Research Corner: Mental Illness

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Helping the mentally ill

Resources are needed to prevent the incarceration of the mentally ill and to get them the treatment they need.

Story By Cagney Kilgore and JORDYN NYKAZA AAC Law Clerks

The Arkansas Constitution, in Art. 19, § 19, mandates, “It shall be the duty of the General Assembly to provide by law for the support of institutions for the .... treatment of the insane.” While the language in this provision may seem outdated, the duty it bestows upon the legislature certainly is not. Arguably, the need for state-supported mental health services in Arkansas is greater today than it has ever been before in our state’s history. The mentally ill in Arkansas have urgent needs. We call upon the General Assembly to address our needs.

Union County Jail Administrator Richard Mitchum describes the grim reality for many mentally ill individuals who do not have access to treatment: “Many of the mentally ill in Arkansas are placed into our county jails because there is nowhere else for them to go.” Often, hospitals will not treat mentally ill individuals unless they are a threat to themselves or others. Furthermore, out-patient facilities are not widely available in certain rural parts of the state and are costprohibitive without insurance. As a result, county jails have become the landing pad for those individuals who have fallen through the cracks of Arkansas’ strained behavioral healthcare system. Sebastian County Sheriff Hobe Runion elaborates, “I run the largest mental health ward in the county.” Mitchum and Runion both believe jail is not the appropriate place to house someone with a mental illness because “they need help” and sitting in a jail worsens mental illness due to the isolation and harsh conditions inside.

Arkansas has tools to help treat forensic patients, or those mentally ill individuals who are within the criminal justice system: the Arkansas State Hospital psychiatric beds, crisis stabilization units, and step-down beds. Unfortunately, these resources are in high demand and unequally distributed across the state, resulting in long wait times in county jails for a forensic bed at the State Hospital to become available.

Arkansas State Hospital Psychiatric Beds and Step-Down Beds As the sole state operated acute psychiatric inpatient hospital in the state, the Arkansas State Hospital (ASH) is the leading provider of mental health care services to forensic pa-

tients. As a result, ASH serves particularly vulnerable sectors of the population, including those who have been accused of a crime but are deemed unfit to stand trial and must undergo a restoration period before being reevaluated. Due to the nature of behavioral health treatment, the average length of stay at ASH is much longer than a traditional hospital stay, especially when treating patients with severe or chronic mental illness. Some patients require indefinite treatment, further reducing the number of available beds for patients requiring emergency treatment and those reserved for referrals by law enforcement. There are not enough psychiatric beds at ASH to meet the current demand. ASH beds have not been added since 2003, despite Arkansas’ roughly 3 percent population growth. There is always a waitlist for ASH, resulting in months-long wait times in county jails. Mitcham has seen inmates wait up to two years for a bed in ASH. The longer a mentally ill person sits in jail, the longer their treatment is delayed, and their condition often worsens. Sheriff Runion describes this process as a “revolving door.” As soon as someone is released from ASH prematurely, they often end up right back in the county jail again to rinse and repeat, says Sheriff Runion. Arkansas is ranked 46th in the United States for the number of state hospital beds per capita, falling far behind Mississippi, which is ranked 10th in the United States, according to a 2016 report done by the Office of Research & Public Affairs. Surely, we can do better than 46th.

Effective behavioral healthcare does not end with ASH. It is crucial that mentally ill individuals have access to behavioral healthcare and community support after release from ASH. This would help prevent a relapse, which would land them back inside. Facilities like Birch Tree Communities offer step down programs, which allow individuals living with mental illness to recover in a safe environment where their basic needs are met. They are monitored by trained mental health professionals. Birch Tree can serve around 440 people and provide access to group and family therapy, illness management, crisis intervention, educational opportunities, and other programs to better their lives. According to Jack Keathley, chief executive officer of Birch Tree Communities, stays can range from a few weeks to several years, with the goal of meaningful recovery. For some, this means reintegration into the community and for others, that means staying out of ASH. However, the growing demand for forensic beds in ASH has affected the ability of non-forensic patients to receive treatment. To try to alleviate the long wait lists in county jails, ASH has increased the number of beds in its facility reserved for forensic patient

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Mental Illness

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awaiting evaluation, which means there are less psychiatric beds available. Birch Tree receives almost half of its referrals from ASH, and so as the number of psychiatric beds shrink in ASH, so does the number of people who have access to Birch Tree’s services through the referral system. A common theme is emerging — when mentally ill individuals are incarcerated instead of receiving treatment, everybody loses.

A meaningful solution to this problem is three-fold: ASH needs more psychiatric beds; Arkansas needs more step-down beds; and we need more regional crisis stabilization units. It is imperative that we do not warehouse mentally ill individuals in the county jails.

In November 2019, county officials requested the Governor and General Assembly to address the urgent need for more beds at ASH and more stepdown beds. Gov. Asa Hutchinson announced the creation of a working group to study the circumstances and need for ASH psychiatric beds and step-down beds in Arkansas. Despite COVID-19, the working group met via Zoom several times during 2020. During the Arkansas Sheriffs Association Convention on Jan. 26, 2021, the Governor announced the creation of another group to study the issue. We anticipate the study will confirm that Arkansas is ranked 46th nationally in the number of psychiatric beds at the state hospital.

We need to note that the American Rescue Plan provides $1.57 billion in funding for the State of Arkansas and authorized the use of funds for the construction or expansion of public health facilities and their operations. This one-time funding provides a perfect opportunity to at least build or expand existing behavioral health facilities for use by the State of Arkansas for ASH psychiatric beds and as well for the construction of suitable facilities for use by providers for step-down beds. Let’s use this one-time money for its intended purpose and rescue those with mental illness in Arkansas.

There is no reason Arkansas should be ranked 46th in the United States per capita in the number of psychiatric beds at the state hospital. We continue to respectfully request the General Assembly, Governor, and the Arkansas Department of Human Services (DHS) to take action to create more psychiatric and forensic beds at the state hospital and continue to

invest in diversion efforts from the criminal justice system, like Crisis Stabilization Units (CSUs).

Regional Crisis Stabilization Units

Any good coach would tell you the best defense is a good offense, and that time-tested strategy will work in mitigating the mental healthcare crisis in Arkansas. Arkansas has made some progress on the front end by implementing regional CSUs in Washington, Sebastian, Pulaski, and Craighead counties. Regional CSUs are critical to Arkansas’ mental healthcare system because they provide a place other than jail for someone to go when they are experiencing a mental crisis. The Governor and the General Assembly have partnered with the counties and providers in these major undertakings. We are thankful to the Governor and legislature for pushing Arkansas in the right direction toward The average stay at a CSU is 2.7 days, and unlike costly outpatient centers, stregthening behavioral healthcare services. However, we no one is denied treatment for lack still have a long way to go. of health insurance. The average hand-off time between a law enforcement officer and a CSU is five to 10 minutes, whereas wait times in the emergency room can be hours. Additionally, officers in counties with CSUs receive Crisis Intervention Training, which trains them how to both assess and help a person experiencing a mental crisis. Re-directing individuals to crisis units rather than jails is safer for all involved and allows the patient to receive quality care until healthy enough to rejoin society. We are thankful to the Governor and legislature for pushing Arkansas in the right direction toward strengthening behavioral healthcare services. However, we still have a long way to go. Southern Arkansas counties are woefully underserved, as there is no CSU below I-40. There is a disparity in the behavioral healthcare services available there. When the State of Arkansas embarked on regional CSUs the State of Mississippi had eight regional CSUs. Mississippi now has 15 regional CSUs, and we are falling behind. Fortunately, law enforcement officers are permitted to take patients to any CSU and are not restricted to sending people to specific locations, a recent change announced by the Governor’s office. However, stable and adequate funding by the state is imperative to continue operating the regional CSUs in Arkansas and to establish create new regional CSUs throughout Arkansas.

The numbers are clear: it is much more expensive to incarcerate the mentally ill than it is to treat them. Research from the Arkansas Public Policy Panel found the average cost of convicting and then incarcerating a mentally ill individual to be $30,000 in the first year alone. The cost ratio of incarcerating mentally ill individuals to running treatment centers is estimated to be roughly 20:1. The legislature passed Acts in 2019 and again in 2021 to create a legislative study on mental and behavioral health in Arkansas. So, there is ample data available to demonstrate the need for more behavioral health resources in Arkansas. Further action to address these priority issues is needed. We need to enlist legislators to champion these causes.

County judges are eager to help and have seen firsthand the benefits of having a CSU in their county. According to Pulaski County Judge Barry Hyde, in April and May of this year alone, more than 200 people were diverted from the county jail through the CSU, and this number continues to grow.

“This shows that our officers, through training, are beginning to see the benefit of using the CSU instead of taking those in mental health crisis to the county jail,” Judge Hyde said.

Judge Joseph Wood of Washington County believes Arkansas needs to keep this momentum going by securing a consistent funding mechanism for CSUs.

“We have an annual fight for funding,” Judge Wood said. This limits the potential for growth. However, he joins Judge Marvin Day of Craighead County in showing immense gratitude for the Governor and his staff for all the progress Arkansas has made so far in implementing the four regional CSUs. We are optimistic that with continued collaboration with behavioral health stakeholders, we can improve the lives of Arkansans struggling with mental illness.

So, what would it mean to Arkansas to increase funding and beds? Joey Potts, director of the Sebastian County CSU, shares how she sees a success story every day. She said she recently witnessed the police bring in a homeless patient and shortly after, the patient was relocated to a residential care facility. If it were not for the CSU’s help, that individual may have been released back to homelessness where he would inevitably end up back in the criminal justice system. Dr. Lisa Evans, director of the Pulaski County CSU, shares a similar success story, in which a homeless patient was picked up by law enforcement and taken to her CSU. This patient had dementia and because of the CSU, was able to get immediate treatment and reunite with his family. These are just two examples of the good that comes from CSUs. Imagine how many more people in similar positions would be saved. We urge the Arkansas General Assembly to fulfill their mandate under the Arkansas Constitution to provide for the treatment of the mentally ill.