Breakdown: In rural Minnesota, mental health safety net is in limbo

WILLMAR, MINN. – Five years after Minnesota closed its last state hospital and promised a new era of rural psychiatric care, patients like Randy May are still sitting in mental health limbo.

Last summer, the 27-year-old grad student from St. Cloud State University suffered a severe manic episode brought on by bipolar disorder. He cycled through five outstate treatment centers, landing in police custody and handcuffs more than once. Eventually, he was committed to state care by a judge. But even that, he says, didn't help him.

"You get put in for [a fixed] amount of time," May said in an interview. "It's like [they're] baking a ham. Once you are done, they're going to move on to the next person. There's no specific plan to get you healthy."

Across Minnesota, hundreds of patients with the most acute mental illnesses are having the same experience — cycling through a system ill-equipped to treat their disorders, winding up in county jails or hospital emergency rooms, and often posing danger to themselves or their communities.

Few places illustrate the problem as starkly as Willmar, where a large state hospital closed in 2008, leaving nothing to adequately serve patients who are aggressive and unstable.

In this city and its surrounding counties, nearly 1,000 adults with mental illness or chemical dependency were arrested and jailed between 2007 and 2012 for offenses ranging from assault to public nuisance, according to arrest data analyzed by the Star Tribune.

Two small treatment centers in west-central Minnesota have been cited for neglect in cases where patients attempted suicide. Employees of at least three area hospitals have been injured in outbursts by psychiatric patients. Now the Kandiyohi County sheriff is considering whether to convert an unused part of his jail into a psychiatric wing.

"In my opinion, we've gone back to the dark ages," said County Attorney Jenna Fischer, who has dealt with the mentally ill for two decades through the court commitment system. "It's a tiny segment of the mentally ill, but we are failing them."

"We're going to have a crisis one of these times," said Jim Pew, director of behavioral medicine at Stevens Community Medical Center in Morris, where a social worker was pushed to the ground and injured by an aggressive patient. "Somebody's going to harm themselves or harm somebody else because we're not able to get them placed in a facility that's set up to deal with [them]."

At the north edge of Willmar — a west-central Minnesota city of about 20,000 — on a pastoral patch of land not far from the lake that bears the city's name, sits a campus of aging, red-roofed buildings. Today it is a technology office park, but for nearly a century it operated as a state mental asylum.

What became known as the Willmar Regional Treatment Center was one in a statewide network of large institutions for the mentally ill, developmentally disabled and chemically dependent. These state hospitals evolved over the decades, but by the 1970s society had come to view them as inhumane warehouses for the vulnerable.

"We put people in hell," said Sue Abderholden, executive director of the Minnesota chapter of the National Alliance on Mental Illness.

After decades of gradually moving patients out of the massive state hospitals and into community settings, Minnesota 10 years ago made a final push to close what remained of the costly treatment centers. Willmar's was one of the last to shut down.

For thousands of those patients, community placement — with medication and therapy — was a welcome success. No one in the mental health field wants Minnesota to revert to the old system.

But for patients who can be volatile or unstable it has been a rough ride: In one recent 18-month period, some 4,000 Minnesotans with acute mental illness washed into the criminal justice system, ended up in jail and were committed by judges to state facilities.

Recognizing that Minnesota would need a replacement for the big hospitals, the state established a network of small, 16-bed psychiatric facilities known as Community Behavioral Health Hospitals (CBHHs). Opened between 2006 and 2008, they were designed to save money while serving patients close to home.

Problems emerged immediately. Because they lacked their own security forces, the CBHHs wound up relying on local police and sheriffs' deputies when aggressive patients become violent.

That, in turn, led to several incidents that alarmed state and federal regulators, including a 2009 case in which a violent patient grabbed a police officer's gun and fired it inside a CBHH in Annandale.

Staff injuries have been another persistent problem. Last year, 37 staffers sustained serious injuries, a three-year high. Workers' compensation claims related to staff injuries also have escalated steadily, reaching a payout of $357,000 in fiscal year 2012.

Overall, state records show 769 physical assaults over a roughly five-year period ending last October — or three incidents per week — according to records analyzed by the Star Tribune.

Some counties have adjusted successfully to the new system, state officials say, but others have been slow to develop community housing and therapeutic services viewed as essential to complement the CBHHs.

In 2009, the state Department of Human Services (DHS) closed the CBHH in Cold Spring, in part because of staffing shortages. Two years later, comparable facilities in Willmar and Wadena were closed and converted to provide other services for the mentally ill.

Deputy Human Services Commissioner Anne Barry says her agency is working hard to fix the problems and to bridge gaps in rural mental health care until a more complete system can take hold across all 87 of the state's counties.

One priority is improving safety in the remaining Community Behavioral Health Hospitals. Among the planned changes: more secure nurses' stations; higher staff-to-patient ratios; and the capacity for staff "surges" when needed.

"I know people are concerned about safety," said Steve Allen, the department's new executive director overseeing mental health and substance abuse treatment. "It's our job as leadership to ensure that our patients and our staff feel safe."

The agency also has taken steps to ensure that the mentally ill don't languish in county jails. Under a law passed by the 2013 Legislature, the state must find a bed within 48 hours for certain mentally ill clients who are in jail and committed by a judge to state care.

In the first few months after the law took effect on July 1, they hit that mark in 85 percent of cases, records show.

In addition, the Legislature appropriated $10.2 million this year to develop community services that would unclog the system by moving patients out of state residential facilities.

In Hennepin County, for example, DHS is helping local officials develop a small residential treatment facility for patients who need continuing treatment but are ready to leave the state's Regional Treatment Center in Anoka, which has severe backlogs.

Even so, psychiatric patients with acute needs in rural Minnesota continue to face daunting obstacles. Minnesota's hospital system has operated for years with little extra capacity for the mentally ill. Between 2005 and 2010, Minnesota dipped to 50th in the country for public psychiatric beds per person, according to one national survey.

On most days, the Minnesota Mental Health Access website shows few vacancies across the state's nearly three dozen public and private hospitals that can care for the mentally ill. Some institutions also note that they won't take aggressive patients or those with a violent history.

"The safety net is pretty much gone, especially for the mentally ill and aggressive people," said Mary Kjolsing, director of behavioral health for the past 38 years at Rice Memorial Hospital in Willmar.

Just last August, the hospital was caring for a severely mentally ill patient who couldn't get into a state facility. While staff members tried to give him medication one night, the man reacted violently and broke a security guard's leg.

The new CBHH system, Kjolsing said, "has failed the entire state."

Willmar and the surrounding 18-county region are a case in point. Public records reviewed by the Star Tribune show that 436 mentally ill adults were arrested for assault here between 2007 and 2012 — a rate of almost two per week. Another 354 were arrested for violating restraining orders, 66 for making threats against others and 33 for stalking.

A residential treatment home in nearby Atwater, one of several designed to supplement the CBHHs, was placed on conditional license status last year after two incidents of neglect — one that involved a suicide by a patient who left the building and walked in front of a train.

This year, another patient slit his wrists while staff members were trying to place him back in the state system, according to Richard Lee, CEO of Woodland Centers, a Willmar nonprofit that runs a crisis center, counseling programs and the Atwater facility.

A similar facility in Annandale, 45 miles to the east, was placed on a conditional license in 2012 after state regulators found neglectful care in the case of two patients who committed suicide.

Today, Lee says, facilities like his are reluctant to accept patients with aggressive tendencies or suicidal histories.

"If we take them and things start to deteriorate," Lee said, "we can't get them out of here."

Brad Schrade • 612-673-4777