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Do Iron Bars a Mental Hospital Make?

Idaho is ready to lock up more mentally unstable people. Are prisons the way to do this?

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Idahoans living with mental illness are about to have their possible destinies shaped by the Idaho Legislature. In particular, those with the misfortune of needing to be locked up are about to have a possible new destination: a state prison warehouse that Gov. C.L. "Butch" Otter wants to turn into a 300-bed facility to house people the state deems too dangerous to themselves or society to be free.

But even as plans for this facility roll along in the Legislature and in Otter's financial planning for the state, numerous experts worry that Idaho is conducting a dangerous experiment with the wrong kind of lab.

The move down this path began a while ago, but began to take shape in legislative hearings late last year.

State Sen. Joe Stegner's, R-Lewiston, Mental Health Subcommittee has been meeting to consider proposed changes to Idaho laws regarding court-ordered commitments. According to public records of the Dec. 11, 2007, meeting, legislators appeared concerned about the "revolving door" system that shuffles people between hospitals and jails. Some, like Rep. Margaret Henbest, D-Boise, have pointed out that clients can receive medication in the former, but become "noncompliant" because of side effects, substance-abuse issues or their confusing nature of the illness itself. But not all people suffering from serious mental illnesses can be described as "chronic," and some, such as spousal abusers, become violent before their conditions are diagnosed.

Rewording of the law would allow for what Stegner calls "a broader definition to allow more consideration in helping people through the involuntary process."

Which means that Stegner has had to beat back assertions that Idaho is going to make it easier to lock up people with mental illnesses, but not because they've done anything criminal.

"We are not trying to attack civil liberties," says Stegner, who is the assistant majority leader in the Senate. "We changed the process to consider outpatient commitments, which are seldom used. We're not sure these changes will increase the rate of utilization, but with a broader set of tools, we're trying to make the process a little more seamless."

There are indications that change—of any sort—is long overdue.

"The system is pretty archaic. It's really bad," says Harry Holmberg, president of the Idaho chapter of the National Alliance on Mental Illness. Holmberg notes that NAMI's 2006 report card on mental health services rates Idaho at an overall "F," below Arkansas, Alabama, Louisiana and Mississippi. Idaho ranks 46th in per-capita income but 49th in per-capita spending on mental health.

Holmberg says NAMI supports the idea of rewording the law to make commitments easier to pursue than arrests, and to allow for outpatient commitments through mental-health courts that resemble drug courts. Holmberg says his organization favors guidelines "that would allow involuntary treatment for those who have stopped taking their medications, or with a past history of deterioration."

He believes that while the old laws condemned people to lifelong hospitalization, recent advances in medication now allow them to stay outside the system as long as they keep taking their prescribed drugs.

Closely linked to these discussions is the Department of Correction's Mental Health Facilities Development Plan, first issued in 2005, and projected for completion by 2014. Despite a paucity of public hearings on the issue, the Legislature will now address that funding gap to provide 300 beds for people whose mental illnesses require high-security housing and treatment. The Legislature's Joint Finance and Appropriations Committee has already allocated $3 million for initial plans designed to house those patients alongside a criminal population overseen by corrections officers.

Lawmakers are still obligated, under Idaho Code, to provide a separate, secure facility for the violently mentally ill. The problem policymakers face is that this category includes people incarcerated under both criminal and civil procedures.

The criminals have, by definition, been tried and convicted. Those committed have not.

JFAC's response was partly in answer to Gov. Otter's initial call for a tented facility in the desert area south of Boise, near the current Idaho State Correctional Institution. According to Correction Department data, 28 percent of inmates housed in Idaho's adult prisons have a mental illness, compared to the national average of 16 percent. Another 44 percent of all Idaho juvenile offenders managed by juvenile corrections have mental health issues, according to the agency's data.

The agency estimates that mental-health treatment costs the state over $1.34 million a year. In essence, as one Health and Welfare official put it, the Idaho state institution and maximum security facility will function as the state's third mental hospital.

Most parties agree that the issue comes down to best use of available funding to achieve the highest possible levels of care. Idaho's Department of Health and Welfare responded to the original report by stating to the Legislature that "one facility appears more cost-effective. Two or more facilities seem more appropriate from a philosophical point of view."

Representative Nicole LeFavour, D-Boise, agrees. In an e-mail to BW, she wrote, "A completely separate facility would be far more ideal. I worry that now we have people in prison cells who have not been convicted of any crime."

Yet the current plan requires some sort of shared arrangement between Corrections and the nominal custodian of mental treatment, Health and Welfare's Division of Behavioral Health. The plan will involve a 300-bed facility, with 260 of these set aside for violent mentally ill inmates, and 40 left over for unconvicted civil commitments. The final site of the facility has yet to be determined.

But while planners use the term "secure psychiatric treatment facility," mental health advocates refer to "the new prison."

"This cooperative venture was of interest to everybody, but [Health and Welfare] has terribly disappointed me with the idea of a facility on correctional grounds" says Linda C. Hatzenbuehler, who specializes in forensic psychology at Idaho State University and chairs the state's Mental Health Planning Council.

"I think the Legislature doesn't like the fact that they need more prisons because so many people are in trouble, so now there's a little bit of blaming that the mental-health piece is clogging the system," she says. "They're trying to keep people out of jail, not for the appropriate reasons, but just from an economic standpoint."

Hatzenbuehler is skeptical that the proposed secure facility will work according to plan. She writes that under the best of circumstances, and without danger of harm to self or others, "only persons with Medicaid or really good health insurance have the luxury of voluntary admission to a psychiatric facility in Idaho." Those who wind up incarcerated don't fare as well, in her judgment, because "Idaho's jails and prisons are decent places, just overcrowded. Idaho's prisoners get some psychiatric and mental-health treatment, but it is at a bare-bones level."

Finally, some high-risk individuals "decompensate and become so ill mentally that the level of treatment they need is not available in jails or prisons," she says. The analogy would be a prisoner who suffers a heart attack. The prison health services cannot manage a physical illness of this magnitude, so the individual is transferred to a hospital for care and then returned to jail or prison once he or she is stabilized.

"If you have a major psychiatric episode, similar in magnitude and severity to a heart attack, while incarcerated in an Idaho prison, you remain in prison," she says.

NAMI's Holmberg seconds these views.

"The Department of Correction is already overcrowded, so how they handle these tremendous case loads without educating guards and staff is by perpetuating the culture of 'lock them up and keep them locked up,'" he says. "When they put the mentally ill into the prison, there's a mixture of population there, but that doesn't work. The only treatment they get there is medication, but they need some real therapy as well."

Hatzenbuehler's own recommendation is for better community services such as out-patient community treatment teams, dual-diagnosis programs for people whose mental illness is complicated by substance abuse, supported housing and employment and "an open door so that you don't have to go into crisis before you get services."

She supports the idea of a model program in one part of the state to see if Idaho can prevent some jailing and hospitalization.

"We have a Band-Aid, patchwork-quilt system that's costing money at the wrong places," Hatzenbuehler says. "So, let's put some money into the communities for this and see if it works."

Former state Rep. Kathie Garrett from Meridian has attended many of Stegner's subcommittee hearings, and worries that jails and prisons aren't the place to store people who need treatment.

"Jails and prisons are for the purposes of punishment and incarceration and are not appropriate places for people who need treatment," she says. In an unpublished position paper, Garrett underscores her opposition to "any placing of non-adjudicate persons with mental illness or the 'dangerously mentally ill' in prison, jail, or any facility ran by [the Department of Correction]. People should not have to go to prison to get mental-health treatment."

Garrett says she is especially concerned that "placing people who need mental-health treatment in prisons feeds the stigma that already surrounds the mental illness." (Full disclosure: Garrett and this writer serve as co-chairs of the Idaho Council for Suicide Prevention).

Like other advocates who disagree with the concept of highly centralized and institutionalized treatment, Garrett argues for a more proactive and localized approach.

"Idahoans with mental illness deserve services and support in their community and before they reach a crisis point," she writes in her position paper. "Idaho needs to expand crisis services statewide in the community that prevent needless institutionalization."

But Gov. Otter has made the secure facility a priority for his administration, and mentioned it prominently in his State of the State speech on Jan. 7.

"If the state of Idaho had a larger population base, and consequently higher budget, the ideal situation would be to have two separate facilities," Stegner says. "The fact is, the state can't afford that today, and this is the most cost-effective way to get there."

"I appreciate the comments" voiced by critics, says Stegner. "I appreciate them and don't reject those concerns out of hand. I do realize that we have economic challenges and that this is the best course of action for this state and citizens who need that service for the next several years, until we can afford a separate facility. It will be my hope, if I stay involved in government, to advocate for that, but today, this is the best way for us to provide for a significant increase in treatment capability for any number of high-security-need patients."

He also rejected the notion that the public has been left out of this decision-making process.

"Other states share these concerns with the new emphasis on mental health and substance abuse, but I'm pretty happy with the way the State of Idaho is going," says Stegner. He shares the views of critics in many respects but also favors "earlier detection, a strong mental-health court system, more options in transitional housing, an increased number of mental-health-care professionals.

"For select populations, we do a reasonably good job," says Stegner. "But there are huge gaps. For example, we tend to ignore the middle-aged white guys who get drunk, and the huge impact they have on society. We tend to target more needy populations but ignore others."

Others in the state's system agree with Stegner.

"I believe that everyone in the Governor's Office and Legislature understands the gaps and wants to do something about them," says Mary Perrien, Ph.D., and chief of the Division of Education and Treatment from the Idaho Department of Correction. "I see some of the bleakest, most disheartening stories from parents whose children are being turfed all around, who have to be part of the criminal process to get service. It's the same story over and over again. There's a disturbance in the house, they call the police to come in, and now their child is caught in a system they can't get out of. I see the desperation and fear of losing their child and they have no options whether their child is 12 or 32."

Perrien believes that Correction and Health and Welfare can collaborate on a workable partnership partly because she's seen it done in other places. As it stands now, she says, those with civil commitments don't get a lot of time out of their cells.

"We definitely need something different from a state hospital, which tends to be contraindicated for people with major, major mental illness and is not well-equipped to meet their needs," she says. "Working with Health and Welfare as partners, we plan on 300 beds, 260 for mentally ill inmates, and 40 for civil commitments who will be housed separately, both males and females."

Perrien says that the opposition by Holmberg, Hatzenbuehler, Garrett and others represents "a very real concern for us, and we are very sensitive to it." But, "the facility is not funded as a prison although it falls within the purview of the Department of Correction. I know that kind of label is on there, but it is not a 'prison' but a 'secure mental-health facility.'"

Perrien says that "the design is to maximize evidence-based treatment, the most cost-effective in an environment that's more inviting to friends and family for visits."

Perrien notes that all the staff, from guards to laundry-room workers, will receive a week's worth of advanced mental health-training.

"Realistically, we will have to grow in that area as well," she says.

The interim step before the facility is finally built involves a temporary $3.4 million, 20-bed remodel of one building at the Idaho State School and Hospital in Nampa, says Kathleen Allyn, administrator of Health and Welfare's Division of Behavioral Health.

The idea is "to make it a more secure facility than anywhere we currently have in the state," says Allyn.

The remodeling budget is down from an initial request for $18 million. Allyn says that the remodel is designated "to outplace most of the current residents, most of whom have developmental disabilities, and either build more appropriate housing for them on campus or [find them] off-campus community placements."

But Allyn emphasizes that while this solution is temporary, it offers longer-term advantages once the secure facility opens some four to six years from now.

"Approximately 41 percent of our current civil commitments come from here in the Treasure Valley," she points out, "which means that we are sending these folks away to either Blackfoot in the eastern part of the state or Orofino in the north because of the limited psychiatric hospital capacity in Southwest Idaho." Allyn projects that the Nampa state hospital might eventually be used "as a psychiatric step-down unit from the corrections facility, to provide family psycho-education space and other kinds of transitional housing."

In terms of the secure facility, Allyn says that it is inaccurate to mischaracterize the project plans.

"Both Dr. Perrein and I are looking at this as a psychiatry treatment facility, not as a prison facility that treats psychiatric folks," Allyn. "We're still looking at what the Health and Welfare side will look like licensure-wise because [there] are a lot of different options we could go to. Obviously, it will be residential. But the sooner we can outplace people from there, the better because we want to get them out of a restricted environment," she says.

In response to patients-rights advocates, Allyn says that the mentally ill will not be "incarcerated" in the technical sense.

"Number one, they're not going to be housed in a facility run by Correction. It will be run by Health and Welfare. Second, we are trying to be sensitive to that perception and working to avoid that appearance as much as possible in the sense of the separation and self-containment of the commitment unit," Allyn says. "I don't know what we can do appearance-wise but it would be nice if we could do something so it would not seem like a correctional facility, which it's not."

While Allyn admits that "design and staffing are still being worked out," she says that "the primary design is it's practically a stand-alone unit within the Department of Correction's 260-bed facility. It would be completely separate residentially. Most of the classrooms and recreational area would be separate. There does seem to have to be some shared facilities in the cafeteria and dietary, and some others things like psychiatrists, but the administration would also be separate.

"For both Correction and Health and Welfare, we need a facility that's more secure than what we currently have," says Allyn. She confirms that, "it probably will include perimeter fencing. Can we try to modify the fencing so that it doesn't look like a prison? I don't know if that's possible or not. We've certainly talked about it. But for the very few people we have who need a facility of that type, we do need something that is secure and something that's safe for staff to work in." Allyn says that workforce considerations also loom large in the plans.

"One of the things I think gets overlooked is the number of injuries to staff, particularly at [the Nampa hospital], where they have 80 percent of the three state hospitals' worker's compensation claims," Allyn says. "One of the problems is that the buildings are simply not designed for the type of client who acts out or tends to become aggressive. I am very concerned about the state staff that we ask to take care of some very dangerous people in space that wasn't designed for that."

While critics and patient advocates remain skeptical about the final details of the division of services between Correction and Health and Welfare, Allyn believes otherwise.

"We feel we can make it work because we've been working together on the whole process so far. It's been a nice example of collaboration between two government departments. I know that from an advocate's point of view, it's probably not the most ideal partnership, but in terms of actually getting something done, it may be necessary, temporarily, to go this way.

"The system has to be constantly be evolving," Allyn concludes. "Nothing is ever static. We have to constantly evolve the system. What works today won't necessarily work in the future, and we've got to be prepared to keep planning for what lies ahead. When we get the sufficient threshold population, we can probably justify having separate facilities, but in the judgment of both the Legislature and the Governor's Office, we haven't hit that threshold yet.

"Some very good solutions could be developed" in the future, says Allyn. "Whether in my lifetime or not, I don't know."

She points to promising vaccination treatment for substance-abuse issues as one example. As for the present, "it's important to realize that, right now, we are long overdue for a secure facility. We have a potential crisis" because the state lacks a facility, she says. Overall, Idaho "is moving in the right direction," in terms of mental-health services, "but we've got to remember that we are only one component of the entire state economy."

"Our movement may be more like a sailboat," is how Allyn characterizes Idaho's changing mental-health system, in response to a comment by an anonymous state employee who likens it instead to "glacial slowness."

"We may have to tack to get to our objective instead of steering right to it because the wind is not blowing [the way] that we want," says Allyn. "It's not that we go backwards, but we may not be going directly towards. We're going a little bit at a time."