The last time I visited him, he was holed up for a while in a small room a caseworker had found him in a Mission District rooming house. His only furniture was a bare mattress on the floor; a rat and flies were his companions. Sadly, he seemed content.
This is the mental health delivery system that I helped build.
What I realize now
More than one educator has told me that I shouldn’t blame the schools: Their purpose is to educate children, not to treat them. I understand this. But I also learned from personal experience that ignoring a child’s special needs makes meaningless the special-education concepts of “appropriate” and “least restrictive” education that are embodied in the laws we passed.
These terminologies — and the realities they represent — were things that policymakers thought about too narrowly. The word “disability,” for instance, should have covered Tim and children like him. But as a friend who worked a generation ago on drafting the regulations for the federal government’s Individuals with Disabilities Education Act told me, “Paul, we were thinking of kids in wheelchairs.”
It’s no wonder that children like Tim graduate from one kind of cell to another when they grow up. On the basis solely of the numbers of people with mental illness who are incarcerated in them, the three largest “mental health facilities” in the nation are Riker’s Island in New York, the Cook County Jail in Illinois and the Los Angeles County Jail. The two most stable addresses in Tim’s adult life have been the Travis County Correctional Complex in Del Valle, Tex., and the San Francisco County Jail.
If I were a legislator today, I’d mandate — and provide funding to ensure — that every teacher receive training in recognizing symptoms of mental illnesses. I’d see that pediatricians are trained to make screening for mental health concerns a regular part of well-child exams. I’d require school administrators to incorporate recommendations from pediatricians and mental health professionals into students’ IEPs.
I’d put much more money into community mental health services. I’d integrate how services are delivered by funding collaborative community mental health programs and have them run by mental health professionals. I’d include services for chronically homeless people under this collaborative umbrella.
At the same time, to clear our county jails of people with mental illnesses, I’d get rid of laws targeting homeless people, such as those against loitering or sitting on a sidewalk. And I’d make sure that there was supportive short-term and long-term community housing and treatment for everyone needing them. Both were promised almost 50 years ago in the federal Community Mental Health Centers Act of 1964 — promises that were broken when it was repealed in 1981 and replaced by a block grant to states.
Mental illnesses cost as much as cancers to treat each year, and the National Institute for Mental Health notes that serious mental illnesses can reduce life expectancy by more than 25 years. That reduction is almost twice the 13 years of life lost, on average, to all cancers combined. When Tim needed hospitalization, an insurer sent him to drug rehab. Imagine the outcry if the insurer had tried to send a smoker with lung cancer who needed hospitalization to drug rehab.
Perhaps, even if Tim had gotten earlier, more effective and better integrated care, he still would have become homeless. But I don’t believe that. Tim is where he is today because of a host of public policy decisions we’ve made in this country. It took a nation to get Tim there. And it will take a national commitment to get him — and others like him — back.
A former legislator and mayor, Gionfriddo has worked for more than 30 years in the fields of health and mental health policy. He is author of the weekly blog Our Health Policy Matters. This article was excerpted from the Narrative Matters section of the journal Health Affairs and can be read in full at www.healthaffairs.com.