There has been a lot of media coverage about the death of Michael Anthony Kerr, an inmate with schizophrenia at Alexander Prison. His personal story is heartrending but sadly familiar. After being in and out of jail, Mr. Kerr was sentenced to prison as a habitual felon. He was incarcerated far from his family. In prison, the symptoms of his mental illness triggered disciplinary actions which eventually landed him in segregation. Any reasonable person hearing the facts of his death – from thirst while in a locked cell – is shocked.
While Mr. Kerr died of dehydration, he also died because the system responsible for his care failed. The North Carolina Department of Public Safety (DPS) has committed to put in place necessary reforms. But the biggest challenges are still ahead: filling vacant positions, ensuring new staff are appropriately trained, implementing treatment for prisoners with mental illness, ensuring they aren’t punished for behaviors associated with their disease, and, most importantly, changing the culture understanding of mental illness within our prisons.
If stories like Mr. Kerr’s are to have a different ending, then how those stories begin must change. We have to move beyond merely addressing North Carolina’s prisons. The only way to ensure a different beginning is to transform North Carolina’s mental healthcare system.
How? Some believe that the solution is to replace the beds lost when ‘Reform’ started over a decade ago. I would like to offer a different point of view. The primary intention of Reform was to shift from relying on institutional care to outpatient services in the community. Its purpose was threefold: to comply with the new requirements of the U.S. Supreme Court’s Olmstead decision, to reduce the social stigma associated with mental illness, and to improve public health.
So hospital beds were reduced. And the people who used to sleep in those beds were discharged. Over the years, thousands of individuals went to Adult Care Homes, institutions which are not regulated to provide mental health treatment. People who do receive treatment in a hospital or other facility are stabilized and discharged, sometimes to homeless shelters, often with only a short-term supply of medication. Others, once stabilized, languish because their discharge plan cannot be implemented for lack of funding or availability of services. Without a feasible discharge plan, transition typically fails, and the person enters a destructive cycle.
The result of all this is that law enforcement officers have become the first responders for mental health crises, even when no crime is committed, and trips to emergency departments have increased. This is called recidivism.
With inadequate, underfunded services, recidivism is predictable. It happens far too frequently in North Carolina.
Funding has always been inadequate, and over the years it has eroded. Accountability and oversight have also been lacking. These shortsighted policies and short-term cost-saving decisions caused mental health reform to fail – not insufficient beds. More hospital beds will not create the services people need to successfully transition to and succeed in the community.
The solution? It is essential that North Carolina develop an array of service definitions and actual services that include Assertive Community Treatment (ACT) teams, crisis services, and supported employment services. The state must also implement a person-centered discharge planning process to help individuals transition to the community and a pre-admission screening process to prevent individuals from becoming unnecessarily institutionalized.
In short, North Carolina must aggressively implement the terms of a settlement agreement that it entered into with the U.S. Department of Justice two years ago after it was shown that the state was violating the Americans with Disabilities Act. Moreover, it should apply those solutions to all adults with mental illness.
For children and adolescents with complex mental health needs, an appropriate system of care with a commitment to high-fidelity evidenced practices must be developed.
And for all ages, true person-centered case management must be available with a focus on recovery.
Together, these changes reduce recidivism, reduce crowding in emergency departments, shift the responsibility of first response from law enforcement to trained mental health professionals and shift the functions of care and treatment from jails and prisons back to health care professionals.
The bottom line: Efforts to reform mental health services and transform the system did not fail because of insufficient beds. They failed because the necessary community-based services were never fully developed and supported.
Shifting our focus from inpatient beds to an available array of meaningful community services is what will ultimately transform the system and assure that the stories of people with mental illness – people like Michael Anthony Kerr – really change for the better.
Vicki Smith is the Executive Director of Disability Rights North Carolina.