Mental Health Meltdown

by Tim Stelloh, June 3, 2009

When cops were dispatched to a rural Redwood Valley address recently, they had little information about what to expect: All they knew was a man with a gun was standing in his front yard shouting insults at passersby. Neighbors thought he might be dangerous, but police didn’t know who the man was, whether he was mentally ill or had a criminal record.

Upon arrival, they found the man shirtless with a gun in a holster; he promptly demanded that they leave his property. After cautiously discussing the situation, one of the uniformed police boldly walked up to the man and, acting as friendly as possible, offered a handshake. Then he snagged the gun from the holster.

After an interview, police decided he was a 5150—the code used for someone who’s a danger to himself, a danger to others or is gravely disabled. The code is typically employed for the most serious cases of mental illness: The people who, for instance, mutter to themselves on street corners, who appear to have never bathed in their life, who without provocation wield firearms and shout obscenities at their neighbors.

The cops confiscated the man’s gun and took him to Ukiah Valley Medical Center. They explained the situation to hospital staff and a mental health worker who had been summoned while the cops were en route to Ukiah. Then they left.

Within hours, neighbors had called again: After being released with what appeared to be minimal evaluation, the man was back home with another gun. So the cops returned—this time with their weapons drawn. They arrested the man and, once again, confiscated his gun; when they searched his house they found three more firearms. The man was arrested and taken to jail for making terrorist threats.

There was no indication of alcohol or drug use, and more than one cop was annoyed that mental health had released the man without advising the Sheriff's department and for providing what was far less than the 72-hour evaluation allowed under a 5150 declaration. Was this standard practice, a fluke error or, more ominously, just another tale of department budget cuts, burnt-out workers and what Supervisor John McCowen recently called the “dismantling” of Mendocino County’s mental health system?

Mental Health Director Mary Elliot said she didn’t know the details of the case, but if a clinician interviewed the man and released him, then they determined he wasn’t a threat. “I’m sure the cops are frustrated because they want mental health to take care of the guy,” she said. “But the county would be bankrupt if every [5150] was held for 72 hours.” It’s the kind of situation, she said, that cops and mental health workers constantly find themselves in—a situation that, given the gutting state and county budgets have undergone (and will continue to undergo), is easy to imagine turning ugly.

With a million dollar deficit, the county’s mental health system has been on the receiving end of the fiscal carnage. So has the department’s crisis unit, which responds to 5150s and which faced a round of layoffs and reductions in hours earlier this year.

Before the cuts, 5150 calls played out much like the incident above: Police would pick someone up and take them to a hospital. They’d be evaluated by a crisis unit clinician, and if their illness was serious enough and they needed to be hospitalized, mental health workers would track down the appropriate psychiatric facility somewhere in the state (which is often far from Mendocino County).

During that process—which can take hours—a human service worker from the crisis unit would sit with the patient for the duration of their time there. Once the new facility was found the worker would drive the patient there in a caged car.

Often, the patient and the worker—along with the clinician—had an established relationship. Perhaps they had been together on 5150s before, or maybe the worker had helped the patient get their meds. In any event, the worker may know what to do if, say, the hulking schizophrenic in the back seat began ramming his head full force into the cage or demanding that they pull over for a bathroom break.

That’s how it used to happen. But in February, the four human service workers employed by the county, along with the seven to 10 contractors who were considered extra help, got laid off. Elliot said the layoffs and reductions in hours would likely have happened regardless of budget cuts: “We had absolutely no activity between 11 p.m. and 8 a.m.,” she said. “We had to make a conscious decision to not be fully staffed at that time.”

Though the unit averages 52 5150s a month, they’re spread out: Some days there might be six calls, other days there might be zero. “That’s the challenge,” Elliot said. “And we just didn’t have the resources to continue funding.” (And what of the admittedly top-heavy administration of mental health and its parent department, social services—are managers getting pink slips, too? No layoffs yet, but several positions have disappeared through attrition, Elliot said.)

With the human service workers gone, the crisis unit’s six clinicians had to adopt the mantra of our woeful economic times: Do more with less. Now, they do the assessments. They sit with the patients. And for a time, they were doing the drives. The crisis unit’s hours have also been trimmed back: A staff member used to be on duty 24-7. Now, between midnight and at 8 a.m., crisis calls go to an answering service. The service contacts one of the clinicians, who may have to travel long distances from their homes to the hospital; this makes for unhappy, impatient police, who have ended up waiting long stretches for the clinicians.

This new, leaner environment has lead to some unpleasant incidents in the emergency room at Ukiah Valley Medical Center. Medical center CEO Terry Burns said that in addition to seeing more repeat patients and less of the crisis workers, the hospital is relying more and more on law enforcement. During one recent week, police were called three times to deal with 5150s who had become aggressive with hospital staff.

“That was week was a bell ringer for us…and it’s symptomatic of not being able to get a crisis worker in to deescalate” the situation, he said. “Our desire is to not call the police for the sake of the patient. We’re here for the patients.” But, he added, it’s gotten to the point where cops need to step in because hospital staff—who are trained to deal with patients non-violently—can’t get the 5150s into a less aggressive state of mind.

More mentally ill patients appear to be ending up in the county jail—though Sheriff’s Capt. Timothy Pierce said it’s too soon to draw any conclusions from recent data since the jail’s general population has risen steadily over the last several years. In March and April 2007, the jail housed 112 mentally ill inmates; during the same period in 2008, that number dropped to 93. This year, those stats have spiked: One-hundred and fifty-two inmates with mental illness have landed in jail in the last two months.

To compound the problem for the crisis unit, the economy has handed workers a new demographic: Mendocino County’s walking depressed. Traditionally, the crisis unit dealt with the county’s most seriously afflicted. If someone was depressed—and they had a job with benefits—they would have been treated through their employer-provided healthcare. But for those who, say, recently lost their employer, their health care and happen to find themselves contemplating suicide, the barely strung together public safety net is where they’re ending up.

For now, the mental health department is planning an “enhanced crisis line” that could help the county’s walking wounded, and it’s outsourced some of the crisis unit’s driver jobs to Manzanita Services, once known as A Healing Cooperative; that contract is good through the end of this month, though Elliot expects it’ll be renewed in July. Crisis unit clinicians will continue the more-with-less mantra and the Ukiah Valley Medical Center, meanwhile, is making its own preparations: Burns said the hospital is coming up with a plan for providing services that human service workers once offered as well as better security. Not that the hospital doesn’t have its own budget problems. At the moment, Burns said, UVMC is providing $250,000 a year in uncompensated mental health care.

Nevertheless, the hospital will continue providing care for mentally ill patients.“I’m not trying to run from that,” Burns said. “We’ve got to do it.”

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