Iowa sheriffs at the front lines of mental health crisis

WATERLOO - Many people in Iowa's jails - as many as a third - do not belong there, law enforcement officials say.

Too many are jailed when what they need is mental health care.

The scenario has become all too common: A person with a mental illness does not get needed treatment or declines to take prescribed medication, then behaves in a way that gets law enforcement involved.

'So, what we've got now, is the jails have become the mental health institutions for the state,” said John Miller, a Black Hawk County supervisor.

The state's mental health care system is plagued, law enforcement officials and mental health advocates agree, by a lack of access because of a shortage of beds and a lack of available mental health professionals. Iowa also lacks a unified mental health care model that involves hospitals, law enforcement and the community.

In Scott County, 38 percent of those in jail have a diagnosed mental health issue, according to Sheriff Dennis Conard. Like many of his colleagues in law enforcement across the state, Conard thinks that number would drop dramatically - perhaps by as much as half - if Iowa had a better system of mental health care.

'The entire system seems to be broken,” Conard said, 'especially in our area. And the jail is the location that the police departments have at their disposal to take care of the issues that they're dealing with on a daily basis on the outside. They're running into people who are under treatment, but for some reason, they make the decision that they're not going to take their medicines anymore or they have a crisis of some sort. … And there's no place else for them but jail.”

Not enough beds

Iowa has the fewest state psychiatric hospital beds per capita in the nation - two beds for every 100,000 residents, according to a 2016 report from the Virginia-based Treatment Advocacy Center.

There are roughly 730 staffed psychiatric inpatient hospital beds in Iowa, according to state data. The number fluctuates daily by a bed or two.

That's not enough, law enforcement officials and advocates say, especially because not all beds are open to all mental health patients. Some, for example, are designated for specific age groups.

'I don't know if there's overall a shortage, but there definitely is a shortage for certain kinds of people,” said Peggy Huppert, executive director of Iowa's chapter of the National Alliance on Mental Illness.

Gov. Terry Branstad's administration in 2015 shuttered state-run mental health institutions in Mount Pleasant and Clarinda. Branstad said the move was made to better serve patients in community-based treatment and to save money.

In early 2015, just before the closures, there were just more than 730 psychiatric beds, according to the state.

A state Department of Human Services spokeswoman said there still are roughly 730 beds in Iowa. She said the number of beds did not change drastically because, in the final years, Clarinda and Mount Pleasant housed only a handful of psychiatric beds each.

Two state-run mental health institutions remain operational, in Independence and Cherokee. Independence has 62 beds; Cherokee has 36.

Advocates and law enforcement officials say they agree that many with mental health care needs are better served in community-based treatment, but not all. They say some people have mental health care needs that are too intense for such treatment.

'I had one person from one of the MCOs (the managed care organizations that are operating Iowa's Medicaid program) tell me it doesn't matter how much I offer to pay a provider, they're not going to take these people,” Huppert said. 'So there is a role for state beds, and it should be for the patients that nobody else wants.”

While state data shows dozens of open beds - a new bed-tracking system showed more than 80 in early June - law enforcement officials and advocates insist the shortage is real, and they insist the mental health institution closures exacerbated the problem.

Difficult to place

They say some individuals are difficult to place and sometimes beds are open but geographically far from the patient, which then requires someone - often law enforcement - to make an hourslong round trip to transport.

'I don't know the governor's reason (for closing the mental health institutes) … but it's killing a county like Woodbury,” said Woodbury County Sheriff Dave Drew. 'And I know other counties have the same problem.”

Branstad spokesman Ben Hammes rejected the suggestion the closures shifted the burden of providing mental health care from the state to local governments and agencies.

State officials pointed to the open beds and said hospitals are not admitting some mental health patients. They also noted a shortage of psychiatrists, an issue Branstad has attempted to address by introducing a program that would encourage psychiatric medical students to work in Iowa after graduation.

'There are still two state institutions that are able to admit patients,” Hammes said in an email. 'We recognize the difficult job that mental health care advocates sometimes experience. However, we are focused on providing a modernized level of care for mental health patients in their local communities whenever possible.”

Hammes said, since returning to office in 2011, Branstad has approved more than $310 million in mental health care funding and signed into law the statewide redesign of the state's mental health care delivery system from county- to region-based. Hammes also said 150,000 Iowans have access to mental health coverage through the Iowa Health and Wellness Plan, a state and federal partnership.

The closures freed more than $8 million in the state budget. State records show the state appropriated $1.4 million for Mount Pleasant and $6.8 million for Clarinda in fiscal year 2015; that funding has since been eliminated.

Jails as CARE

When beds and other treatment options are not available, jails often bear the burden.

'They can't get access to proper treatment, so they're self-medicating with drugs or alcohol. It's often the addiction that gets them into trouble or the behaviors coming out of that that lands them in the criminal justice system,” Huppert said. 'In Iowa, police and sheriffs … are the mental health treatment providers of last resort.”

Law enforcement officials say not only is that an inefficient use of their resources, it often is difficult to provide adequate assistance.

'Once all the beds are full, what's the next best thing? Well, take them to jail. And that's not providing the services they truly need,” Marion County Sheriff Jason Sandholdt said. 'Sometimes, I feel like we're really reactive. … If we get them the help beforehand and have it be long-term care instead of just short-term care, then we might avoid these situations.”

Black Hawk County Sheriff Tony Thompson sees the same issue.

'Way too often, they end up in the criminal justice system because that's the path of least resistance. That's the easiest option,” Thompson said. 'Jailing them while they're mentally ill, while convenient … it in no way, shape or form benefits them.”

Law enforcement officials say people with mental health issues wind up in jail because often it is the easiest solution, but those officials say that is not what is best for the patient who becomes an inmate.

'A lot of people in our custody are in for non-compliance, (not) taking their medication. They didn't do what the court ordered them to, the court has no place to put them, so they put them in our jail,” Drew said. 'Don't you find that disturbing that someone ends up in our jail just because somebody didn't take their meds? It's just not the place for them. So we're all sitting here not knowing where to place them, and (jail) is just not where they belong.”

No funding coming

Although many advocates agree most mental health patients are better served in community settings, those same advocates say the problem is that local governments and agencies received no additional help to make the transition.

'That's all fine, but there wasn't a subsequent shift of dollars into community health centers to help them manage those acute clients,” said Chris Hoffman, executive director of Pathways Behavioral Services in Waterloo.

Advocates lament what they describe as insufficient state funding for mental health care resources, and groups that are trying to address the intersection of mental health care and law enforcement are doing so without expecting any new money coming their way.

'We have to fund it ourselves,” Miller said. 'We have to figure it out on our own, because we're paying, one way or the other.”

Working together

In Black Hawk County, individuals from county government, law enforcement, hospitals, mental health care advocacy and others have formed a group that meets once a month to discuss these issues.

'It brings everybody to the table, not only to identify our various roles in the problem, but also brings to the table some potential solutions,” said Tom Eachus, of the Black Hawk-Grundy Mental Health Center in Waterloo.

'They can come together and say, ‘This is something that we need to do differently, we need to address this problem.' We know what the needs are, now the question is how do we change the process that might impact the problem that is there. … We're all going down the same road together.”

Thompson marveled at how much he has had to learn about handling people with mental health care needs since he became sheriff in 2009.

'I didn't realize when I took office eight years ago how dramatic an issue this was. I ramped up my education very quickly, and that's unfortunate that we are under-recognizing this particular facet of the issue,” Thompson said.

'But in this last eight years, what I've found is my vision for what the mental health funnel ought to look like, where it starts with day programming, routine interaction with a counselor, all the way down to those people who need permanent placement, a housing system, 24-hour monitoring, down to people who really aren't suitable for placement in community care (but) need something more structured, more detailed to their particular affliction. …

'We all recognize that the convergence of mental health and criminal justice needs to be addressed.”