More than 150 years ago, Dorothea Dix visited a jail in Cambridge, Massachusetts, and was horrified to see it filled with people with mental illness. Thus began her campaign to convince lawmakers and judges to house those who needed treatment, not punishment, in mental hospitals. More than 100 such hospitals were built across the country before her death in 1887.
If she were to return to a jail today, she would be shocked to see them again housing people with mental illness (albeit under better conditions than in the 1840s) and would likely wonder what happened.
What happened was a recurring pattern of well-intentioned promises not backed up with the financial resources needed to fulfill them. A century after Dix advocated for more mental hospitals, there were growing concerns that these large facilities were “warehousing” those with mental illness and that smaller, community-based facilities offered a better approach. In 1963, President John F. Kennedy signed the Community Mental Health Act, which proposed more research into and federal funding for mental health services provided by state and local governments. It also called for a system of smaller community-based mental health centers that would allow people with mental illness to receive services in less restrictive settings in the communities in which they lived. The programs were never fully funded.
Two years later, Medicaid was created. It excluded coverage of people “in institutions for mental diseases,” furthering the push to move people with mental illness to nursing homes along with seniors and to general hospitals, where their care was covered largely by federal dollars.
A switch to a block grant approach to mental health funding under President Ronald Reagan further eroded federal support for care of those with mental illness. Federal support has continued to drop, and in the wake of the great recession, state funding for mental health fell to its lowest level since deinstitutionalization, according to the National Association of State Mental Health Program Directors.
Maine’s situation, recently chronicled by the Bangor Daily News’ Nok-Noi Ricker, is sadly not unusual. Although there are no records or systems that track the mental health of inmates in Maine, the state does track use of medication to treat mental health. According to data from the Department of Corrections’ contracted medical provider, Correct Care Solutions, about 48 percent of juveniles and 34 percent of adult inmates were prescribed psychiatric medications in 2015. The numbers are much higher in some county jails, according to a survey conducted by the Bangor Daily News. The late summer survey found that 61 percent of inmates at the York County Jail were receiving such medications.
“My question is: Is that what corrections is supposed to be about?” asked Penobscot County Sheriff Troy Morton. “Is that really how we should be treating people with mental illness and substance abuse? To me, this is really an expensive way to do it.”
The solution is expensive too. The community mental health system that President Kennedy envisioned is partially built. Facilities exist for families with the resources to pay for treatment, which is often long-term. Not so much for poor families, which is why so many people with mental illness cycle through emergency rooms, jails and mental health facilities.
Maine’s two state-run facilities, the Riverview Psychiatric Recovery Center in Augusta and Dorothea Dix Psychiatric Center in Bangor, have only 143 beds, 5 percent of their peak capacity in the 1970s. Two private hospitals, Acadia Hospital in Bangor and Spring Harbor Hospital in Westbrook, and eight community hospitals have 127 beds between them.
Maine’s lack of adequate mental health services is a long-term problem that pre-dates the LePage administration. The administration’s response, however, has been inconsistent. In recent months, Gov. Paul LePage has called for housing some Riverview patients at the state prison in Warren and for redoing renovation plans at the medium-security Windham Correctional Center to accommodate them. Forensic patients, those who are sent to Riverview by court order, are at the center of the debate. Judges have ruled these patients not criminally responsible for their crimes because of their mental state or not mentally competent to stand trial and sentenced them to Riverview in the custody of the Department of Health and Human Services. Housing these patients in jail would violate such court orders. It may also violate a decades-old consent decree that settled a 1989 lawsuit against the state over mental health services.
Earlier this month, the department announced $420,000 in funding for the private Spring Harbor, which said it will reopen a 12-bed psychiatric unit.
Maine won’t improve the situation quickly, but policies that emphasize community-based treatment — including an emphasis on treatment at early ages — and the commitment of resources to fund them will lay an important foundation. Government leaders must also resist the urge to divert attention and resources elsewhere.