As our government continues to decrease funding to states, so to our states decrease their funding for key programs. When this happens mental health tends to be one of the first program areas where funding is cut. Education is also heavily impacted. As a result of these cuts, critical resources often disappear seemingly overnight and without warning.

My state, Texas, tends to be one of the worst at dedicating funds to mental health care. Despite this, we have done the best we can to meet the growing need in our communities; often with private funding and innovative community programs. However, only so much can happen with less and less available money. Our state hospitals are decreasing civil bed capacity dedicated to individuals committed on a civil commitment and are instead dedicating what few beds remain to forensic populations (competency restoration and not guilty by reason of insanity). The state, after doing this, funded “contract beds” in the community in private hospitals to address the need and the decrease in access to the state hospital system; specifically, to incentivize private hospitals to provide care to un-insured (indigent) individuals (of which Texas has many-at least 19% in 2016 and growing). But, I lovingly refer to the math involved in this transaction as “magic math” because the number of state beds lost does not, in any way, equal the number of beds funded in the community. Additionally, all this program did was act as an insurer for indigent individuals in private hospitals; it did not actually add any bed capacity within the community. As such, my county, which is supposedly host to about 660 psychiatric inpatient beds divided between adult, children, adolescents, and geriatric patient populations, did not gain any physical capacity, only 30 beds inpatient and 15 beds of crisis stabilization specifically ear-marked to fund the care of indigent residents of the county (or homeless individuals in the county).

This program is a double-edged sword. On the one-hand, it is great that our community has a way to incentivize private hospitals to care for indigent individuals (sad that you have to incentivize that but that is a topic for another blog post). On the other hand, a community of almost 2 million residents in 2018 and a 1.4% growth rate[1]  should have access to more than the few beds we have. According to the Meadows Mental Health Policy Institute’s assessment of this county in 2016[2], about 500,000 of these individuals live with some level of mental illness, about 60,000 adults and 37,500 minors live with serious and persistent mental illness (SPMI), and about 56,000 live below 200% of the federal poverty level. While my county can boast that it is the 4^th largest in Texas, it also is 4^th in the number of individuals within the county living with SPMI. According to our local trauma and emergency response center (STRAC), about 1,600 emergency detentions (detention by a peace officer of individuals experiencing a psychiatric crisis) are completed PER MONTH.

With that in perspective, hopefully you can see how under-prepared this community is to address the needs of our current individuals living with mental illness.

Now…enter the crisis. It is always a challenge and a struggle when communities lose important resources; though it is usually the most vulnerable populations that bear the brunt of that weight. In my county, the size of this crisis is significant and there is no timely solution available. Like most communities, we hid our head in political holes of hopefulness, refusing to believe the inevitability of this resource depletion and plan ahead to mitigate the impact of it. But, as of last month, one of the largest providers of inpatient psychiatric beds (and one of the sites for those state-funded “contract” beds) announced it was closing its doors. This is a loss of about 161 beds, some of them specializing in geriatric and child/adolescent care, from the community. Holy cow!

Let’s just say the community is freaking out (and that is a bit of an understatement). With fewer resources to address critical needs in communities, you tend to see that the justice system picks up the slack (see: the high rates of individuals with SPMI being arrested and detained for minor, nuisance crimes) and the criminal justice system is not the best place for mental health care to be provided. In Texas, the Harris County jail (Houston) is the largest mental health provider in the state.[3] Texas also has the highest rate of in-custody deaths by suicide, with 11% of all deaths in jails and prisons being by suicide[4], though this does not even begin to address the deaths that are linked to drug and alcohol withdrawal or intoxication and unaddressed medical issues.

So, what do we do when a community loses key resources and finds itself on the edge of the abyss?

1. Form Coalitions

   It is imperative that in times of crisis, the community bands together to problem-solve. You may find that together, you can stretch what resources you do have farther than if you attempted to address the situation independently. Coalition-building allows for more voices, more ideas, and more creativity when all partners come together with open minds and the sole goal being to help the community.

2. Strategic Funding

   When communities form these coalitions, they can create a loud enough voice (and compelling enough data) that funding sources for new projects or bolstering current ones, may be found. In some communities, these sources are not external to the community; they are instead the partners within the coalition contributing to the cause together. In other communities, they may appeal to larger grant organizations and seek grants and then match those funds as a community. Either way, the coalition must be strategic about their funding sources as money speaks politically and money also drives expectations and outcomes. For example: if a community receives a grant from a specific source with specific interests, the community may be responsible for reporting specific outcomes back to the grantor in order to maintain funding; whether or not this reporting or data collection actually falls within the patient population that you wish to serve. Sometimes that special interest may have to be accommodated in order for the greater good to happen.

3. Creating Political Will

   I am sure you have heard the concept that all politics is local. In cases such as these; this cannot be more true. Because of the power of the combined voices in the pre-established coalition and the voice of their data (more important sometimes) there is the potential to seek political movement from local stakeholders such as judges, representatives, mayors, etc. They key is to show these individuals how the current status will impact them or their constitutes and then how the proposed solution would also do these things (hopefully in a more positive fashion). Often, mental health services are touchy subjects and are hard to get political will and buy in for. But when a community is in crisis, politicians tend to listen especially when their funding sources speak up.

   There may also be room for the coalition to get special representation from state representatives to lobby on their behalf for strategic change. This is more geared towards policy change than funding, however often policies drive the necessity for or access to funding; especially in mental health.

4. Data, Data, Data

I cannot stress enough the necessity for clear and well analyzed data. The more data you can present showing the specific impact a loss of resources has had on the community the better you are able to speak to funders and politicians. If you can tie that data to tax payer dollars you are more likely to succeed in garnering the attention of the “right people.” This may take completing a community needs assessment. If no one in the area is capable of doing this, sometimes bringing in an outside third party can be helpful as these organizations have no stake in the community and can give a non-biased assessment of the strengths and weaknesses of a system; allowing for community partners to see where the most attention needs to be focused.

In my community we have already had the benefit of a needs assessment completed in 2016 by the Meadows Mental Health Policy Institute. Sadly, the community landscape has changed quite a bit since then, but thankfully (and not-so-thankfully) the gaps in care largely remain the same. They are simply deepening.

While previously this community was filled by a lot of separate entities more or less acting independently; this recent crisis has created some strange bedfellows that will hopefully lead to a strong coalition that can work together and create the political will and drive strategic change. We are in the beginning stages of this crisis and focusing on management of the current situation. In the coming months hopefully we will have enough bandwidth to step back and create a more long-term plan for sustainable change. You too can do what we and many other communities like us are doing and have done. It is about advocacy and squeaky wheels. As care providers, you are on the front lines of this change and sometimes may have to be the squeaky wheel that advocates for the rights and needs of the vulnerable individuals that we serve.