Whether it’s the homeless woman you pass every day going to work, the new mother or a neighbor battling cancer, mental illness hides itself in many forms and behind many other conditions. Mental illness has been a pervasive issue in both rural Nebraska and metropolitan areas like Omaha.
When Nebraska dismantled its regional system over a decade ago, it never fully funded the replacement, according to local experts, stressing mental health services and pushing the most severe cases into homeless centers and prisons.
Adding to a lack of services and increase in diagnoses, Nebraska’s is rapidly losing its mental health workforce.
While nothing can replace a lack of community commitment and especially resources, new licensure efforts, first response treatments and growing community awareness provide some hope, even while the shortest route to mental health services might remain committing a crime and being incarcerated.
Community services and treatment
Nebraska made the switch from treating mental illness in regional institutions to community-based programs in 2004. The prospect of more humane services was a positive change, except the state never developed the programs that were promised, said William Spaulding, a psychology professor and researcher at the University of Nebraska – Lincoln.
“The people who really need the services aren’t getting them,” Spaulding said.
Aileen Brady, the executive vice president of Community Alliance, said the community services were implemented to a very limited extent. “I don’t think we knew what we know now. We just need more people,” Brady said.
Spaulding said misdiagnoses in mental health and overreliance on medication are huge issues in Nebraska, as well as on a national scale. In some cases, he said, no real diagnostic assessment takes place. This is particularly common among patients diagnosed with attention deficit disorders, he said.
“They’re on six or eight medications and no one really knows what’s wrong with them,” he said.
The state has invested heavily in practitioners with master’s degrees, Spaulding said, but it’s not up to them to make diagnoses.
“The diagnostic system has changed and is still in the process of changing,” he said. Right now, he said, nobody can determine what’s “sane” and what isn’t.
Spaulding said many of the programs to help treat schizophrenia and other severe mental illnesses were gutted when Nebraska altered its mental health system. Schizophrenia comes with huge costs, he said, ranking along with cancer in terms of economic burden.
A potential solution could be the introduction of First Episode Psychosis (FEP) care, Spaulding said, a type of treatment that be used after a person experiences their first psychotic episode. According to National Alliance on Mental Illness (NAMI), a psychotic episode typically involves a break from reality and is accompanied by visual or auditory delusions.
FEP care includes services such as illness management, medications, family psycho-education and substance use disorder treatment.
According to a report by TriWest Healthcare Alliance in 2015, approximately 180 adults in the Omaha area experience a first psychotic episode each year. There is currently no known FEP care program in the region, despite Omaha having quality medical centers for implementing FEP efforts, the report said.
Spaulding said specialists in the CHI psychiatric center at Creighton University are currently trying to implement an FEP program. Not only does FEP care have promising outcomes, but it is also extremely cost-effective, according to the TriWest report.
Despite limited treatment options, there are programs to help assist and inform Nebraskans affected by mental illness, said Linda Jensen, board member of the NAMI in Omaha.
NAMI developed a family education program for 2016 to help caregivers and family members support individuals with mental illness while maintaining their own well-being. The program provides information on getting medication, coping, family communication, and other types of resources available.
The limited availability of services for individuals dually diagnosed with mental illness and addiction is another issue that needs to be addressed, Jensen said. About 50 percent of people with mental illness also struggle with addiction, she said.
There need to be more organizations like CHI Health’s Lasting Hope Recovery Center, Jensen said. Lasting Hope is a psychiatric facility specializing in multi-occurring disorders, such as mental illness and substance abuse. The recovery center also recently held a conference on FEP treatment.
“ I think the treatment has to work together to be most affective,” Jensen said.
Homelessness and aging out
According to Candace Gregory, the president of Open Door Mission in Omaha, a lot of the burden of dealing with mental illness falls on nonprofits and homeless shelters.
She said the lack of funding limits the professional resources available, particularly in mental health. This includes locating resources for psychiatric evaluations, prescriptions, counseling and supportive housing, she said.
Mike Saklar, the executive director of the Siena Francis House in Omaha, said it’s extremely difficult to provide the homeless population with the help they need. “Some of them are beyond our ability to help, but we take them anyway because there’s no alternative,” Saklar said.
He said the only solution is more community-based programs with more providers and support staff. He said the Omaha area needs more group homes and programs like Lasting Hope, a recovery center offering various psychiatric services.
Outreach workers and case managers are important to help homeless people navigate the system, said Brady of Community Alliance. It’s often that people have had bad experiences with the system and need help from someone they can trust.
Through Community Alliance and other local agencies, homeless individuals have access to basic services and needs, such as emergency shelters. However, Brady said, there is still an extreme lack of resources. “For people who are homeless, there aren’t enough options,” she said.
Within the community programs, Brady said it’s important to have services that address addiction in addition to mental health. Approximately 75-80 percent of the people Community Alliance serve have both a mental illness and addiction, she said. “The challenge is that many self-medicate themselves with street drugs,” said Gregory from Open Door Mission.
More than 30 percent of Open Door Mission’s guests self-disclose the need for mental health services, said Kate Fischer, the mission’s health and healing director. “Although 30 percent self-disclose, there are about 30 percent more that don’t,” she said. “They are the self-medicating ones.”
Once they’re helped not to rely on drugs or alcohol, it’s easier to address their mental health needs and determine appropriate medication, Fischer said. “Once they get on the right medications and start feeling ‘normal’ for the first time in a long time, they will begin the process of learning how to cope with everyday activities sober,” she said.
UNL’s Spaulding said the prospect of “aging out” is also a huge issue in Nebraska in terms of mental illness and homelessness. “On their 19th birthday, the state just walks away from them,” he said. “That’s been a huge problem.”
Gregory said Open Door Mission has seen a huge increase in the homeless population between ages 18 and 25.
YES House, a street outreach center, provides help and shelter to a lot of Omaha’s homeless youth, Fischer said. However, the Mission has to accommodate for those individuals when YES House is full, she said.
YES House is a wonderful resource for that demographic, Fischer said, but not large enough to meet the growing need for those services in Omaha.
Fighting the stigma
However, for many, the largest obstacle in treating mental illness isn’t access to treatment. “There is such a stigma with mental health that does not exist with physical health,” Gregory said.
“A person with diabetes would take their insulin and no one would think any differently,” she said, “but once psychotropic or mood altering prescriptions are mentioned, it becomes much different.”
Fischer said stigma is an issue that the Open Door Mission tackles daily. “Helping them understand that their mental health diagnosis is as real as their physical health problems can be a challenge,” she said.
According to Saklar of Siena Francis House, it begins with education. “Awareness is important,” he said. “I think mental illness touches a lot of families.”
Saklar said he often gets calls from parents asking how to get help for their children. “That information needs to be out there,” he said.
When referring to mental illness, Saklar said he’s not just talking about people who experience psychosis. It’s important to understand that there are many levels and types of mental illness, he said.
Jensen of NAMI said the level of awareness is slowly improving. “It’s a difficult thing to work on,” she said.
It helps when people come forward and are open about their illness, Jensen said. Programs that NAMI offers, such as “Say It Out Loud,” encourage young people to speak about their mental health. “It’s an illness, just like any other illness,” she said
Prisons: the new asylums
Recent studies suggest approximately 15 percent of all inmates have a severe mental illness, according to a report published by Disability Rights Nebraska in 2014.
A significant number of inmates are placed in solitary confinement or extreme isolation, the report stated, where their conditions typically worsen. “The largest mental health institution in the state is Douglas County Jail,” said Spaulding.
He said the Nikko Jenkins case in 2013 exposed some of the major gaps in Nebraska’s mental health system. Jenkins committed four murders within a month of his release, leading to the formation of a special investigative committee by the Nebraska Legislature.
Jenkins was dually diagnosed with a psychiatric disorder and personality-related disorder while incarcerated. Despite recommendations from a psychiatrist in the Nebraska Department of Correctional Services (NDCS), Jenkins was never given a forensic evaluation or placed in a regional center, according to the committee’s report.
“It brings up a lot of the urgent issues,” Spaulding said. “Psychological treatment and social support systems have been undervalued and we’re paying a big price for that now.”
Lisa Jones, a psychologist in the Nebraska Department of Correctional Services, said she was drawn to the job because she thought there wasn’t any treatment going on.
After being in private practice for 13 years, Jones said she was pleasantly surprised by the amount and quality of services available to prisoners in Nebraska.
As a behavioral health administrator, Jones oversees programs provided by mental health, substance abuse, sex offender and social work.
The department offers a violence reduction program run by specially trained mental health staff, serving the most violent offenders. Mental health staff provide services from basic anger management to domestic violence treatment, Jones said.
Inmates within the program don’t face solitary confinement; they are required to live in the same residential unit.
“It helps them be more accountable to one another,” she said.
Aside from basic mental health services, Jones said Nebraska’s correctional department offers psychoeducational groups, coping skills, basic job training and more.
“We recognize that this is a population that definitely could benefit from those skills,” she said.
According to the Disability Rights Nebraska report, within the first two weeks after inmates are released, they are particularly vulnerable to fall back into old patterns. During this period, they are also 12 times more likely to die from health problems than the general population, said the report.
Jones said the Nebraska Department of Correctional Services tries to get inmates established with a person or group in the community so that they have a support system. She said by establishing a relationship before they leave, inmates may experience a much smoother transition back into society.
“Each inmate has his or her own special needs, so it’s not a cookie cutter approach,” she said. “But support is imperative.”
Providing caseworkers and other support services for incarcerated patients is a step in the right direction, Jensen of NAMI said, but there is a downside.
“People need to commit a crime to be in that program,” she said. Similar services need to be offered for people outside of the prison system, she said.
Addressing the workforce
“One of the biggest issues in mental health is the workforce crisis,” said Dr. Howard Liu, Director of the Behavioral Health Education Center of Nebraska (BHECN) and psychiatry professor at UNMC.
Liu said approximately half of mental health care providers in Nebraska are nearing retirement age. Within the next 10 years, he said, current gaps in services are going to grow tremendously.
There is already a shortage of providers in certain areas, Liu said, including addiction services and child psychiatry. One of the biggest issues potential mental health providers face in Nebraska is the licensing process, he said.
“It takes some time to get licensure,” Liu said. “That’s something we’re trying to address.”
In November, the Nebraska Legislature held a hearing on Legislative Resolution 185, an interim study to examine the licensing process for mental health professionals. Senator Sue Crawford of Bellevue said the resolution is still a work in progress.
“We noticed there was a large number of people who were in that provisional status,” Crawford said. “That really initiated my concern.”
She said a large part of the issue remained at the administrative level. The Department of Health and Human Services (DHHS) is engaged in some substantial process improvement, Crawford said, including changing how the phone is answered and monitoring the flow of documents.
“We want to make sure that we get those professionals up and credentialed as quickly and efficiently as possible,” she said.
Crawford said DHHS will continue to work through some of the smaller issues over the next couple years. This includes efforts to recruit and retain a workforce in Nebraska, she said, as well as helping them earn enough provisional hours.
Liu is involved in some of the recruitment himself. As the director of BHECN, Liu helps encourage high school and college students in Nebraska to enter the mental health workforce. He said it’s important young people understand a career in mental health can be extremely rewarding.
“There’s a positive piece,” Liu said. “It’s not all doom, gloom and depression.”
BHECN was developed in 2009 to help address the need for a skilled mental health workforce in Nebraska, according to the organization’s 2015 legislative report. Along with recruitment, BHECN helps train and retain current behavioral health workers as well as evaluate the state of the workforce in Nebraska.
According to the same report, 32 counties in Nebraska do not have a behavioral health provider and 71 Nebraska counties do not have a psychiatric prescriber. Though metropolitan areas have a greater distribution of providers, these areas experience major access issues due to the limited number of professionals.
“We desperately need a mental health workforce,” Crawford said.” ,