Dec 30, 2012

Dear Vice-President Biden, Here’s what it takes to fix mental health

Vice-President Biden,

We've had from thirty to fifty years of mental health deinstitutionalization in America. Don’t listen to people who whine about the days of yore when we locked people away in big institutions. Presidents Kennedy and Carter were right. That should not happen again.

It’s time for Americans to adjust. As disorderly and chaotic as deinstitutionalization has been, every one of our civilian institutions has had enough time to figure out some basic strategies that work. The practices outlined below are well-documented and in place today, but on a hit-and-miss basis.

Access to treatment

The problem: People have difficulty accessing care and connecting with systems.

The solution: A single point of contact telephone number for a region or a county, connecting with multi-system resources for screening, assessment, and referral. A “no wrong door” mutual aid policy within healthcare and mental health systems that includes some basic protocols for data exchange. A tiered entry into care, with an emphasis on delivering the first appointment in a timely fashion.  Neighborhood health centers and public clinics with sufficient capacity for delivering assessments and delivering basic care for depression, anxiety, bipolar disorder and first-onset schizophrenia, plus family and caregiver education. More specialized care available promptly for more complex cases.  De-couple assessment systems from resource allocation systems. Do not change standardized assessments so that they “ration care.” Use mobile crisis teams to prevent escalation to the criminal justice system.


The problem: When we had big institutions, we underfunded them, but even then they were among the largest budget items for state government. As deinstitutionalization progressed, state governments kept funding the big hospitals for many years. For the most part, when these institutions closed, their former funding did not transfer to communities. And if it did, the money generally went for mental health treatment, not housing. Deinstitutionalized people found themselves with no way to access housing, because SSI, the primary source of income for people who never had substantial work histories, did not pay enough to cover the cost of market rate housing, and Medicaid, which pays for treatment, does not pay for housing.

The solution: Subsidized housing using housing dollars, plus case management services covered by Medicaid. “Housing First” policies work because they simply deliver a housing product, and, after thirty years, the mental health system has figured out how to keep people connected to mental health care. Small scale group homes also need enough supplemental funding to permit operators to deliver realistic levels of programming for people with a high burden of disability.


The problem: Unruly people with mental illness are clogging our courts and jails. The most difficult population has moved from mental hospitals to jails and prisons.

The solution: Diversion programs throughout the entire criminal justice pipeline. Pre-arrest solutions that give street level officers discretion to drop people off for mental health evaluation in lower-cost settings than emergency rooms or psychiatric hospitals. Jailhouse coordination with mental health agencies to provide early release of clients already in the system. Secure mental health facilities under criminal justice jurisdiction separate from local general population jails. Social workers available at all levels of the criminal justice system, including courtrooms and probation offices. Restorative justice programs that address the needs of crime victims and offenders, but allow a way out of imprisonment. Note: This works once the housing issue is fixed.

Police killings of people with mental illness

The problem: Too many people with mental illness end up dead after encounters with police.

The solution: Training every officer to identify mental illness and use appropriate tactics that de-escalate situations. Specialized units to respond to mental health calls. These practices must be incorporated into use of force policies and firearms training protocols. Many deaths of people with mental illness occur because these training protocols and policies were designed before the era of deinstitutionalization.

Violence and suicide connected with mental illness

The problem: People with mental illness become disconnected from treatment, stop taking medication, or use drugs or alcohol, and commit violent acts or suicide. People decompensate and become violent or suicidal without being connected with treatment.

The solution: Better communication, coordination and data exchange between all levels of the mental health, general health care, education, criminal justice, and court systems. More suicide prevention training within the general population. Risk management protocols that give greater weight to leaked signals of harmful intent. Sufficient secure healthcare facilities to handle immediate needs including mandatory minimum stays in step-down facilities for medication stabilization. Protocols within treatment systems that facilitate information sharing with caregivers or family members. Protocols that integrate college counseling centers with the community’s mental health provider system. Consider “safe harbor” provisions to permit and encourage information sharing under HIPAA and professional practice systems. Increase funding for substance abuse detox and treatment.

Suicide of armed forces members and military veterans

The problem: We are losing more soldiers to suicide than to other war wounds, and the high number of veteran suicides is simply tragic.

The solution: Increase the capacity of soldiers, families, churches, community groups and employers to detect problems as they are developing. This involves having face to face conversations and perhaps following a simple script, plus the willingness to ask about suicidal intent. You can find a script in my book Defying Mental Illness, and free suicide prevention training through the QPR Institute. Every community already has a front door for treatment.

That’s a start. I think we get the rest of the way with more emphasis on what ordinary citizens can do, starting with simply talking with each other, and recognizing that mental health and mental illness are not obscure and unfathomable or disgraceful, but legitimate topics for everyone. The experts are needed too, but many ordinary people with a little more training can do a lot to keep us safe. It takes an hour or two to train anyone on the basics of mental illness.

Let me know if you need some help rolling this out.

Best regards,



Mama P said...

Dear PK,

Thank you for your well thought out comments regarding a terrible crisis. It seems obvious that you are a pro with much experience on what goes wrong in dealing with mental illness, in it's various phases, as well as what we can do to improve. I pray the Vice President will be listening to you.

As a mother of a son hospitalized, jailed, homeless many times I have walked the walk feeling each door is closed, not open. The dramatic events it takes to get help are rediculous! If our kids were affected with MS, or cancer they wouldn't have to become homeless, delusional, or serve jail terms to get an appointment with the correct medical professional. We are doing it wrong!

As a mother of a 24 year old daughter teaching kindergarten, my heart is tragically divided.

I stand with you. How can I help?


Paul Komarek said...

Right now, the best thing you can do is to write VP Biden and let him know what you have experienced.

Beyond that, it is your political choices and the activism of the groups you participate in (in terms of changing national policy).

On a local level, it's important to advocate for change that can happen right now.

Keep at it.


Bipolar Bandit said...

I shared your letter on one of my Pinterest boards.

I also wanted to share a blog I wrote that touches on the same topics. "Has the Talk about Mental Illness regarding recent shootings over?"

and a petition I hope that you will sign and share.