It is one of the tragedies of their lives, then, that it is completely unnecessary for them to bear this awful stigma, or for their families to suffer as they do, or for society to be saddled with such high costs as a consequence of a small minority's mental illnesses.
- Outreach helps homeless and community
THE SERIESPart 1: System failure
What killed the promise of a new life for the mentally ill? And what is the cost to society?
Part 2: A system under stress
A 1994 Broward County grand jury blasted the county's mental health system and issued 16 recommendations for improvement. Sadly, a decade later, most of the important ideas have not come to fruition; the crucial ingredient -- sufficient funding -- is still missing.
Part 3: Solutions that work
There is a broad consensus that what is needed is a better system of community-based mental health care. But inadequate funding makes even the herculean efforts of mental health professionals, advocates and courts a well-intentioned sham. It will take political will, integration of services and accountability to turn things around.
Part 4: Baker Act reform
While the law aims to protect the civil rights of the mentally ill, untreated mental illness makes their freedom a mixed blessing.
- Jails and Prisons
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Standing in the way are an extreme shortage of funding to support mental health services, psychiatric beds and the latest and best medicines; a fragmentary delivery structure and dearth of accountability; and a weakness in the Baker Act, Florida's mental health law, that often prevents the state from acting in the best interests of the mentally ill.
But the situation is far from hopeless. The solution lies in finding the political will to improve funding and the way it is allocated, strengthen the mental health leadership structure and the integration and delivery of services, and reform the Baker Act.
The political will shouldn't be hard to muster, for this is an issue with built-in appeal both for compassionate liberals who want to help a disadvantaged and poorly represented minority, and for fiscally prudent conservatives who want the mentally ill to stop sleeping on sidewalks, urinating in public, distracting law enforcement from other duties and bleeding the taxpayers. Besides, the law already requires that the state provide a consistently high level of care for the indigent mentally ill, a level that currently is not being provided.
Of course, there is considerable will, political and otherwise, at the local level. Both DCF and the Henderson Mental Health Center, for instance, have strategic plans designed to improve their ability to make the most of limited resources. Two mental health courts, one for misdemeanors and one for felonies, have been established in Broward County and have been modestly successful as a means of pre-trial intervention, giving mentally ill and substance-abusing defendants a chance to get treatment and keep their records clean. These steps by the state, the providers and the courts are welcome signs of movement toward solutions.
Best of all, if political will can be galvanized, there is substantial consensus among mental health experts, advocates for the mentally ill, law enforcement, the courts, federal government advisers and even the Florida Legislature about what constitute the ingredients of an effective mental health system. That consensus must be converted into action backed by sufficient financial support, preferably from both public and private sources.
Broward County and the rest of Florida are not facing this challenge alone. Last July, the President's New Freedom Commission on Mental Health, in a letter to President Bush announcing completion of its report, wrote:
"Today's [national] mental health care system is a patchwork relic -- the result of disjointed reforms and policies. . . . State-of-the-art treatments, based on decades of research, are not being transferred from research to community settings. In many communities, access to quality care is poor, resulting in wasted resources and lost opportunities for recovery. More individuals could recover from even the most serious mental illnesses if they had access in their communities to treatment and supports that are tailored to their needs. . . . The nation must replace unnecessary institutional care with efficient, effective community services that people can count on [emphasis added]. It needs to integrate programs that are fragmented across levels of government and among many agencies. . . . The commission recommends fundamentally transforming how mental health care is delivered in America."
Sadly, the transformation of which the commission speaks has been under way for decades, at least in theory. It just hasn't been very successful. It is failing because of insufficient funding, political commitment and follow-through. The good news, though, is that paradigms of more effective treatment systems do exist and, if properly funded, can bring fulfillment of the promise of the deinstitutionalization movement.
Providing care 24/7
One such paradigm is the Program of Assertive Community Treatment. PACT, developed at Mendota State Hospital in Madison, Wis., in the late 1960s, is a service-delivery model for providing comprehensive community-based treatment to people with severe and persistent mental illness (SPMI). It is championed by NAMI (National Alliance for the Mentally Ill), an advocacy group that also had its origins in Madison.
PACT consists of "a multidisciplinary mental health staff organized as an accountable, mobile mental health agency or group of treaters who function interchangeably to provide the treatment, rehabilitation and support services that persons with severe mental illnesses need to live successfully in the community. . . . The PACT team works collaboratively to deliver the majority of the treatment, rehabilitation, and support services required by each client to live in the community. The team provides these necessary services 24 hours a day, seven days a week and 365 days a year [emphasis added]."
In other words, full-service mental health care. This is what the presidential commission means when it refers to "services that people can count on." The PACT model offers the continuity of care that is absolutely essential to the treatment of mental illness and to the ability of the mentally ill to live functional lives in the community. Indeed, with the right kind of housing support and enough PACT slots, there'd be little need ever to hospitalize the mentally ill, some experts say.
There are assertive community treatment teams in Florida, based on the PACT model, but they are called FACT teams, for Florida Assertive Community Treatment. There is one FACT team in Broward County, affiliated with the Henderson Mental Health Center. There are also two less formally organized ACT teams.
There is no better way to serve the SPMI population than through the PACT/FACT paradigm. Each FACT team, usually consisting of between six and 12 members, is responsible for no more than 100 clients (and no more than 10 per team member), and provides each client with the consistency and continuity of care and support services they need.
This is the most intensive and effective form of treatment for the severely and persistently mentally ill, but each FACT team costs about $1 million to staff and operate. It helps that FACT teams help reduce recidivism and thus save money. But with an estimated 10,000 indigent mentally ill in Broward County, it's obvious there can never realistically be enough FACT teams to go around. Then again, experts say the PACT/FACT approach is not therapeutically effective for everyone anyway.
The key is to accurately identify those who can best be helped by it, and then to secure funding for as many FACT teams as possible. One potential obstacle is that federal approval and Medicaid funding are necessary, and they are no sure thing. Those holding the purse strings at the federal, state and local levels should bear in mind, though, that this community is spending a fortune -- about $65 million a year -- in the criminal justice system dealing with the consequences of untreated or poorly treated mental illness. Spending more money up front on things like FACT teams should be considered an investment, not a mere cost.