Editor’s note: Reporters from the Topeka Capital-Journal and KHI News Service collaborated for a six-month exploration of how the state’s legal system deals with people with mental illness. This is the first in a four-part series.
A four-part series
America has a long history of criminalizing mental illness.
Well into the 20th century, courts, not clinicians, committed people with mental disorders to state hospitals, where too often they were warehoused and received little if any meaningful treatment.
A report written in 1948 for the Kansas Board of Health titled “A Study of Neglect” concluded that “a seriously mentally ill person (in Kansas) is almost a criminal before the law.”
The report — written by Harry Levinson, a psychologist of national stature who began his career at the Menninger Clinic, and two colleagues — also noted that more than one-third of the approximately 46,000 Kansans who had entered state mental health hospitals between 1866 and 1946 had died in them.
The Levinson report and another issued about the same time by a special commission formed by former Kansas Gov. Frank Carlson that included Dr. Karl Menninger prompted the first of several sweeping reforms of the state hospitals and the mental health system in Kansas.
Today, the system is inarguably better as a result. But as this series of stories, “Mental Health on Lockdown,” to be published over the next several days illustrates, many Kansans with mental illness continue to find themselves ensnared in a criminal justice system that is largely ill-equipped to provide them with the treatment that they need.
Financial and human cost
The criminalization of mental illness is a both a national and state issue.
In Governing magazine, Jane Wiseman, director of a nonprofit government and management consulting firm, recently asserted that “America’s jails are the central address for the mentally ill.”
She and co-author Stephen Goldsmith, a former Indiana district attorney and deputy mayor of New York who now teaches at the Harvard Kennedy School of Government, provided evidence to back up their assertion.
“There are 10 times more people with mental illness in the criminal justice system than are being treated in psychiatric hospitals,” Wiseman and Goldsmith wrote. “As a society, we pay an extremely high financial and human cost for criminalizing behavior better addressed by diversion into mental health treatment. Incarceration costs for those with mental illness run from 60 percent to 20 times higher than those for other inmates.”
Kansas taxpayers are helping to foot that bill. Medical and mental health care spending made up $53 million of the $194 million Kansas Department of Corrections fiscal year 2015 budget.
An estimated 37 percent of inmates in the state prison system have a mental disorder, up more than 120 percent since 2006, according to Viola Riggin, director of health care services for KDOC.
The number of inmates diagnosed with severe and persistent mental illness also is going up, Riggin said, noting that the treatment they receive has improved greatly since inmates brought a series of lawsuits against the state in the 1970s seeking better mental health care.
“There was a tendency to simply lock them down,” said Bill Rich, a professor at the Washburn University School of Law who represented inmates in some of those lawsuits.
Today, county jails in Kansas also have become de facto mental health treatment centers. About 20 percent of the inmates serving time on any given day in the Johnson County jail have some kind of mental illness, according to Sheriff Frank Denning.
“I have been running the largest mental health hospital in the state of Kansas,” he said in an interview about mental health courts for this series.
Sheriffs in several smaller counties say they don’t have the resources to emulate Denning. They’re struggling to handle the increasing numbers of people with mental illness in their jails.
In addition to county jails, many hospital emergency rooms have become repositories for Kansans with severe mental illness waiting for an open bed at Osawatomie State Hospital, which was forced to restrict admissions in 2014 due to staff problems and to reduce its capacity in 2015 to make renovations ordered by federal inspectors.
At the same time, millions of dollars in state budget cuts over successive years have hindered the ability of community mental health centers to respond to the growing crisis.
History of neglect
Complaints of underfunded and overcrowded facilities date back to the establishment of the first state asylums in Kansas. The 1948 report for the state board of health briefly recounted the history, noting that Kansas policymakers “grudgingly” appropriated $500 in 1866 to build the state’s first asylum in Osawatomie. But from the day it opened, the six-room facility lacked the space to care for the growing number of “broken” Kansans in need of help, according to the report.
“Slowly the state stirred to meet its responsibilities — always slowly, always too late,” the report said of the construction a second asylum in Topeka in 1879 and a third in Larned in 1913.
Eventually, the report said, “the state belatedly agreed its institutions should not be asylums, but hospitals, and that a determined effort should be made to cure the mounting number of patients.”
But that commitment was short-lived, according to the report, which described the failure of state leaders to sustain it in colorful and unequivocal language.
“There was ever a reluctance on the part of consecutive, uniformly dispassionate legislatures to grant funds to meet even the most urgent needs,” it said. “At times the hospitals were allowed to become political footballs, staffed by incompetents, mired in the filth of political corruption and rocked by scandals. There was no money to pay decent help, to build adequate buildings. There was only money enough to give them meager sustenance so that they could continue to be burdens to the state, useless to themselves, and a continuing sorrow for their troubled families.”
Then, as now, many in need of mental health treatment “languished in jails” while awaiting admission to overburdened state hospitals, according to the report.
Stung by the reports and critical newspaper accounts that included graphic descriptions of unsanitary conditions at state hospitals and patients strapped nude to their beds, Kansas lawmakers in 1949 heeded Carlson’s call to nearly double what the state was spending on its state hospitals for people with mental illness.
“The condition of our state hospitals with respect to equipment, medical care, humane custody, sanitation and personnel requires immediate positive action,” Carlson said as justification for his $15 million request, which would be about $150 million today when accounting for inflation.
“The original scope of our mental hospitals was limited almost entirely to the custodial care and confinement of the insane,” he said in his annual budget message to lawmakers. “But recent advances in the field of psychiatry and modern methods of treatment for the mentally ill give new hope to those afflicted. Their return to useful active life in the state and community is desirable from every standpoint.”
Carlson’s reform initiative resulted in rapid improvements thanks largely to a partnership between the state and the Menninger Clinic, then in Topeka, which expanded its psychiatric training program and assigned students to work rotations in the state hospitals to gain clinical experience.
Dr. Roy Menninger, a former president and chief executive of the Menninger Foundation, said the initiative helped create a “model for psychiatric training that was gradually assimilated by medical schools all over the country.”
“The condition of our state hospitals with respect to equipment, medical care, humane custody, sanitation and personnel requires immediate positive action.”- former Kansas Gov. Frank Carlson, in 1949 during his annual budget message to the Legislature
By the early 1950s, Kansas had gone from last in per capita spending on treatment for mental illness to near the top of state rankings. Throughout 1960s and 1970s, with the reputation of the Menninger Clinic growing, Kansas was seen as a national leader in mental health.
But starting with the lawsuits filed in the 1970s over the quality of mental health care in state prisons and continuing through the 1980s, much of that progress was lost. A sweeping reform bill that the Kansas Legislature passed in 1990 aimed to reverse that slide by emphasizing treatment in a growing network of community mental health centers over that provided in state hospitals.
However, that commitment also wasn’t sustained.
David Johnson was named chief executive of the Bert Nash Community Mental Health Center in Lawrence in 2001. By that time, he said, “it had already been years since the state grants had been increased.”
With the reform bill, lawmakers intended to use the money saved from closing state hospitals to instead boost community mental health centers. But that funding increase wasn’t sustained.
The reforms of the early 1990s accelerated the trend toward deinstitutionalization. Since then, the closure of Topeka State Hospital and the shuttering of psychiatric units at several private hospitals have eliminated approximately 5,000 mental health beds.
People in the mental health field acknowledged that many of those acute-care beds were no longer needed. But Roy Menninger and others said some of that lost capacity was needed to backstop community treatment centers that weren’t prepared to care for patients with severe mental illness displaced by the changes.
“The system wasn’t ready for that, especially the seriously ill patients. So they were not adequately treated from the very beginning,” Menninger said.
A series of funding cuts in recent years exacerbated by another $30 million reduction this year have further hindered the ability of community mental health centers to provide adequate care to severely ill patients.
“Over the last several years it’s seemed to me that we have had a slow dismantling of the mental health system across Kansas,” said Tim DeWeese, executive director of the Johnson County Mental Health Center.
It also seems that way to Lenexa Police Capt. Wade Borchers. His officers are encountering more people with mental illness engaging in antisocial if not criminal behavior.
“The ones that get left holding the bag, really, are law enforcement,” Borchers said. “And we are not getting people (with mental illness) the help like we did 10 to 15 years ago. That’s just a bottom-line fact.”
Police and sheriff’s departments in higher-populated, urban Kansas counties are attempting to proactively deal with the issue by putting their officers through an intensive training program where they learn how to defuse encounters rather than allow them to escalate into situations that result in arrests and jail time. But many smaller departments can’t take advantage of training because they don’t have enough staff to cover for officers who must take up to a week off to participate.
Awareness of the problem is growing among state and local officials. Tim Keck, interim secretary of the Kansas Department for Aging and Disability Services, is working to regain federal certification for Osawatomie State Hospital and restore approximately $1 million in monthly Medicare payments.
Also, in a year in which many state budgets were cut, Kansas lawmakers approved salary increases for state hospital workers in an attempt to help KDADS solve chronic staffing problems at the institutions.
Still, advocates and mental health providers caution that a piecemeal approach won’t solve the problems, which are longstanding and systemic. They say nothing short of a comprehensive and adequately funded set of reforms, such as those spelled out in a 2015 report from a special committee to the KDADS secretary, will do the job.
"We need to address these issues because what's happening right now is that tremendous pressure is being put on our community hospitals and our county jails to hold people who have mental health issues," said Sen. Laura Kelly, a Topeka Democrat. "They don't have criminal issues. They need access to services."