An inside look at Albuquerque's mental health emergency
Ruth was in the Navy. She was a damage control firefighter. When she began her service in 1995, she was 26. Things were good.
But two years later, in the summer of 1997, life began to change. It started when one of her friends, who she had kept in contact with through letters, decided to cut off communication. Soon after, Princess Diana died in a car crash, and although Ruth had never been much of a follower of the lady, she felt a connection with the departed. After all, Diana died in Paris while being followed by French photographers; Ruth owned a moped made in France.
The next blow came a couple months later, when Ruth was transferred off the ship that had become her home to a land-based fleet. She was saddened by the change, and for two to four weeks wandered around the western half of the U.S., looking for her new station. Making matters worse, she was anxious during this time, as she had discovered an underground conspiracy to harm those with the letter “J” in their name (the evidence was astounding—Janis Joplin, Jimi Hendrix, J.F.K., John Lennon, the list goes on).
But the climax to Ruth's transition came one night while she was at a friend's house. An 8-foot spider with a mouth like a crawfish appeared to her, informing her that the conspirators were after her as well, despite the fact that her name contained no “J.” To fool them, the spider ordered her to alter her naval uniform to appear civilian. And so she did.
Eventually, Ruth decided to tell a police officer about the conspiracy she had unearthed, who in turn took her to a hospital. Now, nearly 10 years later, Ruth doesn't see 8-foot spiders with mouths like crawfish. She realizes the Navy doesn't have land-based fleets. She knows the conspiracy to hurt those with the letter “J” in their name was a delusion. Ruth wasn't able to go back to the Navy, but she does have a part-time volunteer job, owns a house, has pets, goes to church, talks to a psychiatrist once every three months and speaks regularly with In Our Own Voice, a recovery education program with the National Alliance on Mental Illness (NAMI).
Ruth, whose name has been changed for the purposes of this story, has schizophrenia, and is one of an estimated 70,760 people in New Mexico with mental illness (including those diagnosed with depression), 18,000 of which are children. She also represents a portion of New Mexico's population that is underserved, underfunded and on the cusp of losing even more resources. Ruth is one of the lucky ones. Because without proper care, she might still envision 8-foot spiders.
Welcome to the Jungle
Like every proper story, this one begins with setting the stage.
Act I: The year is 2003. Albuquerque Police Department (APD) Sgt. Carol Oleksak is shot in the head with her own gun by Duc Minh Pham, a man with a record of mental illness, homelessness and more than 50 arrests. Sgt. Oleksak survives. Pham is killed by police while fleeing the scene.
Act II: It's 2005. John Hyde, a man treated for schizophrenia and bipolar disorder who is no longer taking his medication, shoots five people, two of which are APD police officers.
Act III: Early 2006. The 30-day Legislative Session includes “Kendra's Law” (HB 174), a regulation already on the books in 42 states which would allow the courts to order mandatory outpatient treatment for mentally ill patients whose behavior meets certain requirements. The session runs out of time before the bill, which has garnered large support, passes.
Act IV: Present. Due primarily to financial difficulties, a large amount of outpatient behavioral health services in Albuquerque prepare for closure. This includes all of the Lovelace Health System's behavioral health outpatient treatment, run out of the Journal Center, which cared for an estimated 7,000 patients, and the University of New Mexico's (UNM's) intensive outpatient treatment for the mentally ill, which cared for about 150 patients since the program's inception last year. Most displaced patients will be funneled into either Presbyterian Kaseman Hospital or the UNM Hospital, both of which are near or at capacity. Also set for closure are the behavioral health acute inpatient beds for children and adolescents at Memorial Hospital. There are also rumors that the Albuquerque Regional Medical Center, also run by Lovelace, will soon reduce or completely get rid of its inpatient psychiatric beds.
There. The stage is set. The final act has yet to be written.
Lovelace, UNM and Everything in Between
Last fall, Lovelace began to make preparations for the closure of their behavioral health outpatient services. According to Susan Wilson, spokesperson for Lovelace, the decision to close was ultimately made by the Lovelace Physician Group. The announcement to close was made early this year, with a 90-day transition to end outpatient services beginning on March 1. By May 30, Wilson says, the transition will be complete.
The change will affect the approximately 7,000 patients that Lovelace saw last year through the program, as well as the program's 24 physicians, social workers, councilors and nurses, and 26 staff employees.
But Wilson insists the transition will be a relatively smooth one, with a plan in place to make sure patients continue to get the treatment they need. “We've worked very closely with all of the different organizations that had individuals within our program,” she says, “and [will] continue to work with them as we go through this transition period to try and make sure that every patient is properly transitioned to a provider.”
Wilson says that in terms of staff, as many people as possible were transferred to other departments. She says the decision to close wasn't easy, and was made for a variety of reasons, but ultimately the closure made the most sense for the forward direction of the organization.
UNM's situation is slightly different. Its behavioral health intensive outpatient treatment program was started only a little more than a year ago, but shut down on March 24 for financial reasons.
Dr. Steven Jenkusky, president elect of the Psychiatric Medical Association of New Mexico, who works in the UNM Psychiatric Clinic, explains the situation. “Financial difficulties are a chronic problem with behavioral health,” he says. “We see a lot of people with no income, or who are indigent, and we don't turn anyone away. We rely on whatever funding the city or state gives, and for the remainders rely on Medicare and Medicaid. ... We saw many people without getting any reimbursement; and even for those who had insurance, in order to be reimbursed the patients had to attend 9 hours of programming a week, and it was difficult to get patients to show.”
Jenkusky says the rest of UNM's psychiatric programs are still running, such as the psychiatric emergency room, three inpatient units and outpatient clinics. “They're financially struggling, but still going.”
Yet even though the Lovelace and UNM closures are distinct from each other, they will both have similar effects on the community. UNM and Presbyterian Kaseman are the only hospitals left in the city with outpatient treatment, and will therefore end up receiving much of the patient load from the two closures.
“Right now we're at capacity,” says Jenkusky, who is concerned about the outcome of the closings. “The issues are making sure we have enough clinicians to see the patients sent to us and having contractual agreements with Lovelace to care for patients.” As it currently stands, UNM is able to see Medicare and Medicaid patients as well as those with Lovelace insurance who are UNM employees. But UNM currently doesn't have a contract with Lovelace to see those under its coverage who aren't UNM employees. If a contract isn't signed, UNM won't be reimbursed for those patients. Jenkusky says he believes negotiations for a contract are being discussed.
Cynthia McConnell, a nurse and director of Behavioral Health Services for Presbyterian Health Systems, also has concerns about the closures but says Presbyterian will do all it can to meet the needs of the community. “The University and Presbyterian will be arm in arm in helping patients who can't get outpatient services. [But] there's a limit to what we can absorb based on physical design. [If the patient load] goes beyond that, patients will have to be referred somewhere else. It will be a difficulty for both UNM and Presbyterian.”
McConnell says Presbyterian's outpatient clinic loads differ greatly depending on what time of year it is, as does their inpatient clinic. Currently, she says inpatient care is running at close to 90 percent of its budgeted beds, although it can go down as low as 50 percent during the holidays.
McConnell adds that Presbyterian, a nonprofit organization, is currently looking at expanding its services, but until the changes at Lovelace are complete, it won't be able to predict what or how many services will need to be added.
In addition to the Lovelace and UNM closures, Memorial Hospital is scheduled to lose its 20 acute inpatient beds for children. There have also been rumors among mental health professionals in the state that Lovelace will shut down its behavioral health inpatient services, which are run out of Albuquerque Regional Medical Center, at the end of May. Lovelace's Wilson says she hasn't heard those rumors and the number of inpatient beds at Albuquerque Regional has not changed.
“[After these closures], I think we're going to see more overloaded systems and caregivers,” says Jenkusky, when talking about the long-term effects of the outpatient closures. “Eventually there'll be a backup in ER rooms, people waiting in ERs for beds. And there will be a ripple effect—we won't be able to help out surrounding communities as much as we do.”
Jenkusky doesn't seem to be the only one worried about the future of mental health in the state. Many behavioral health experts are voicing concerns over the already existing lack of resources for mentally ill patients, which are only compounded by the recent and upcoming closures in the system.
“For consumers of mental health, the options are shrinking,” says McConnell. “The reimbursement to fund programs appears to be shrinking. This is probably true all over the country. The need right now has exceeded the capacity to provide services for mental health; the need is there, but the resources [aren't].
“I'm concerned about the needs of the mentally ill; services not always being there for them. What about the working poor? Maybe they don't have insurance—can they afford to get the health care they need? Are the resources sufficient to meet the needs of the community?”
According to Leslie Tremaine, behavioral manager for the Behavioral Health Collaborative out of the state's Human Services Department, the state is a long way from meeting all of the needs of the mentally ill. “Even if we put back everything Lovelace was doing, and UNM, it's still a strapped system,” she says.
Tremaine also speaks to the need of outpatient services in particular. “In substance abuse, if someone goes into inpatient or residential treatment, if they don't have ongoing support when they get out, they will slip back into problems.” she says. “The same is true for those with serious mental illness. It's not like we don't need inpatient treatment, but without ongoing followup, [their treatment program] isn't going to work. That's illustrated by these closures.”
Tremaine says that because of financial difficulties like those mentioned earlier, behavioral health organizations are closing down programs all over the country.
Locally, organizations beyond hospitals are also feeling the pressure of a condensed system. Dr. Paul Hopkins, executive director of Samaritan Counseling Center, says Samaritan is already starting to experience an enormous increase in volume from the outpatient closings—and it may be more than they can currently handle. “Historically, we had about 80 to 90 new [patients] a month; but now the numbers are way up,” he says. “In the course of one week, we had 100 phone calls from people looking for services. We're not equipped to handle all these people.”
Samaritan is a general outpatient service for children, adults, couples and families both with and without health insurance. It receives all of its funding through fees, donations and United Way. Presently, Samaritan employs 15 therapists, with another one set to start in June and yet another that will hopefully come on in the next few weeks, says Hopkins, adding that the nonprofit organization will probably have to open another branch office to make room for the needed services.
“We're trying to do our part in responding to this enormous, explosive need,” Hopkins says. “We're looking for funding, ways to provide services without suffocating and drowning ourselves.”
Yet even while Hopkins is dealing with the pressures on his own organization, he looks to the bigger picture. “The real story here is the rapid deterioration of behavioral health services in Albuquerque,” he says, “with Lovelace, UNM and Memorial Hospital's plans to temporarily close acute care for children and adolescents. Within the last year and a half, La Familia, the All Faiths Shelter have closed; it's another example of dwindling resources. Now First Nations is under threat of closure.
“I think the closings have a huge effect. When people cannot get needed mental health care, it spins off in other ways.”
Jane Lancaster, president of the National Alliance on Mental Illness (NAMI) in Albuquerque, also understands the effects of mental health care. “The closures—they're terrible,” she says. “It's going to be a crisis. People have to realize it's going to take some money [to fix]. Everyone in the community benefits by having these needs met. This is everyone's problem.”
Despite problems the state and city have in the mental health care industry, there is cause for hope. Within recent years, both Gov. Bill Richardson and Mayor Martin Chavez have taken significant steps to improve local resources. But there's still a long ways to go.
According to a NAMI study released about a month ago, New Mexico currently ranks 51st in the nation for per capita mental health spending (out of all 50 states and the District of Columbia), fifth for suicide rates and 47th for total mental health spending, devoting $54 million to mental health care every year. New Mexico is also ranked 47th in the nation for per capita income; a clue as to why our scores may be so low.
Yet in the same study New Mexico's given an overall grade of C-, with our infrastructure for mental illness receiving a B-, a sign that Lancaster says may be good news. “My bottom line is this: Yes, this is a terrible situation statewide,” she says, “we're unbelievably low on services; but we've had some really fine civic response in the last five years to this crisis. So many states look at us with envy because we're putting real programs in place. We've got some things right, but we desperately need funding for services.”
One of those programs Lancaster is speaking of is the Behavioral Health Collaborative, which was established in 2004 after passing the 2003 State Legislature. The program works by streamlining behavioral health services that were previously offered by nine different agencies into one agency. The hope is to eventually make services more easily available to patients and to make better use of taxpayer dollars, but the initiative is still very new. On April 1 of last year, Value Options was chosen by the state to oversee all mental health and substance abuse programs in the state, which are offered by 15 different state agencies.
“The initial goals are to create a single, integrative delivery system,” says the Collaborative's Tremaine. “But I think it's important that people understand that it doesn't make problems go away overnight.”
Tremaine says the Collaborative is working with organizations in Albuquerque to make sure the Lovelace and UNM transitions go as smoothly as possible. She also says the Collaborative is currently working with UNM along with Value Options to help develop a new UNM intensive outpatient program that might be more successful than the last.
The state has also been working on other initiatives in behavioral health. Of those, Kendra's Law is the one that is garnering the most press and the most controversy.
The law was originally passed in New York in 1999 and is named after Kendra Webdale, a young woman who was pushed in front of a subway train by a man who failed to take the medication prescribed for his mental illness. The law states, in short, that the courts can order assisted outpatient treatment (AOT) for mentally ill people who do not volunteer for treatment and who, based on their treatment history and present circumstances, are unlikely to survive safely in the community on their own. Today, 42 states have similar legislation.
In this last 30-day Legislative Session, New Mexico introduced a Kendra's Law bill, sponsored by Rep. Joni Marie Gutierrez. The bill made significant progress through the Legislature, but the session ended before it had time to make it all the way through. It is expected that Kendra's Law will be introduced in next year's 60-day session.
The proposed legislation has provoked passionate responses from the community, both in support and opposition. Some believe the bill could greatly improve the quality of life for many of the mentally ill in the state, as well as possibly save lives. Others fear that civil liberties are at stake if the bill passes, because those who are mentally competent could still be ordered through the bill to undergo treatment. Yet, for the purposes of this article, the main issue with Kendra's Law isn't whether or not it violates civil liberties or whether it should be passed, although these are valid concerns. Rather, our main focus is the possible influence the bill may have on the outpatient closures, and vice versa.
At a March 22 panel on Kendra's Law at the UNM Law School, such matters were discussed. Nancy Koenigsberg, legal director with Protection & Advocacy System, spoke to the panel on the lack of services available to the mentally ill. “By trying to enact a law like [Kendra's Law], it's like saying, ’You're in trouble if you don't go to school, but we're closing the schools.'”
Koenigsberg argued that with a huge void in the mental health service system, laws like Kendra's won't make much of a difference; she said that instead resources need to be put into place to support already existing systems among new programs. “We as a society have failed people who need treatment. We blame people with mental illness, when we have really failed them.”
Other behavioral health professionals seem to agree. “If Kendra's Law is passed, who will provide services, who will pay for them?” says McConnell. “It's easier to pass that law than it is to answer the question of who will provide services.”
Samaritan's Hopkins agrees, adding that he's worried about the situation patients will encounter upon the passage of such legislation if adequate services aren't in place. “Kendra's Law is a very complicated issue,” he says. “Will there be sufficient services to serve people since at the present time people are finding doors closed, long waiting lines and difficulties finding providers?”
Jenkusky, who was also a speaker at the panel, also thinks Kendra's Law will be futile without more funding. “My worry is that Kendra's Law might give families false hope about getting their kids into treatment,” he says. “We can have Kendra's Law, we can have our current laws, but it won't do any good if there aren't more resources—more case management, more wraparound services. I think it's probably up to the ACLU-types over whether [the law's] a violation of civil rights, but I don't see Kendra's Law helping without more resources.”
Still, some are optimistic about the effect Kendra's Law could have on the mental health system, even in the current situation. One of the optimists is Mayor Martin Chavez. Barry Bitzer, the mayor's chief of staff, says Kendra's Law could actually reduce the demand on services, since it could lower the number of mentally ill patients who are hospitalized. Bitzer also explains that the number of people in the state who would even qualify under the law would be relatively low. He estimates that around 70 people a year might be eligible.
The mayor is so supportive of Kendra's Law, he's decided to bring it to the City Council. “The mayor doesn't want to wait another year for it to happen at the state level,” says Bitzer. The bill will be sponsored by Councilor Michael Cadigan and was introduced this last Monday, April 17. The bill will then go to a Council committee before being voted on within the next 45 days. Monday's Council meeting had not yet taken place when this article went to print.
Kendra's Law isn't the mayor's first attempt at increasing services for the mentally ill. Following the shooting of Sgt. Oleksak in 2003, the mayor held a Behavioral Health and the Homeless Summit, which worked to draw out a plan to address mental illness in the city. Many initiatives came out of the event, such as funding for a Crisis Residential Facility, Extended Stay Detox and a Housing First voucher program which allowed some patients receiving treatment services to get money for a home.
A police specialty force called the Crisis Intervention Team (CIT), who are trained to recognize mental illness and interact appropriately to diffuse bad situations, was also formed, as was an Assertive Community Treatment (ACT) team, which collaborates with patients and a team of professionals to custom-serve patient needs. ACT teams have been wildly successful in other states, and have worked to lower the number of mental health hospitalizations and crimes. The mayor is proposing to start a second ACT team in the city this year. Bitzer also says the mayor is concerned about the outpatient closures, and has met with Lovelace and Value Options to see how he can help.
Yet, in the end, it seems most mental health professionals echo one sentiment: Programs are great; but until the system receives more funding, Act V of this drama hangs in limbo.
To contact the author, e-mail firstname.lastname@example.org.