The Downward Spiral

How CriminAL And menTAL HeALTH SySTemS BreAk down — And wAyS we CouLd Fix THem

by Chris Bowling

This is ins T

“The s piral:” a series from The abou men Tal heal T h and criminal jus T ice sys T ems. see The reader’s online Table of conTenTs on page 4 for parT 3 and check our march issue for The fourTh and final insTallmenT at first the outbursts and strange behavior seemed like something jacque, who asked for her last name not to be included in this story, could manage. but then the arrests came. Then the assaults. life became doctors’ offices, police cruisers, jails and emergency rooms. during his latest, longest incarceration, jacque’s son said he’d been sent to hell without a trace of exaggeration. jacque’s experience isn’t uncommon in omaha. many people with serious mental illnesses get trapped in cycles of arrests and incarcerations spurred by systemic issues in the mental health and criminal justice systems — not enough space, not enough workers, not enough money and too many problems to tackle. but there are reasons to be optimistic. douglas county has some say it’s not enough — workforce development, longterm care or preventive options are more important. but to douglas county commissioner mary ann borgeson, it’s a start.

Trying to save her son felt like fighting gravity in a landslide.

“it’s just so, so very scary,” jacque said.

$55 million left in pandemic relief funds to be allocated by the end of next year. much of that, if not all, could go toward a new mental health facility.

“you can look at the dollars that you’re going to potentially save in having people not locked up in your jail,” borgeson said. “but the bigger issue is not having them locked up in your jail and in a place where they’re getting their mental health services. To me, you don’t put a dollar amount on that. That’s just the right thing to do.”

Always a Little Behind

when borgeson started representing southwestern douglas county in 1994, mental health was a problem.

The douglas county community mental health center did not have its own building. it didn’t even have its own department inside the douglas county health center, an art-deco structure built in 1932 as a “pest house” — a place to isolate and treat people suffering from communicable diseases.

decades later the mental health center has its own program, but it’s still inside the same building with only 16 beds to treat people with psychiatric needs. The department also occupies one floor near the top of the building, making it difficult to access during an emergency and causing security issues for patients, staff and nursing home residents. it’s a recognizable story for many in the mental health industry, which has faced perpetual challenges. in 1999, the u.s. supreme court deemed institutionalization of those with mental illness and disabilities unconstitutional. in 2004, nebraska began clearing its institutions and sending people instead to community-based services, which the state was supposed to fund. To determine how much that would cost, the state got estimates from the six regional health care providers that oversee mental health care across nebraska. on march 30, 2004, the regional providers said it would cost about $27.7 million. The state gave them $15 million. region 6, which covers dodge, washington, douglas, sarpy and cass counties, got about 38% of its estimate.

“i have not been able to wrap my head around it in the time that i’ve been here,” said sherry driver, clinical director of the douglas county community mental health center.

“i don’t think there was ever this catch up … to try to get us up to the level that we said we needed in order to fully fund all of those services,” said patti jurjevich, administrator for region

6 Behavioral Healthcare. “So we’re always a little bit behind.”

Laws designed to protect people’s civil rights can also end up holding some back. Police are able to take people into “emergency protective custody” for 36 hours to force them to receive a mental health evaluation. But many hospitals are short on space and end up having to discharge people as long as they’re not deemed a threat to themselves or others.

Beyond that, families can request the county attorney file a Board of Mental Health petition to force someone to receive treatment. It must be proven the people are a danger to themselves or others and will not, or can not, get treatment voluntarily.

Inside the Douglas County jail, people with serious mental illnesses spend about twice as many days incarcerated as other inmates. At least one contributing factor is the five-month wait time to restore competency, which happens when inmates don’t understand their basic rights in the courtroom.

Samantha Douez with the public defender’s office said this happens maybe two to three times a week. The public defenders typically contract a professional to evaluate their client at a cost of $200-$400 per hour depending on the situation, then a state employee will do an evaluation. If a person is deemed incompetent to stand trial, he or she goes to the Lincoln Regional Center, one of the few remaining state mental hospitals, where competency is restored. That likely means medication and answering questions like, “What does a judge do?” before they’re sent back.

The Lincoln Regional Center is overseen by the Nebraska Department of Health and Hu- man Services, which did not respond to requests for comment.

For public defenders, the long waits are a glaring injustice. Their clients are spending too much time in jail, which is mentally degrading, and not even getting real help when they’re sent to Lincoln.

“Getting them to the level that they can get through court proceedings is not the same as getting them to the level that they could function in society,” said Martha Wharton, an assistant public defender in Douglas County.

“He’s not doing any other type of rehab,” said Jacque, whose son was sent to the regional center. “They’re not explaining to him what his illness is, why this is happening … I said, ‘So when you guys consider him competent to go to court, will there be a plan if they let him out?’”

“‘No,’” Jacque remembered them saying, ‘“there’s no plan once they let him out.’”

“So Far Downhill”

Many families hope once their loved ones get involved in the criminal justice system, someone will notice the prob- lem is less criminal and more mental-health related. But that’s not always how it goes.

Jacque’s son spent his 20th birthday in jail on a trespassing charge. He got out on a $1,000 bond then broke the mirrors and dining room table at Jacque’s house, caused a scene at a hairstyling school and went back to jail. When he was out again, a resisting arrest charge landed him in a hospital. He was home a few days later without medication or a follow-up plan.

Then he took Jacque’s car, drove to his father’s house and assaulted him. The Board of Mental Health stepped in, got the charges dropped and sent Jacque’s son to a hospital. There he attacked his sister and Jacque.

“Three days after he attacked me, they said he can come home,” she said. “I’m like, ‘You know that he came after me in the hospital. Right?’ And they’re like, ‘Yeah, he’s fine now.’ So they sent him home.”

His next psych appointment wasn’t for six months.

Meanwhile, the combination of pills made him unable to move, Jacque said.

“He’s on too many pills. We have to drop these down,” Jacque remembered a psychiatrist saying when she took her son to the hospital. “I’m full, but I’ll take him as a patient.”

Things got better, but then he didn’t want to take his medications. Illegal drugs took their place. He scared the psychiatrist and got dropped as a client. Eventually police were called and he ended up back at a hospital. For two weeks, staff tried to find an available bed, searching in Omaha, Lincoln, Scotts Bluff and Norfolk. But there was either none or nobody wanted a violent patient. They sent him home with medication, which he dumped down the garbage disposal.

Later he got into an argument with his manager at a fast food restaurant and smashed her windshield with a baseball bat. Jacque begged his manager not to call the police as she drove her son around for four hours — he had an appointment with a new psychiatrist that day.

Then he went back to the hospital where one night he attacked his dad and three nurses.

“You saw the look in his eyes,” his dad told Jacque. “It was like … he was an animal being attacked.”

He went back to jail and waited six months for his trip to the Lincoln Regional Center. When he refused to shower, the jail had no choice but to force him into a cage and hose him down.

“He went from being somewhat in psychosis where you can still kind of talk to him to now he has six different voices in his head,” Jacque said. “He’s talking to them. I mean, he went so far downhill. He’s worse than when it first started.”

Local Options

The jail is not a good place to treat mental illness, said Mike

Psychiatric Bed c aPacity in c ass, dodge, douglas, sarPy, and Washington counties

Proponents of mental health reform say the community needs more beds to care for people in crisis. However, short staffing means many operating at less than full capacity for facilities in the counties that make up Nebraska’s Region 6 Behavioral Healthcare system.

In Cass, Dodge, Douglas, Sarpy and Washington counties, there are 129 psychiatric inpatient beds, though staffing shortages limit that (on Dec. 15, 2022, only 92 beds were available), according to Region 6 Behavioral Healthcare data. A new Douglas County facility could raise that to 205, which is roughly the average number of people with a serious mental illness inside the Douglas County jail.

ugh, think the county could increase capacity and access to care without running up the bill by targeting existing county-owned buildings. He also thinks long-term care is a must.

“Douglas County currently does long-term residential physical disability care,” he said. “We could augment that to include people with mental disabilities.”

Myers, director of the Douglas County Department of Corrections. None of its facilities were designed to be calming or therapeutic. Mental health workers often have to speak to people through small holes in the wall.

The jail has had success working closely with the Douglas County Community Mental Health Center, and Myers hopes much of the county’s $55 million in pandemic relief money can cement that relationship through a co-located facility.

Some have raised concerns that putting the facility too close to the jail, or having men- tal health center staff working alongside jail staff, stigmatizes mental health as a criminal problem. But that’s already the reality, Myers said, and if they want to make a difference now, they have to go where the need is.

“Even if money was not an object, the clientele that are being served at the community mental health center are the same people we’re already working with,” said Myers.

One of the big improvements this facility could make is adding capacity to a strained system.

But increasing beds without having the people to staff them worries organizations like Omaha Together One Community (OTOC). The group, which organizes people across faiths and community organizations to advocate for policy and social change, suggested $2.75 million go toward a scholarship program, specifically to help more people of color and Spanish speakers — both of whom are underrepresented in the industry.

“You could build all the buildings you want in the world,” said Mark Stiles with OTOC, “but if you don’t have the workforce development plan to get people into these jobs, you’re going to have a bunch of empty beds sitting around.”

Others, like Douglas County Commissioner Jim Cavana-

But some say it’s not that easy. The longer someone stays, the more beds you need. The more beds you have, the more staff you need to pay. It’s also fraught given the legal framework the state implemented to move away from restrictive care, not to mention unpopular given the abusive history of such facilities.

Others hope the facility can be an assessment center to streamline the process and divert people from jail.

“Your assessment center is kind of that point of entry,” Borgeson said. “If you have a friend you think needs [help], you can take them to this assessment center. If a loved one is having a psychotic episode, the ambulance can come and take them to the assessment center … If we had something like that in a co-located facility, then you continued on page 20  would be able to make those determinations much quicker.”

Luckily, Douglas County has some good examples to follow.

Win-Win Argument

When it comes to addressing the intersections of mental health and criminal justice, it seems there aren’t many better places to work than Arizona.

“Over the years, the state has continued to invest in crisis care, because it does make good financial sense … regardless of whether you’re coming at it from social justice, clinical or as a responsible stewardship of taxpayer funds,” said Dr. Margie Balfour, chief of quality and clinical innovation at Connections Health Solutions, which runs a crisis response center in Tucson. “It’s kind of like a winwin argument in that way.”

Instead of going to crowded emergency rooms, law enforcement can bring people to the crisis response center and be out in under 10 minutes. Patients wait an average of 90 minutes to see a doctor. Staff put together patient exit plans, which can include housing, health care and social services.

Ultimately about 85% of the 12,000 adults the facility serves annually remain stable in community-based care, according to 2019 data from Arizona Complete Health.

The work also benefits from a more streamlined funding model. After Arizona became the last state to adopt Medicaid in the 1980s, it created the Arizona Health Care Cost Containment System (AHCCCS, pronounced “access”).

By putting health care funding through one funnel, it forces providers to work together, build stronger relationships and avoid duplicating work, Balfour said. The synergy also helps people follow through on their care plans once they’re back in the community and has led to decreases in repeat visitors to the crisis center and fewer civil commitments.

“What Arizona does is they braid [all funding] through AHCCCS,” Balfour said. “So AHCCCS gets the federal funds, the state local funds, all the Medicaid funds, and then when they give their money to the [regional providers], they have all that together.”

Medicaid funding is a perennial issue in Nebraska, said Annette Dubas, executive director of the Nebraska Association of Behavioral Health Organizations. Most providers don’t make enough of the federal health care money to break even, she said. In 2021, Nebraska’s per-capita spending on Medicaid ranked near the bottom nationally — Arizona spent about $1,000 more per person by comparison.

A popular solution for some is Certified Community Behavioral Health Clinics. These facilities are required to serve anyone regardless of their ability to pay, carry an array of care options and include 24/7 crisis services.

Funding comes straight from the federal government at an enhanced rate that providers set.

“That helps them with recruiting staff,” Dubas said. “It’s also a very integrated system. They’re working with physical health providers; they work with the courts; they work with the schools; and it has a heavy focus on crisis services.”

Solutions like these are important because they emphasize capacity isn’t always the answer. Tucson’s crisis center has only 15 subacute beds where people stay for 3-5 days. Communication, organization, collaboration and good data to back it up mean lower costs and better outcomes.

Statewide the crisis system costs about $185 million annually; however, it saves about $370 million with fewer long hospital stays and lower emergency room bills and other incidental costs, Balfour said.

For their work they’ve received a MacArthur Grant and been designated a learning site by the U.S. Department of Justice, and Balfour was awarded Behavioral Healthcare Profes- sional of the Year at the 2021 Crisis Intervention Team international conference. They’re also getting interest from other states to implement similar systems — and they’re more than willing to help.

“There’s a lot of things people don’t agree on,” Balfour said. “But one of the universal things that pretty much everybody agrees on is that law enforcement doesn’t need to be the default first responders for mental health.”

‘He Sees Your Pain’

It’s complicated. That’s the common sentiment about the relationship between criminal justice and mental health. And it’s not going to be solved easily.

But that’s not what Jacque wants to hear. As bad as things have gotten, she doesn’t think about her son as too far gone. She still thinks about the popular high school athlete with lots of friends and dreams for the future. Jacque hopes that future, in some capacity, is still possible — a steady job, a wife, kids.

How is he going to get there? At this point, hope doesn’t look like people and systems.

“God wants me to tell you that he sees your pain,” Jacque remembered a woman telling her in church. “He wants to take it away from you.”

At that point Jacque had been crying herself to sleep. She knew her son was scared, confused and alone. She couldn’t stop thinking about him.

They prayed for a few minutes and since then, Jacque has felt more peace. At least someone has her back, she thinks.

“You do anything for your kids,” she said, “and when they’re in pain, or if you don’t know what’s going on, it’s horrifying.”