State experiments with new approach to mental health care

In 1955 the world was introduced to a wonder drug. It was touted as a miracle that would change peoples’ lives forever. This drug was called Thorazine and it is considered the first effective antipsychotic medication. It allowed psychotic behaviors to be somewhat managed by swallowing a pill.

With the introduction of Thorazine as the main impetus, psychiatric hospitals began closing around the United States. The assumption was there wasn’t a need for inpatient mental health hospitalization if people can live in the community with reduced symptoms.

After the deinstitutionalization of people with mental illnesses and the closing of most mental health hospitals (often referred to as “asylums” years ago), the prevailing thought was that people would simply find care by other means.

Possibly the severity of the conditions were exaggerated and thus the person could fend for themselves in their home.

Or, possibly a person’s primary care or family doctor could take care of their mental health needs. Or, possibly there would be alternatives created that were not hospitals that could meet the needs of the people with a mental illness.

As it turned out, none of those scenarios were consistently true. The truth is that people were, quite literally, dumped on the street with the hope things would work out for them. Without a comprehensive system to accommodate the needs of the folks with mental illness, the cracks in the system rivaled the Grand Canyon.
Where could a person with a severe mental illness go if they are kicked out of a hospital? They had few options. They could live with family if their family wanted them and could take care of their mental health needs.

They could be incarcerated as they may behave in such a manner in public that would, at the time, justify being arrested and put in jail or prison. Or, they could learn to survive on the street and become part of the faceless and nameless homeless population.

There have been piecemeal attempts at creating mental health systems, but without a true national effort (and funding to support it), it will not happen. There are small corners of the United States that have attempted innovative approaches, but they all continue to lack a central focus and a clear vision.

The difficulty of creating a unifying vision is that, unlike medical intervention for physical ailments, mental health is more complex. Consider you broke your arm.

You are outside trimming your tree and you accidentally fall on your arm. You are in excruciating pain, go to the doctor and they deem it broken.

They fix it with a cast and eventually everything is back to normal. Mental illness doesn’t work that way. It is invisible and there is not a simple or clear remedy. Often times it takes months or years to find the “fix” for mental illness. Sometimes it never happens.

Imagine it taking a doctor months to fix your broken arm.

Current thought is there needs to be a comprehensive continuum of services to more adequately meet the varied needs of people with mental illnesses. Minnesota is considered a national leader in providing mental health services across a continuum of needs as we have some psychiatric beds (high intensity and high cost), some community based residential options (medium intensity and medium costs) and some community based non-residential options (low intensity and low costs).
However, there isn’t currently enough of any of the levels of intensity.

Minnesota is one of eight states experimenting with a different approach to mental health care. From the Minnesota Department of Human Services (DHS) website:

“Certified Community Behavioral Health Clinic (CCBHC) is a service delivery model being piloted for further integration of substance use disorder and mental health services, using a cost based reimbursement structure. This new service delivery model aims to coordinate care across settings and providers to ensure seamless transitions for individuals across the full spectrum of health and social services, increase consistent use of evidence-based practices, and improve access to high-quality care.”

CCBHCs were established as a result of the passing of the Protecting Access to Medicare ACT (PAMA) which allowed for the creation of the Excellence in Mental Health Act.

The hopes are high that CCBHCs will help reduce the isolationist structure we currently have where collaborating across systems is an exception rather than the norm.

The Minnesota DHS website states some of the services provided at or in conjunction with CCBHCs include but are not limited to outpatient mental health and substance use services, primary care screening and monitoring, crisis mental health, peer support and veteran’s services.

CCBHCs may not be the comprehensive nationwide solution we should be searching for, but it may introduce us to thinking about the delivery of mental health services in a different and more collaborative way.

If the assumption is correct that we need a more comprehensive system to deliver mental health services, Minnesota may be onto something.

Gary Norman is the Manager of Behavioral Health for Carver County and Director of First Street Center. He is also President-elect of the Minnesota Association of Community Mental Health Programs Board of Directors.