Even though more services are becoming available to divert the seriously mentally ill from the justice system, rural communities are struggling to find the resources they need to bring those services to the people who need them.
Transportation, for instance, can make the difference between success or failure.
“We have no public transportation here,” said Pamela Hopkins, a Fremont, Neb., lawyer who is running for Dodge County Attorney. “Many of these people are unable to drive, for one reason or another, whether it’s because they use alcohol as a substitute for their treatment and they lost their licenses because of that, or they’re too poor to have a car.
“They’ve got to depend on the kindness of strangers.”
Without ready access to counseling or treatment often located far from their homes, defendants might otherwise find it hard to prove to judges that they are serious about addressing their problems.
Nebraska, like many states with large rural populations, is at the sharp end of the challenges of dealing with mentally troubled individuals. Most of the state is experiencing a shortage in mental health and psychiatric providers, according to the state’s Department of Health and Human Services (DHHS) Office of Rural Health.
Linda Witmuss, deputy director of the DHHS Division of Behavioral Health, acknowledged that the system needs to undertake a “richer review of data” to better determine how the state’s finite resources should be allotted to meet the need.
But she argues that mental health reforms launched by the state in 2004 have led to more services at the community level.
“There’s always room for more services—don’t get me wrong there,” she said. “ (But) all of our rehab options (and) services, including expansion of medication management, came about as a result of that reform.”
In 2004, the Nebraska legislature passed Bill LB1083, which was designed to reduce the use of inpatient psychiatric services at the state’s three Regional Centers in Lincoln, Norfolk and Hastings, and invest more in outpatient and community-based services that could help those struggling with mental health in their own communities.
The reduction of inpatient beds was consistent with nationwide efforts to move away from institutionalizing the mentally ill and instead treat them in their communities. But those interviewed by the Tribune say that the infrastructure for community care was slow to materialize, and it still isn’t adequate for those who may be in need of more intensive care.
“There’s a lot of people who aren’t even leaving their homes to get the services that they need because they’re just homebound because of their anxiety,” said Hylean McGreevy, a licensed mental health practitioner and alcohol and drug counselor at Methodist Fremont Health’s Behavioral Outpatient Services.
“They’re not functioning well and they fall through the cracks.”
According to numbers provided to the Tribune by the Nebraska Jail Standards Board, of 1,225 individuals discharged from the Regional Centers in a four-year period following mental health reform, nearly 500, or around 40 percent, ended up in the county jail system at least once.
About six percent ended up in the prison system.
Collaboration Between Police and Health Providers
The challenges often begin at the street level, where rural law enforcement encounters individuals in desperate straits.
“There is a lot of stress on the community,” said Fremont Police Lt. Kurt Bottorff. “Times are hard for certain people — the stress builds up and that’s where some mental health breakdowns can take place.
“Their behavior ends up being a law violation and they’re sometimes jailed because of it, instead of addressing the core problem.”
Under a pilot program that started in July, the Fremont Police Department became one of only two departments in the state to hire a crisis response co-responder—a licensed mental health practitioner who works directly in the police department two days per week, responding to 911 calls alongside officers when she believes mental health is an issue in the complaint.
The pilot program, funded by a two-year grant from the Behavioral Health Support Foundation and operating in collaboration with Lutheran Family Services, aims to help keep those struggling with mental health issues out of the criminal justice system or avoid involuntary hospital stays, and to connect them with community resources.
Until recently, even the nearest medical services were a 40-minute drive away, in Omaha.
Now, mental health practitioner Rachel Wesely can respond at her own discretion instantaneously, from within the department, and can follow up with callers after law enforcement leaves.
‘When people are released (from jail) into the community, and they don’t have the supports in place, it becomes a revolving door.’
But as concern mounts about a growing number of mentally ill individuals entering the criminal justice system and winding up in county jails, local stakeholders are taking a more focused approach to line those individuals up with more appropriate services.
“There’s a need for access to treatment in jails and when individuals are incarcerated, it’s not getting filled,” Wesely said. “Sometimes when people are released back out into the community (and) they don’t have the supports in place, it kind of becomes a revolving door.”
Medication and services can be expensive. Many lack insurance to help cover costs, though some programs offer sliding fee scales, which can adjust payments based on income and family size. In recent years, co-pays and deductibles have become more expensive even for those who have insurance, providers say.
Additionally, treating mental illness is more complicated than treating physical ailments, and ensuring compliance to treatment plans poses challenges, providers say. Psychiatric treatment requires significant “trial-and-error” to find the right medications, doses and strategies. That means lots of time spent taking medications that may ultimately need to be adjusted or changed, and that may carry unpleasant side effects that deter compliance.
It’s a process that requires patience and follow-up. And ensuring that patients comply with their treatment plans, remain stable or avoid self-medicating with illicit drugs and alcohol is a challenge that’s only exacerbated by barriers like access and affordability.
“Let’s just use a hypothetical,” said Dodge County Attorney Oliver Glass. “I can’t afford my medication, my medication makes me feel strange anyway, but I do know that when I self-medicate with street drugs or alcohol, that’s going to make me feel better at least.
“And that’s when, at least in my experience here, a lot of crimes are committed.”
Intensive Care Challenges
The Regional (Health) Center has some space available to the regions for more intensive care. It houses individuals who have been ordered by a court to receive a competency evaluation or restoration, as well as individuals committed by a local mental health board. The latter process only occurs if an individual in crisis refuses to be voluntarily committed and is put under an emergency protective custody.
But wait times to get into the often crowded Regional Center have gone up, officials say.
Witmuss of the DHSS said that the state is looking into the need to increase capacity, but cautioned that opening new beds alone wouldn’t solve the problem.
“We have a lot of complex cases,” she said. “When you can’t discharge folks, then you can’t admit folks, either.”
Mental health programs and services are funded through Medicaid as well as the state’s behavioral healthcare regional system. Providers contract with one of the six regions, which then funnels funding from DHHS’ Division of Behavioral Health, federal block grants and county-level matching funds.
But grants and pilot programs, like the Lutheran Family Services’ co-responder program, are only guaranteed for fixed periods of time. Agencies and organizations are always shifting their appropriations to keep up with where the demand is highest, which can lead to changes in program availability.
Meanwhile, at the local level, stakeholders are giving new focus to the issue. Providers are exploring more innovative solutions to staff shortages, such as Telehealth, which would allow for remote counseling or med management.
Last year, Behavioral Health Care Region 6, which encompasses Douglas, Dodge, Cass, Washington and Sarpy Counties, hired Vicki Maca as a full-time employee, dedicated to trying to keep mentally ill individuals out of the criminal justice system.
That hiring decision was spurred by a nationwide initiative involving the National Association of County Officials, the American Psychiatric Association and the Council of State Governments known as the Stepping Up Initiative.
The initiative is a data-driven effort to reduce the number of people with serious mental illness booked into jail, shorten their average length of stay, increase the connection to care for those individuals in jail and reduce rates of recidivism.
While other behavioral health care regions are engaging with the Stepping Up Initiative, Region 6 is the only one that’s hired a full-time employee devoted to the topic.
But officials and providers remain optimistic. Rachel Wesely, the co-responder at the Fremont Police Department, law enforcement’s enthusiasm and willingness to cooperate with the co-responder model has led to success, she said.
Lt. Bottorff agrees.
“What I’m seeing now is reduced calls for service for the same problem,” he added. “There are times when we get so bombarded with the same situation—they didn’t have the tools to fix their problem.”
James Farrell, a staff writer for The Fremont Tribune, is a 2018 John Jay Rural Justice Reporting Fellow. This is an edited version of Part Two of a series exploring the intersection of mental health and the criminal justice system in rural Nebraska. To see the full version, click here. Part One can be accessed here. Readers’ comments are welcome.