By Julia Steiny
Back in the 1970s, Leon Evans became the director of a community mental health center in San Antonio, Texas. A social worker by training, Evans knew how to manage organizations that deal with mental illness, keeping afloat often-stressed frontline workers as they serve those suffering all manners of distress. Little did he know that to succeed, he’d have to build an entirely new model.
Bear in mind that mental illness can mean anything from disorders like schizophrenia or bipolar to the frantic, terrified state of a woman whose partner suddenly abandoned her with three kids. Mental illness is when a mind’s dysfunction is beyond the TLC of family and friends.
By 2000, San Antonio’s county government tapped Evans and his vast experience to run its entire mental health system. Immediately this giant bear of a man, an ex-wrestler, looked around and realized that he, the mental health Centers, and the people they served were drowning. Both the sheer numbers of people and the severity of their illnesses were increasing at rates defeating him and his budget. Texas is 49th in the nation in funding on mental health.
The jails were stuffed to the gills with people whose real problems were substance abuse, PTSD, and other varieties of mental illness. Evans couldn’t address his systemic problems without collaborating with the police and judicial system. This was way easier said than done. As Evans said in an NPR story, just getting folks to the table was by far the hardest part. For starters, mental health workers don’t speak the same language as police. Nor do they share the language, traditions and expectations of doctors, courts, transportation, housing, hospitals, town governments, child protective services or education. Together they were a public services Tower of Babel.
It took a county judge to help Evans push them together.
When they finally sat down together, of course, agency representatives found that they were serving many of the same clients — repeatedly and ineffectively. Recidivism to jails, hospitals and drug treatments was and is astronomically high. Clients have overlapping needs. A flare-up of mental illness might precipitate homelessness, alcoholism, the commission of a crime. Each problem had its own solution from a different agency or system. The community mental health centers were only one of many systems.
These centers had grown as a response to the 1960’s public outrage sparked by exposes on scandalous hospitals that warehoused the mentally ill. The resulting “deinstitutionalization” movement involved creating community-based mental health centers to manage the care for the mentally ill in far more humane ways, in home and neighborhood settings. For a while the system worked well, or at least better. But over time politicians chipped away at their resources, often reallocating funding to less stigmatized populations. And no one anticipated the rapid fraying of nuclear and extended families, nor the decline of informal social supports like clubs and churches. As money tightened, the demand for services grew.
Getting a fix on the public expenditures for mental illness is nearly impossible because the dollars are spread across different agencies’ budgets. For example, most calculations fail to acknowledge that jails and prisons have become the largest mental health providers in the nation. According to some estimates, well over half of all people incarcerated suffer some mental dysfunction — substance abuse issues, depression, PTSD, or other ailments. And I would say that estimate is low.
To work towards a sustainable solution, Evans talked the relevant parties into pooling their money for what he called a “Restoration Center.” The police contributed their drug seizure money. The courts, jails, hospitals, and the county government also kicked in.
This money made it possible to run a large one-stop drop-in center where representatives from all the services are co-located. It has 24/7 psychiatric services to stabilize the mentally ill and get them to an appropriate longer-term facility. It has a detox program, a homeless shelter across the street, a physician on staff, and so forth. Sometimes the police bring someone. Sometimes whole families walk in off the streets. The Center serves about 18,000 people a year.
The savings to the County so far are about $10 million a year. As the agencies hone their systems, and as the population hopefully gets healthier, they will save even more.
Thanks to Evans, I now dream of a Restoration Center, but one servicing children and families at the other end of the spectrum where mental illness, homelessness and substance abuse might be prevented. Evans’ Restoration Center is across from a homeless shelter, but mine would be across from a fabulous park or adventure playground. There, mental health workers could interact with families to support actual mental health, resilience, social skill-building, and conflict management. Children would get help at early signs of distress or dysfunction. Imagine the savings if we did that.
Working together, humans can accomplish the miraculous. Evans did. We need more people like him to bulldog us into it.