Ms. Megan Hart of the Kansas Public Radio Station KCUR and the group Heartland Health Monitor partner KHI News Service has been following and chronicling the long sad story of the Osawatomie State Hospital in Kansas for quite some time now, nearly two years or perhaps longer, that this writer has been aware. Ms. Hart’s latest article, “Osawatomie State Hospital: A Leading Light for Mental Health Care Slowly Dims.” published July 25, 2016 documents very ably both the issues of this state hospital, its parent state, and the social vise that all too many such state hospitals more or less find themselves facing in this time of hoped for reform.This piece of American state hospital history is in many ways not unique to the fascinating and very checkered social history of the American state psychiatric hospital for public inpatient care of the seriously and chronically mentally ill.
I have long awaited this juncture, the partial passage of the most significant, and hopefully helpful federal mental health reform legislation in this country since President Kennedy’s 1963 Community Mental Health Center Act, the Helping Families in Mental Health Crisis Act,” or HR 2646. [I would encourage readers to actually follow the link to the text of the bill and give it a studied read]. Politics is ordinarily as an area I steer away from in my public blog writings as for the last 30 years it has been nothing more than a hopeless, dirty, pointless and non-productive quagmire that until recently has held no real relationship to the issues dear to this effort’s mental health professional’s heart.
But the time has come to start commenting upon, openly following in [I hope] responsible medical journalistic fashion, the life, future and fruits and/or unintended consequences of the slow legislative efforts and developments of years of failed political/legislative efforts to repair our long broken mental health care delivery system, both public and private. The Helping Families Crisis Act now appears to be the first piece of legislation with at least a reasonable potential to effect a vast amount of good effort in the right directions and quarters. One of the many recent news articles, printed over the last year or so to keep this bill alive in the public’s mind, prompted my entering into the national discussion regarding this legislation and its significance. I had held off doing so as for months it has appeared that it would be lost in the polarization of the political parties of the last four Presidential terms or buried/ignored because of lack of support since it concerned “mental health issues,” and all their complexities that at time legislators seems to avoid like the plague. But now it has recently “made it over the top,” as it were and appears destined for passage by the Senate in the near fall. In fact, it has seemed to gain a sort of hallowed status as one of those bills that the pols finally realize they had better jump on to the bandwagon rather than ignore any longer. And politically speaking, it has greatly helped that two brave Republican Congressman have fought hard for this legislation and made it politically acceptable to even most extremists to support.”
This writer keeps monitoring for positive developments in the realm of mental health reform and there are more than a few beginning to materialize around the country.
Of brief note is the fact that yesterday, Congress began finally to take positive legislative forward movement on Representative Tim Murphy’s “MHealth Care for Families…” bill to move it toward the Senate and the President’s signature. It is a huge step in the right direction.
Another positive development of note is that New Hampshire, according to a news report by KSL.com, “State hospital opens 10-bed mental health crisis unit,” on its online site for the states’ KSL TV channel, of July 5, 2016, reported that “A new 10-bed mental health crisis unit is open at New Hampshire Hospital after almost a delay of years.” The unit opened in Concord NH but illustrated immediately the enormity of the need in “little ol’ New Hampshire,” as we might say here in the South. On the day after it was opened it already had a waiting list of 23 people for emergency admission.
The article also mentions quite significantly that this entire effort was prompted by the state’s need to comply with a federal lawsuit over these very issues that had been initiated in 2013.
This observer sadly notes that even noble catch-up efforts in the nation’s and states’ mental health reform effort that are need, all good, and well intentioned, often are behind even when they get started but at least we are finally going in the right direction in places now.
But in the neighboring state of Vermont, things are not good. For months there has been well-deserved focus on something one does not hear much about anymore, since President Reagan broke the air controllers’ strike in the 1980’s and the decline of “organized labor” and “unions’ began in this country. Another striking feature of this situation has been that this new labor against management movement has involved healthcare professionals and mental healthcare professionals, which is truly almost totally anState opens new mental health crisis unit unheard of this country. This story has been a gathering storm since last year. It seemed to start in this writer’s mind a few years ago when whichever torrential “Nor’easter” storm savaged its way up the East Coast and into inland New England which is a bit of a rarity. That storm wiped out the state’s only public mental health hospital. Vermont has been limping along borrowing/leasing psychiatric inpatient beds in the state’s small private psychiatric inpatient hospital world. The state has relied most heavily on the Dartmouth Medical School’s inpatient psychiatric services for temporary relief.
This seemed at the time the best solution that could be had on a sort of moment’s notice state of urgency and emergency. But there was trouble in paradise so to speak. Labor problems began within months and built to the point where psychiatric nurses and psychiatrists themselves were fed up with working conditions which I am not privy to at all and began to voice their concerns at the state political level. Apparently, not much was responded to and too little positive corrective action appeared.
So they began to talk of work stoppages, strikes and other things that this writer associated with the United Mine Workers’ and United Steelworkers’ and Teamsters’ unions of the 1960’s and 1970’s that were every few years regular events. It was like Yogi Berra summarized in his most famous quote, “Deja vue all over again.” I personally know of psychiatrists through indirect sources that the psychiatrists were not just posturing to wangle higher wages, but were so serious that they were actively looking for jobs elsewhere, so strongly did the group of them feel about the deficiencies of patient care and availability. And Dartmouth and the State were caught in the middle I suppose, trying to generous and even-handed about all this.
This is yet another symptom of how bitter and unfortunately rancorous the processs of advocating for change can be anywhere, in any system, when the vehicle being ‘recalled and repaired and retooled’ can be at present when we attempt both short term and long term fixes that neither come easily nor rapidly enough. Again this writer will follow this story closely. I for one have never been on strike, though I went through them as a child decades ago as both my parents worked in the mining industry and this a regular every so many years event. And in the spirit of transparency, I know I could not do this and abandon my own patients.
In a recent editorial, the Virginia News & Advance newspaper published on May 29, 2016, entitled “Trying to Remake State’s Mental Health System,” Virginia’s commendable mental health reform efforts were enumerated in a concise fashion. Virginia’s efforts are somewhat unique in the country’s landscape concerning this issue which now dominating many American state legislatures.
Virginia’s efforts, similar to a few others states’ efforts, have been singularly prompted by a highly publicized tragedy, that of the death of a young adult, Gus Deeds. What is very different is that his father is a mental health professional, and a Virginia state legislator.
This young man while psychotic tried to stab the father, Craige Deeds. He was held in a local hospital emergency room for several days while awaiting a referral and placement in either a private or public state psychiatric hospital. There was no bed to be had and he was released a few days later. Shortly thereafter, he suicided. His father, state senator Deeds Ph.D. has made this a personal and public service legislative cause and mission to author and see enacted to address the deficits in Virginia’s mental health system to prevent another tragedy.
State Senator Deeds’ efforts have been very well placed and appropriate. However, even he has had difficulty in seeing this well crafted and reasonable legislation passed as the above-cited editorial, unfortunately points out. This is emblematic of many state’s efforts. The limiting factors are budgetary and many state legislatures, governors, and legislators are finding it very hard to find and devote the long needed monies to mental health reform. Some states have made creditable progress such as my home and practice state of North Carolina. But it remains quite hard to address the funding issues in many states that have permitted the development of state mental health system crises that we see presently almost everywhere. One can only hope that these difficulties can be overcome as efforts continue.
A very recent article, Colorado Still Lacks Inpatient Psychiatric Care by Ms. Elizabeth Drew published May 10, 2016 documents the same kinds of problems with psychiatric acute inpatient treatment resources that many other states have faced around the USA for the last 15 to 20 years.
Ms. Drew highlights the backdrop that started the mental health reform effort in Colorado so suddenly and starkly. Colorado suffered the misfortune to have the two double tragedies of mass shootings, the Columbine High School tragedy a number of years ago and the more recent Aurora CO theater shootings of 2012 committed by the then clearly psychotic James Holmes, whose trial riveted the nation. The James Holmes shooting caused a huge outcry from the public in that state for major and thoroughgoing changes in mental health services’ delivery.
Colorado has closed two state hospitals due to aging facilities being shut down and not being replaced. Colorado ranks now well below the current statistical average of 14 or so (13.9 in the previous blog posting’s article) per 100,000 beds for public inpatient psychiatric care in the state. Like many other states, its public mental health system has suffered greatly in the past two decades with inadequate funding and lack of growth of services commensurate with its higher than national average population growth. And like many other states, tragedies have begun to ramp up in severity, frequency and publicity as the “chickens have come home to roost.”
This article describes the very ambitious and quite rapid changes in point of fact, that Colorado put into place just last year, only about three years or so after the Aurora theater shooting. A massive state-wide system of acute outpatient crisis centers and much more rapid access to mental health contact, screenings and referrals to treatment resources was put in place. This clearly had a positive effect. Admirably, Colorado has begun a serious open effort to evaluate only one year into the operation of its new system. The results have been mixed and no matter what criticisms or kudos one may choose to endorse. Colorado, in my opinion as a long-time observer of mental health reform efforts nationwide, had commendable courage to permit and undertake this open review process. This review effort, documented in Ms. Drew’s article appears to show two results if I may condense and categorize them: 1) positive results in the delivery of acute mostly outpatient services, and 2) the common bugaboo of the yet unaddressed shortage of acute inpatient hospital beds seen now almost everywhere. Ms. Drew succinctly summarizes the reasons for this as relating to loss and closure of state hospital psychiatric beds and facilities, and, inadequate funding at the state and federal levels of the riddle of the expense of inpatient psychiatric hospital based treatment. [In a coming post I will try my psychiatric hand at explaining why inpatient psychiatric treatment is always expensive].
In coming posts, I will try my psychiatric hand at enumerating other issues common to all states beyond hospital beds that make the current mental health delivery crisis so severe. These issues will include the shortage of mental health professionals especially psychiatrists and the history of some more discrete and largely unknown to the public, mental health training fund losses that have caused our current severe practitioner shortages.
This subject and set of events is dated, and I offer my apologies to the reader. But this offering will serve to remind what can go wrong when in the course of the mental health reform process, things can go very wrong when the health care sector succumbs to criminal insufficiencies in their immediate continuum of care system, gives in ethically to a dishonest set of circumstances, does not fight back and falls back upon devising equally criminal ways of coping and inventiveness instead of advocating at any cost for their powerless patients who are dependent upon them for everything and anything they need to start over and begin the recovery process outside life in the hospital.
Over two years ago the Los Angles Times reported on a story that I thought I would never see again in my practicing lifetime, that of “dumping patients.” I practiced in Arizonaover 15 years ago and saw the now extinct Charter hospitals do this when a patient’s health insurances would be exhausted after a month or long stay in the free-standing hospital and then be “discharged to the street” literally and abruptly. I was witness to this process as our hosptal system having a rather compassionate approach to psychiatric care would willingly accept these unfortunate and truly traumatized persons when their desperate families brought to our admission doorsteps, those of the Camelback hospitals, once a group of psychiatric hospitals in the Phoenix and Scottsdale areas, started in the 1940’s and in the days of affordable psychiatric healthcare, a nationally recognized system for its superb quality of care. These dumped persons from the for-profit hospitals, still suffering acute symptoms such as severe unremitting depressions, suicidal impulses or pressing urges and thoughts, would be admitted no questions asked–at a loss to the hospital and to us attendings who took them on as inpatients, not expecting to be paid at all, and saw this as part of our responsibilities and part of universe of care we should offer out of our senses of service and ethics. I saw no practitioner at the Camelback system of hospitals ever turn down such a patient or take on their care resentfully.
The process of discharge in modern inpatients psychiatric care literally begins with a day or two of admission, not so that we can hurry up the process, but so that we can get a head start in lining up the needed outpatient resources, financial support, sometimes a place to live for a homeless person, sometimes family resources for a homeless minor, but always for a “best fit” between the patient and the all important team of team of therapist and psychiatrist. Often during the patient’s inpatient “do-over,” we would have the prospective therapist and future psychiatric come to visit the patient in person to have a get-acquainted session to make sure there was a good personality fit and rapport among them all, thereby giving often these persons brutalized by the “for profit” systems genuine hope that after discharge, whenver all arrived at a consensus decision made together, there would be the help ready in place to support them, giving them genuine hope instead of another trauma.
The article I came across recently in my constantly Google searchbot curating system for developments and trends inthe massive nationwide effort at changing our mental health care delivery system for all for the better was in the Los Angeles Times, entitled “S.F. sues to recoup costs for patients ‘dumped’ by Nevada hospital,” published ‘way back” in September 10, 2013. Its dated historical time of occurrence does not make it any less timely and happens to follow up on my previous post, which documented the emerging and alleged corruption of a privatized (read also for profit but sanctioned by the state who handled over inpatient psychiatric care to a national money making hospital system, to deliver service and make profit like the experiment with privatization of state prison systems who crowed about saving money to state legislatures, and of course pocketing the difference.) Well that did not go so well in a number of instances and the practice is still be re-examined in states who went in this direction.
The LA Times article though documented simply horrendous new heights of patient care callousness in patients at hospitals in Nevada, at discharge, from the Rawson-Neal Psychiatric Hospital in Las Vegas, often by bus with no resources, not provision at all for any outpatient care or personnel to San Francisco. The investigation by the newspaper the Sacremento Bee, started small but uncovered a scam/scandal of monstrous proportions and scale. It was found that about FIFTEEN HUNDRED patients had been shipped off to cities and towns in California over the previous five years. The investigation at that time was headed up by San Francisco City Attorney Dennis Herrera.
Those days were a unique confluence of corporate greed, and the growing appearance in the 1980’s of the seeds of the crisis we now face: the national shortage of adequate outpatient resources to replace which that hospital, especially the state public psychiatric hospitals could furnish even if at times, it bordered on “institutionalization.”
The solution is obvious and in everyone’s sight and radar. Outpatient resources and its infrastructure must be constructed nationwide, and governors and the no more taxes ideology of the present day and last 0 years must confront the reality that this costs money. Period. Good luck all you politicians trapped by your ideologies that do not square with reality. You need a paradigm shift in the biggest way and it will painful for your as you have to rethink your dearly held assumptions and shibboleths.
Approximately 3 weeks ago I read one of the most distressing that most informative articles I have seen in over 20 years. It was published in the Oklahoma City newspaper on January 2, 2015 and written by Jaclyn Cosgrove. It was entitled “‘Epidemic ignored’: Oklahoma treats its mental health system without care.” It was described as: “a yearlong investigation into Oklahoma’s mental health system.’
It had the usual now almost obligatory saddened startling photographs of dilapidated antiquated hospital facilities with patients in threadbare clothing without shoes crowded into dining halls or sitting hopelessly in empty hallways.
Much more startling to me the reader of such articles now spanning nearly 30 years since I have made it special interest of mine, were reading quotes from legislators, treatment advocates, and mental health professionals from time periods ranging from 40 to 100 years ago. The statements that were discovered and published in this article were quite riveting and unsettling because they could have been uttered in the last few years and without there being identified in the context of the years long past when they were first uttered, I would’ve had no idea if these were statements made by people long deceased. It was like reading the history of our present dilemma in mental health care system delivery and its failures nationwide, that existed in a parallel almost identical universe of similar mistakes, failures to adequately fund mental health programs, many of whom had forms and objectives and methods similar to the “new” massive programmatic renovations proposed in almost all states in this country today
For instance in 1895 the governor at that time of Oklahoma William C Renfro began proposing a novel idea that residents should be treated for their mental illness closer to their homes. This arose out of the unbelievable practice in that time in Oklahoma when the territory was sending mentally ill residents away by train to the state of Illinois. A second example is the fact that this newspaper article reported, “almost 80 years ago, the national mental hospital survey committee published a report that noted that air Oklahoma would save money if it invested in its mental health system.’ Whatever the future may bring,’ the report concluded,’ Oklahoma cannot look on itself with pride until provision is made for adequate care of its mentally helpless citizens. The year of that statement was 1937. It was recognized even then that the few state-funded inpatient hospitals then supported by the state of Oklahoma were only the first part of the treatment continuum that had to include community placement for the chronically mentally ill
One of the fundamental hypotheses of this newspaper article was that Oklahoma has been far behind in most other states in this country in providing mental health services. For instance the news purple article noted that in the year is surrounding World War II, Oklahoma had one of the worst doctor to patient ratios ranking it number 43 in the United States for care of the mentally ill. One other telling statistic was cited that each of the doctors at Central State Hospital in approximately 1947 had a caseload of 700 people, one of the highest psychiatric physician caseloads in the United States. It also had one nurse for every 45 patients in the hospital. The problems with safety of the psychiatric hospitals and facilities began very early in the history of treatment of the mentally ill in Oklahoma. For instance Western State Hospital at Fort Supply was overcrowded by nearly 500 patients and had building buildings which had already by the 1880s been repeatedly condemned by fire marshals as fire hazards and there were only four doctors to treat 1603 patients and no nurses or social worker
This is the historical backdrop to the looming mental health serivce crisis in Oklahoma today. This beginning examination of the mental health crisis in Oklahoma will be examined further in the coming weeks in a series of posts that will sketch the usual elements that have already beeen seen to operate in so many other states the last 20 years. These all too well known factors include: economic shortfalls in the state’s budget that suddenly jeopardize everything except football program at the state universities, poor foresight and plannnining, shortage of mental health professionals and delaying for still years the easy to have been seen to explore still further the outpatient agenices, facilities, physicial plants and staff cohorts of the world of public outpatient mental health services.
Further I will go on to document in following posts the same kind of story in another state with very unique twists and hardships of its own in meeting lesser mental health care needs in that state, Alaska which is slowly grinding toward a large crisis of its own.