This is the third installment in “The Downward Spiral,” a series about Omaha’s mental health and criminal justice systems: how they work, when they fail and what we can do to make them better. Read parts one, two, and four.
To those who know Nebraska’s mental health system, Tim Heller’s story is all too familiar.
His son grew up in a good family, went to private Catholic school here in Omaha and attended the University of Nebraska at Omaha.
Then things fell apart.
Heller said a cocktail of illegal drugs triggered what a doctor would later diagnose as a combination of bipolar and schizoaffective disorders.
Over the last six years his son’s life has been a revolving door of hospitals, police cruisers, treatment centers and jails. And Heller’s learned, like so many other families, that his experience is not the exception.
“It isn’t a crack,” Heller said of the gap between where Nebraska’s mental health system is and where it needs to be. “It’s a chasm.”
The relationship between crime and mental health is fraught in Douglas County — from people with serious mental illness crowding the Douglas County jail, staying for longer and being more likely to come back, to mental health providers continually operating with too few resources.
There are reasons to be optimistic. Local partnerships are leading to more collaborative solutions, new investments are changing how police as well as hospitals can help those with mental illnesses and the county has $55 million in pandemic relief funds it could invest in a new mental health facility.
But is it enough? For families like Heller’s, the answer is “No.”
“The system needs to be rebuilt… it needs to be scrapped and reconstructed,” Heller said.
A Crash Course
Heller doesn’t say that flippantly.
These last few years have been a crash course in all the ways a system can fail. Despite having good insurance for the hospital bills (some of which totaled more than $100,000 before insurance), lawyers to explain complicated mental health law and a family that wouldn’t quit, Heller’s son is still struggling.
He’s been to every hospital in Omaha, Heller said, and continually been released before he was stable. The Board of Mental Health, which is supposed to connect people in need with providers to create treatment plans, never followed through, Heller said. His son has been in several programs to stabilize people in crisis and never completed one, Heller said — often being kicked out for not meeting progress goals.
Frustrating doesn’t begin to explain how someone like Heller feels. He keeps an excel spreadsheet to log each of his son’s hospital stays. An email from him about what’s wrong with Nebraska’s mental health system will contain 20 different PDF’s — and if you meet in person he’ll print extras just in case. He’s the kind of guy who doesn’t just call his political representatives, but drafts ideas for legislation and badgers them to take it on.
He’s organized, pragmatic and a problem solver.
Those qualities eventually led to an appointment to the State Advisory Committee on Mental Health Services and was elected chairperson in November of 2022. He hoped having an audience with the state’s Division of Behavioral Health would mean progress, but he still feels stuck.
“I thought we’d be providing information and helping them to improve the state of behavioral health in Nebraska,” he said. “Instead, it’s them providing us handouts and statistics about what’s going on.”
The main problem he’d like to see solved is the lack of communication in Nebraska’s continuum of care. In an ideal world, providers communicate so that when someone leaves one care facility for another the patient doesn’t fall through the cracks.
Some encouraging developments in that process include the Stepping Up program. The initiative aims to increase communication about mental health between government, nonprofits and other organizations. It’s spearheaded by Region Six Behavioral Health Care, which oversees mental health care in Cass, Dodge, Douglas, Sarpy and Washington counties.
In 2019, Region 6 the Douglas County Mental Health Center and the jail piloted the Familiar Faces program which identifies people dealing with mental health issues who’ve been incarcerated multiple times. Those people are connected with more, longer lasting case management to build a stronger re-entry plan.
The pilot, which started in July 2019 and lasted 18 months, included eight people and led to half as many incarcerations.
How much it saved is hard to quantify: while it led to $120,000 in savings from jail expenses, Region Six did not track how much was spent on case management. There’s also future cost savings if the person is less likely to return to jail.
Prior to the pilot, the jail and Region Six identified 15 people with multiple incarcerations and estimated they collectively cost $1 million to treat and house. Douglas County Department of Corrections Director Mike Myers estimated the jail spends about $6 million annually on medication alone.
But even if nothing was saved, it’s hard to argue the money isn’t being spent better.
“Even if it was an equal amount, the costs are for the care and treatment of the [person] in the community, not for room and board in a jail,” said Kim Kalina, director of quality improvement for Region Six.
Another development has been the creation of the Psychiatric Emergency Services (PES) unit at Nebraska Medicine. The facility is separate from the general emergency room and allows people to access mental health care more directly, which has been a problem in the past.
“[The emergency rooms] were becoming overcrowded because people weren’t getting the mental health care they need,” said Jennifer Sparrock, manager of PES. “And so this [bottleneck] becomes a problem where the person doesn’t get access to the care that they need and they’re essentially boarding in an emergency room.”
PES opened in October 2020 in Clarkson Tower and so far the results have been encouraging.
The facility saw 941 people from July 1 to Dec. 31, 2022, according to data shared by Sparrock. The majority of people stayed under 24 hours and readmission rates hovered below 20%. The majority of people are still being sent home directly from the hospital, however, PES’s data shows they have lower readmission rates compared to those transferred to other facilities.
PES has a team of nine psychiatrists who rotate to keep the facility staffed 24/7. They also nurses, mental health practitioners and peer support eight hours a day, seven days a week. They’re encouraging numbers for Sparrock, but she knows they could do more.
“There isn’t enough, right?” Sparrock said. “I think we have really good things, but it’s having enough of them, and having them be accessible [that’s the problem.”
‘If You Build It, They Will Come’
Lindsay Kroll understands what it feels like to have more need than you could ever meet.
For about three years, the Omaha Police Department has had a mental health co-responder program which sends health professionals alongside police to certain mental health calls. Currently the department has six, one for each precinct and an additional co-responder for juveniles.
“It’s a big undertaking, right? It’s kind of like, ‘If you build it, they will come,’” Kroll said. “When we started we had one and a half positions. And then I was like, ‘Oh, my goodness, we need more.’ So we currently have six co responders. I could easily have 12 and it still wouldn’t be enough.”
As of mid-December 2022, Omaha police had 4,638 mental health related interactions. About half of those received either face-to-face or over the phone contact from co-responders.
But growing the program might be tricky in the near future. The mayor and chief of police have both pushed for more uniformed officers and the mental health program only recently made the transition to being a part of the department’s annual budget. Prior to the 2023 budget, the program’s half-a-million-dollar budget (about 0.3% of the total police budget) was originally paid by private money and grants.
In lieu of a co-responder, 44% of Omaha police officers have also received nationally recognized training to aid people in crisis.
But it’s still not enough, said Colene Hinchey, a retired OPD captain who spent 17 years as the department’s mental health liaison.
“A lot of [people suffering from mental illness who commit crimes] are non violent — shoplifting or jumping out in traffic — but what ends up happening is they can’t post bond or their pretrial hearings are delayed because they get in a fight in jail,” she said. “I mean, it’s a vicious cycle, but it all stemmed from mental health. And it’s not going to fix itself overnight, but we got to break that cycle.”
One potential solution that could advance the work OPD’s started can be found in Denver.
In 2020, the city launched the Support Team Assisted Response (STAR) program. The group, made up of emergency medical and behavioral health workers, is dispatched by 9-1-1 when someone is experiencing a mental crisis. Preliminary studies from Stanford University showed that during a six-month pilot, crime in STAR-patrolled neighborhoods dropped by 34%. The average cost of a STAR response came out to $151 while an average police response was $646.
“I would…argue that it’s simply about doing the right thing,” wrote Stanford researcher Thomas Dee. “People in mental-health crises need appropriate health care and they are simply less likely to get that when we direct them to the criminal justice system.”
Since then the program has become permanent, according to program specialist Evan Thompkins. The team only responds to calls that are deemed safe for non-law enforcement where violence or serious criminal activity isn’t a factor. A mid-year report from 2022 showed the team had responded to more than 2,800 incidents and never had to call law enforcement for back up. The numbers also show they have work to do — emergency dispatchers identified about 3,000 more calls the team could have responded to. Thompkins hopes in the next few years the team can expand because it’s clear the service is needed.
“It’s kind of been a slam dunk,” Thompkins said. “There’s a lot of buy-in from the city, and from the community with the work that we’re doing…Starting out our budget was significantly less, because we had less people and less vans. As we’ve expanded, we’ve had to buy more vans and get more staff members. So our budget has increased. But that hasn’t been a struggle.”
More options are also being added statewide. In 2016 Nebraska cleared the way for a mental health court alternative that allows people to receive treatment and wipe their records clean. Sarpy County established the state’s first pilot program with funds from the Nebraska Supreme Court in late 2021.
The state’s prison, where about 30% of the population has a serious mental illness, is another situation. In 2020, Nebraska’s commission to the federal government on civil rights found the state’s prisons had “no defined system of care” for those with mental health issues. The findings were based on testimony from people who’d been incarcerated as well as representatives from organizations like the American Civil Liberties Union.
“Essentially what we’re doing is warehousing [people],” said Jonathon Benjamin-Alvarado, then the commission’s chair. “They get out worse than they came in and, in many cases, any kind of existing mental health issues are just exacerbated by the lack of care and the conditions that they’re subjected to when they’re incarcerated.”
Doug Koebernick, Nebraska’s Inspector General of Corrections, put it more lightly saying the prison’s system was inconsistent.
Right now someone who comes to the department of corrections receives a variety of assessments and intakes, including mental health evaluations. Based on those results, as well as past medical history, people are placed in one of five levels of care — one being the most minimal and five being the most intensive. Those with the highest needs receive care in dedicated mental health units with mental health staff available 24/7. As it goes lower they may be on medication, visiting with a professional once a month or not need care at all. People can also move through levels throughout their incarceration.
People can take non-clinical programs within prison which range from violence reduction to emotional hygiene to peer support and more.
What makes this system seem undefined, or inconsistent, depending on which critic is talking, stem from a few factors.
Not only are Nebraksa’s prisons among the most overcrowded in the country, but they’re also short staffed. An October 2022 memo from Koebernick’s office showed the state employed 0 psychiatrists and had high vacancy rates for psychologists and behavioral health practitioners.
Non-clinical programs have also received scrutiny. Some programs and services are only available in certain facilities, limiting what a person can access. A Flatwater Free Press investigation found many inmates were required to take a domestic violence reduction class the prison didn’t have the staff to offer. A Reader public records request for a list of offered programs, the number of people who’d completed them and their waitlists would have taken 107 hours and about $5,000 to fulfill, a prison employee said.
“There’s a lot of questions about whether certain programs are actually following the evidence-based model that they’re built on — whether they have the clinicians that they need, whether they have the therapeutic settings that they need, or are there waitlists to get in there?” Koebernick said. “We need to know if we’re providing substance abuse treatment to 500 or 700 people, whatever the number would be each year, we need to know whether or not it’s actually working, what the cost is and what we can do to make it better.”
When asked how prison officials know whether people are improving or not under their care, interim chief of staff Dawn-Renee Smith didn’t know what recidivism rates looked like for the seriously mentally ill. She also didn’t have an exact figure for how much the prison system spends in total on mental health care, although they’re budgeted about $7 million for drugs in the coming year and spent almost $15 million contracting outside medical work last year.
But to say staff don’t care about the quality of care they give is offensive, she said.
Smith pointed to expansions the prisons made in nationally recognized peer-to-peer programs that pair incarcerated people with positive mentors with similar lived experiences. She also said while prisons are short staffed it doesn’t affect people’s ability to receive care.
“As an agency, and as individual team members, we are treating people with humanity and with dignity,” Smith said. “And the idea that we are not doing that is absurd, and is offensive. We are working very hard to make sure that people are treated well.”
One of the biggest problems the prison faces is lack of internal data gathering to improve their programs, something they hope to gain through a new partnership with the University of Nebraska at Omaha. Some states like Washington have publicly available cost/benefit analyses of prison programs that show what has an effect on reducing recidivism and future cost to taxpayers and what doesn’t.
“We’re excited about having those clinical programs evaluated,” Smith said. “The goal is to make people healthier, and so we want to make sure that’s actually happening, that we’re doing everything we can…And if we’re not, then figuring out what our next step is.”
What Smith said administrators of Nebraska’s prisons don’t get caught up on is the fact their facilities have become the state’s largest treatment centers. It’s their job to carry out the sentences that come to them. They’re just a part of the system.
And for some, incarceration is their best hope to get treatment in Nebraska. It can take a lot of trial and error before someone gets better, a lot of calls to the police, a lot of hospital stays, a lot of heartache. Without enough options in the community, at least inside they’re guaranteed to stay in the same place.
“It’s heartbreaking,” said Sherry Driver, director of the Douglas County Community Mental Health Center. “If you had a son or daughter and they…commit crimes over and over again, sometimes you sleep better at night when they’re in corrections. Because you know, they’re safe. You know, they’re not going to overdose or hurt somebody else or hurt themselves.”
“It is a sad reality,” she said.
‘He’s Still in There’
Tim Heller has had to face many heartbreaking realities.
He’s had to accept the future he once imagined for his son is gone. All Heller hopes is he can see his son get better, and even that feels like a losing battle.
But he tries to stay positive.
“A diagnosis is not the end,” he said. “It’s just a new beginning. It means that things have changed, and you’ve got a new way to go.”
But really he has no other option.
This is his son. The son he took on a cross country road trip with stops for a Cubs game, a private tour of the United States Capitol and, their end destination, Myrtle Beach, South Carolina. The son who, right after he started talking, watched Disney’s Tarzan with his newborn baby sister. He rocked her cradle back and forth while Phil Collins sang “You’ll Be in My Heart.”
Come stop your crying
It will be alright
Just take my hand
Hold it tight
I will protect you
From all around you
I will be here
Don’t you cry
“I heard that song about three weeks ago,” Heller said, “and I texted my daughter with that memory.”
“‘He’s still in there, Dad,’” his daughter said, Heller recalled through tears. “Somewhere.”
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