs elsewhere, such as in the criminal justice system,” she said. “We are also seeing a need for more medical psychiatric facilities as our population ages and their mental health needs are complicated with physical health issues that prevent them from being accepted into psychiatric facilities due to their medical instability.”

Hospitals can bear major costs due to insufficient psychiatric services.

“If there is no medical reason for an admission to the hospital, insurance will not pay and the hospital will likely end up counting that admission as a loss,” said Hoeksema.

And, the issue is only getting worse.

“We have seen an increase in mental health admissions over the past several years, with discharge needs being much more complex as services available decrease,” Hoeksema said… “These issues are increasing in frequency and severity.”

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