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Mind Traps

The state's mental health system is bogged down with patients stuck in psychiatric hospitals. They're not all supposed to be there.

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Matthew's eyes became glassy before each of his three outbursts, fixated on some perceived injustice or pet peeve. That's how his father knew something was wrong.

Six years ago, at age 19, he descended the staircase in his Virginia Beach home and announced to his father that he was the Lord, and then tore into the local 7-Eleven where his girlfriend worked. The next year, he had a screaming match at the restaurant where he bused tables and ended up hurling his eyeglasses at his manager.

Both times the police intervened but recognized the problem was medical, not criminal, and took him to get help. Virginia tries to ensure that those suffering from mental illness aren't caught up in the legal system or, as is often the case, in jail. But it didn't work out that way for Matthew.

“Here's what little I know,” says Michael, Matthew's father, whose last name is being withheld to protect his family's anonymity. On Nov. 20, he got a call at the car lot where he works. It was from the wife of a man who worked at the same warehouse as Matthew. “I've never met [her] and the wife just tells me Matthew's in jail.”

Matthew had been charged with reckless driving and speeding, Michael says, “and here's the kicker — a felony for eluding the police.”

After two months in jail at Virginia Beach, the state deemed Matthew, who was diagnosed with bipolar disorder at age 16, incompetent to stand trial. That was Feb. 3. Now he waits for a bed at Eastern State Hospital, a publicly run psychiatric facility. It's been five months since the arrest, and the jail social worker has warned Matthew's parents that it could be July before a bed becomes available. Until then, Matthew will remain behind bars.

Matthew isn't the only one stuck in a place he's not supposed to be. A dearth of available beds for state psychiatric patients such as Matthew contributes to a bottleneck in the state's mental health system. In fact, 10 percent of the state's 1,400 hospital beds are occupied by patients who clinically no longer need to be there, according to records obtained by Style Weekly. At Central State Hospital in Petersburg, for example, 16 of the facility's 100 civil patients are ready for release. (Central State has an additional 177 beds reserved for patients caught up in the criminal justice system.)

“These are individuals who have been clinically ready for discharge and are waiting for available nursing home beds, assisted living facility beds, [not guilty by reason of insanity], specialized medical services or geographic placement to accommodate family and consumer preference,” writes Meghan McGuire, spokeswoman for the state mental health agency, in an e-mail to Style.

Matthew's case is a symptom of a problem Virginia has battled for years. The state espouses a preference for treating people in the least restrictive environment available — group homes in neighborhoods rather than isolated hospital campuses and local jails. But when one of the treatment options gets backlogged, such as the current lack of assisted living or group home beds, the entire system can break down, often with disastrous results. It can leave patients in dire need of medical attention, such as Matthew, sitting in a jail cell for months on end. 

Colleen Miller, executive director of the Virginia Office for Protection and Advocacy, says that when the 2007 massacre at Virginia Tech drew attention to the state mental health system, “the legislature focused on the ways to make it easier to put people in, but made little headway on how to get [them] out. It [goes back] to the legislature's inability to adequately fund community services.”

Matthew's situation took a turn after a family trip to drop off his older sister at the College of William and Mary just before Labor Day 2000. The family had moved from New York City to Virginia Beach in 1997 for a job transfer — Michael was working as a manager for a company that sold uniform insignia to the military. 

Michael switched jobs, however, and began working as a car salesman. The new job took up more hours and ate into his weekends, and in the summer of 2000 his son began staying up all night locked in his room. After returning from the trip to William and Mary, Matthew refused to leave the garage and eventually kicked out the car windshield.

Michael took him to the hospital, and Matthew, at 16, was diagnosed as having bipolar disorder. Two years of therapy and drug treatment seemed to be working, however, and by 2002 he started school at Virginia Commonwealth University.

But there he stopped taking his medication and gained 60 pounds. He dropped out after Thanksgiving the same year, in 2002. Since, he's been managing his illness relatively well without drugs, save the incidents at the 7-Eleven and the restaurant.

After his arrest Nov. 20, the holidays rolled by. Matthew spent Thanksgiving, Christmas and New Year's Eve in jail. He wouldn't put his parents on the visitor's list for weeks.

Visits at the Virginia Beach Correctional Center can't run more than 30 minutes and are conducted over video link, not through glass. During the past five months through these digital glimpses, his parents have seen his hair and beard grow longer, his weight drop some 60 pounds. There's a mysterious cut under his chin from some kind of altercation with another inmate.

During their weekly Sunday morning visits — Michael calls it “going to church” — Matthew can be noncommunicative, or ramble, or occasionally be hostile. During one visit he made an unseemly racial comment to his mother about her German ancestry.

Most distressing, though, was that shortly after Michael and his wife were allowed to visit with their son in mid-December, he started spending time in solitary confinement. He had thrown urine at a jail employee. It's unclear to Michael how long a stretch Matthew was in there, but for at least five consecutive visits when he was called down it was from the medical isolation unit.

The implications of the solitary confinement really began to strike Michael after reading an article in The New Yorker entitled “Hellhole,” in which Dr. Atul Gawande argues that the use of isolation in American jails is tantamount to torture.

“McCain and the [Lebanon] hostage,” journalist Terry Anderson, “talk about how after a month your mind starts deteriorating,” Michael says. “Your son is in solitary. How in God's name can that be helpful in him getting the help he needs?”

He's never deteriorated this far and certainly never for this long.

Michael is circumspect. “He could still be in the general population and being picked on. At least he's being watched, but therapeutically you know it's just more baggage for him to work through,” he says. His arrest was at 4 a.m. after a long stretch of punctuality and good sleep, “so he could have had a manic phase that night,” Michael reasons. “The other episodes I saw it coming days ahead, I saw the glaze in his eyes. There was no anger, rage or pet peeves, so it would be horribly ironic if the arrest itself made [him] this way.”

Being in the wrong kind of facility can have detrimental effects on patients at every level, experts say. Although psychiatric hospitals are meant to restore an individual's ability to interact with broader society, a longer than necessary stay can have the opposite effect, says George Braunstein, director of Fairfax County's mental health board and former director of the mental health board in Chesterfield County.

“It's a very narrow world in an institution,” Braunstein says. “You see the same staff day after day, year after year. And the things that are important are privileges or a treat of some sort. You don't get exposed to making good decisions.”

June 22 marks the 10-year anniversary of the landmark U.S. Supreme Court decision in the Olmstead case, which concluded that states are required to offer treatment to people with mental illness or intellectual disabilities in the least restrictive setting possible — certainly not months in solitary confinement.

Local mental health boards across the state offer a variety of programs to help people with mental illnesses stay out of hospitals, such as in-home training to teach basic skills such as cooking, cleaning and making a budget — everyday caretaking that gets done by others during hospitalization.

If mental health patients begin to fall into crises where they present a danger to themselves or someone else, some localities have crisis stabilization programs where patients can cool off without the more extreme step of entering a hospital.

But Virginia's spending patterns still tilt toward institutionalization. In 2006, Virginia's Department of Mental Health, Mental Retardation and Substance Abuse Services spent $613 million on mental health. According to the National Association of State Mental Health Program Directors Research Institute, the 2006 average — the most recent figures available — show other states had a much different mix, spending 28 percent in state hospitals and 70 percent on community services. Virginia spent 50 percent of its mental health money on hospitals and 47 percent on community services.

Statewide there's no comprehensive system for how to keep people from getting to the point where they need to enter hospitals, or assist them in getting back out.

“There are shelves full of studies about what needs to happen with Virginia's mental health system and the conclusions are all the same,” says Arnold Woodruff, who works through the Richmond Behavioral Health Authority coordinating services regionally. “We need more money.”

Once again, supply and demand might suggest that building more assisted living facilities will solve the problem, but it's more complicated, Fairfax's Braunstein says.

For example, someone like Matthew may need only acute, short-term stabilization but there are only long-term beds available, then when it's time to get out there may be no transition planning money left. “The dollars can't be flexibly moved,” he says. “What you end up with is some people are stuck in hospitals solely based on the fact that there isn't enough money to create the right housing option.”

It's a chicken and egg problem, Woodruff says. “Until you have the community programs, you can't have the [hospital bed freed up], and you can't close the bed until you have community programs.”

Mental health advocates long have argued that keeping people in the community rather than the hospital is not only more humane, but also cheaper. Gov. Mark Warner's budget crisis in 2003 illustrated that deinstitutionalization can work financially and clinically. Looking for savings, Warner closed down two units — 40 beds — at Central State Hospital. The money saved went to setting up community programs such as Richmond's Grace House, a group home with support services, says Susan Hoover, who oversees the clinical services offered there. The treatments are more effective and less expensive. It costs the state $720 to house one person for one day at Central State Hospital, Hoover says, compared with an average $157 per day at Grace House.

The demand for such community programs is only increasing. Jim Bland, director of social work at Eastern State Hospital in Williamsburg, is trying to find out-of-hospital placements for 50 of the facility's 385 residents. “We have a number of people that have been on the list for more than six months,” he says.

Help may be on the way. The state is launching a pilot program this summer that attempts to create housing choices for the mentally ill. As a population, people with mental illnesses are generally poor, their diseases having interfered with work and relationships. Even when cobbling together entitlements, such as funding from federal Social Security to help pay for expenses, the money often isn't enough.

State governments try to bridge the gap with what are known as auxiliary grants, but that money is tied to particular beds in particular facilities. So a person may be clinically ready to leave Central State, but can't get the money to transfer to a group home or some other community facility.

The pilot program beginning July 1 will attach the grant to the person rather than the bed, which should make it easier for those stuck in state hospitals to re-enter the community. But there are drawbacks. The grant only becomes portable — that is, it can move with the recipient — once a person has spent six months in an assisted living facility, so freeing up supportive housing that will in turn free up hospital beds will have a trickle-down effect, says Mary Aab, regional support services manager for the nonprofit Virginia Supportive Housing.

“In my personal opinion you just literally make it portable, period, so people could take that funding and live in the community wherever they want,” Aab says.
Or with whomever will take them. Life outside a hospital setting is certainly cheaper, but not without its own complexities.

Mental illness frequently coincides with alcoholism or addictions often cultivated as a way to deal with an illness before its diagnosis. Nationally, the rate of people in psychiatric hospitals with both psychiatric and substance abuse disorders hovers between 35 percent and 40 percent, according to a report from the National Association of State Mental Health Program Directors Research Institute. Small snowballing crimes, or larger ones, related to the disease — like urinating in public or an assault born of confusion — create resumes many people aren't willing to take a chance on.

Wrapped up with crime and poverty, the complexity of sorting out the system remains frustrating at every level — acutely so for Matthew's family.

His big sister, Vanessa, a medical malpractice lawyer in New York City, was able to visit him for the first time over the Easter holiday.

“I have a psychology degree from Princeton and a law degree and I can't do anything for him,” she says. “Other people have gone through it and there's still no road map for us. It's profoundly frustrating.”

The jail social worker has put the family in touch with support groups that have offered useful literature and advice and given Michael and his wife the skills to communicate more clearly with their son, leading to their three most recent visits being the most productive yet.

“Going to see my brother and seeing that there are those wonderful personality quirks are still there — they might be masked a little bit by his disease and the really inhumane circumstances at the moment — but he's in there and I'm not going to let them rot in there,” Vanessa says.

“He is someone who has the capacity to contribute greatly to the world and greatly to the family and he deserves that chance,” she says, “and to do that he needs to be in a therapeutic setting.” S

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