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Changing Definitions Of Trauma Are Leading To New Alternative Therapies

When I was a resident at NYU in 2009, I worked extensively at Bellevue Hospital's Survivors of Torture Center. I was training to be a psychiatrist, seeing patients who'd endured unspeakable terrors in war-torn regions of Bosnia, Côte d'Ivoire, and Sri Lanka.

Even though they shared similar experiences, their trauma presented itself differently. For some, there were little to no traumatic symptoms, while others could not escape their painful memories for more than a few hours a day.

At the time, there was little consensus on whether you'd want to encourage patients to speak about their trauma, which could desensitize them to the negative emotions of the memory (an arguably positive result), or else risk retraumatizing them (an obviously negative result).

As our knowledge of mental health expands, we are beginning to see that trauma isn't relegated only to survivors of war or serious abuse, but that the experience is more universal, with a variety of different forms and severities.

The DSM-V currently recognizes three types of trauma: Acute, Chronic, and Complex.

Acute trauma — or what I often call Trauma with a capital T — involves a single incident, usually surrounding the threat of loss of life or limb, such as a sexual or physical assault or a serious car accident. Chronic trauma is on-going, such as persistent bullying, abuse, neglect or domestic violence. Complex trauma entails repeated or multiple traumas from which there is no escape (feeling trapped).

After having treated trauma as a psychiatrist for over 15 years, I befriended the founding director of the International Trauma Studies Program, Dr. Jack Saul. He introduced me to the term "moral injury trauma," which is where people have done, by no choice of their own, unspeakable things like killing mothers and children in war, and then come home and must carry this moral burden (it can also include simply witnessing moral atrocities).

Dr. Saul explained to me that the way to treat moral injury is through group therapy, treating the so-called perpetrators (the people who went to war) alongside other members of the community who did not go to war. Those individuals who did not themselves endure the trauma are able to be present and hold space for those who did, and breaking their silence about these crippling memories can help patients break free of the shame and social isolation that comes with having to endure moral injuries.

One-on-one therapy is a privilege not afforded to all people of the world, making group therapy a more accessible form of treatment for developing nations or the working poor.

Another cost-effective form of therapy, controlled breathing, which can be done individually or in a group setting, has been shown to have remarkable effects on calming the sympathetic nervous system, reducing the amount of the stress hormone, cortisol, which causes sensations of alarm and danger when PTSD victims are triggered.

This is different from Somatic Experiencing Therapy, which aims to reduce or eliminate the stress response to memories through an encouraged focus on internal sensations.

Created by neurobiologist Peter A Levine, author of Waking the Tiger: Healing Trauma, Somatic Experiencing pulls from both mainstream science as well as various shamanistic practices from around the world.

Spirituality has been making a resurgence in mental health treatment in recent years, particularly in the treatment of trauma. Doctor of Divinity Erin Fall Haskel has been taking a more metaphysical approach to the treatment of trauma. Her approach is supported by scientific literature that holds that it's not as important what happened to you, but what happened within you, that determines how your trauma materializes and how to treat it.

During my psychiatry residency at Bellevue, I spent a month in Rwanda, helping survivors of the brutal genocide process their trauma. Perhaps most horrendous was the use of rape as a tool of war, which created a whole generation of babies produced by the atrocity.

While in Rwanda, I met Jean-Baptiste Ntakirutimana, whose mother was killed by his best friend and neighbor during the bloody rampage of "kill or be killed." When the genocide was over and his neighbor was in jail, Jean-Baptiste was filled with rage and a desire for revenge for the man, which he soon realized was draining him of his life force. After a period of fasting and praying, Jean-Baptiste visited his old friend in jail, and ultimately forgave him. Afterward he felt an enormous burden of hatred and pain lifted from him in what he describes as "the most liberating moment of my life." Based on his life-changing experience, he began The Forgiveness Project.

In addition to social and spiritual therapies, psychedelic interventions have proved successful where other trauma treatments have failed. Pharmaceutical treatments like SSRIs have proved helpful for many sufferers of trauma, but often these medications treat only the symptoms of illness. In contrast, a medication like MDMA (i.E., Ecstasy) can act as a kind of surgery of the mind, targeting the specific memories, perceptions, and narratives created by the trauma and removing or transforming them.

MDMA has been found to be effective across all forms of trauma, but that doesn't mean it's effective for all minds, bodies, and spirits. I have seen time and again how two people can endure the same traumatic experience and wind up with different presentations of trauma (or none at all). It comes down to an individual's worldview, genetics, spiritual perspective, community, access to treatment, and a host of other factors that determine how they will respond to horrifying experiences.

The future of trauma therapy is likely to involve an increasing emphasis on integrating different trauma modalities. While traditional evidence-based therapies, such as psychotherapy, Eye Movement Desensitization and Reprocessing (EMDR), and Somatic Experiencing are likely to continue being prominent, there will likely be a greater recognition of the value of integrating spiritually-based approaches and mind-body practices like breathing techniques. With ongoing research and clinical trials, psychedelic-assisted therapies will likely also become more accessible to clients in mental health settings. As these developments unfold, the ultimate goal will be to provide more effective, holistic, and compassionate care for individuals experiencing trauma.

The trends in therapy are why our expanding knowledge of what trauma is, and how to treat each individual case, is one of the most exciting developments in mental healthcare today.

They Needed Mental Health Care Treatment. They Were Thrown In Jail Without Charges Instead

When sheriff's department staff in Mississippi's Benton county took Jimmy Sons into custody several years ago, they followed their standard protocol for people charged with a crime: they took his mugshot, fingerprinted him, had him change into an orange jumpsuit and locked him up.

But Sons, who was then 20 years old, had not been charged with a crime. Earlier that day, his father, James Sons, had gone to a county office to ask that his youngest son be taken in for a mental evaluation and treatment. Jimmy Sons had threatened to hurt family members and himself, and his father had come across him sitting on his bed with a loaded shotgun.

On Sons's booking form, in the spot where jailers usually record criminal charges, was a single word: "LUNACY".

The booking form for Jimmy Sons, identifying his 'offense' as 'lunacy'. Photograph: Mississippi Today

In every state, people who present a threat to themselves or others can be ordered to receive mental health treatment. Most states allow people with substance abuse problems to be ordered into treatment, too. The process is called civil commitment.

But Mississippi Today and ProPublica could not find any state other than Mississippi where people are routinely jailed without charges for days or weeks during that process.

What happened to Sons has occurred hundreds of times a year in the state.

Examined jail dockets from 19 Mississippi counties – about a quarter of the state's 82 – had clearly marked bookings related to civil commitments. All told, people in those counties were jailed at least 2,000 times for civil commitments alone from 2019 to 2022. None had been charged with a crime.

Most were deemed to need psychiatric treatment; others were sent to substance abuse programs, according to county officials.

Since 2006, at least 13 people have died in Mississippi county jails as they awaited treatment for mental illness or substance abuse. Nine of the 13 killed themselves. At least 10 hadn't been charged with a crime.

We shared our findings with disability rights advocates, mental health officials in other states and 10 national experts on civil commitment or mental healthcare in jails. They used words such as "horrifying", "breaks my heart" and "speechless" when they learned how many people are jailed in Mississippi as they go through the civil commitment process.

A civil commitment patient is transported back to the Chickasaw county regional correctional facility after a court hearing. Photograph: Eric J Shelton/Mississippi Today

Some said they didn't see how it could be constitutional.

"If an ER is full, you don't send people to jail," said Megan Schuller, legal director of the Bazelon Center for Mental Health Law, a Washington DC-based organization. "This is just outright discriminatory treatment in my view."

We also interviewed 10 people who had been committed and jailed, as well as 20 family members.

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Many of those people said they or their family members had been housed alongside criminal defendants. Nobody knew how long they would be there. They were often shackled when they left their cells. Some of them said they could not access prescribed psychiatric medications or had minimal medical care as they experienced withdrawal from illegal drugs.

"It felt more criminal than, like, they were trying to help me," said Richard Millwood, who was booked into the DeSoto county jail in 2020 following an attempted suicide. "I got the exact same treatment in there as I did when I was in jail facing charges. In fact worse, in my opinion, because at least when I was facing charges I could bond out."

DeSoto county leadership, informed of Millwood's statement, did not respond.

Millwood spent 35 days in jail before being admitted to a publicly funded rehab program 90 miles away.

Jimmy Sons did not receive a mental evaluation when he was booked into the Benton county jail in September 2015, according to documents in a lawsuit his father later filed. Less than 24 hours later, he was dead. Left alone in a cell without regular visits by jail staff, he had hanged himself.

Jimmy Sons at age 18 at his father's home in Mississippi. Photograph: Courtesy of John Sons

He had been back in Mississippi for just a few days, planning to join his dad in electrical work, said his mother, Juli Murray. He had set out from her home in Bradenton, Florida, so early in the morning that he didn't say goodbye.

Murray remembers the phone call from Sons's half-brother in which she learned her son was in jail. She didn't understand why.

"If you do something wrong, that's why you're in jail," she said. "Not if you're not mentally well. Why would they put them in there?"

The lesser sin

When James Sons went to the clerk's office in the tiny town of Ashland to file commitment paperwork for his son, he took the first step in Mississippi's peculiar, antiquated system for mandating treatment for people with serious mental health problems.

It starts when someone – usually a family member, but it could be almost anyone – signs a form alleging that the person in question is "in need of treatment because the person is mentally ill under law and poses a likelihood of physical harm to themselves or others".

James Sons filled out that form, listing why he was concerned: Jimmy's guns, his threats, his talk of suicide.

Then a special master – an attorney appointed by a chancery judge to make commitment decisions – issued a "Writ to Take Custody". It instructed sheriff's deputies in Benton county, just south of the Tennessee border, to hold Jimmy Sons at the jail until he could be evaluated.

The sheriff's office asked Jimmy Sons to come in on an unrelated matter. When he showed up, the chief deputy, Joe Batts, told him he needed a mental health evaluation. Batts tried to reassure Sons that the process would be as quick as possible and would end with him back home, according to Batts's testimony in the lawsuit Sons's father filed over his death.

Then Batts told Sons: "What we're going to have to do now is take you back and book you."

What he never told Sons, he later acknowledged in a deposition, was that the young man would have to wait in jail for days before he would see a mental health provider. The first screening required by law was four days away. If it concluded he needed further examination, he would be evaluated by two more medical professionals. Then the special master would decide whether to order him into treatment at a state psychiatric hospital.

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The whole process should take seven to 10 days, according to the state department of mental health, but sometimes it takes longer. And if someone is ordered into treatment at their hearing, they generally have to wait for a bed, though the department says average wait times for state hospital beds after hearings have dropped dramatically in the last year.

While waiting for their hearing, people like Sons are supposed to receive treatment at a hospital or a short-term public mental health facility called a crisis stabilization unit. But state law does allow people to be jailed before their commitment hearing if there is "no reasonable alternative". (The law is less clear about what's allowed following a hearing.)

We spoke to dozens of officials across Mississippi involved in the commitment process: clerks who handle the paperwork, chancery judges and special masters who sign commitment orders, sheriffs who run the jails, deputies who drive people from jails to state hospitals, and the head of the state department of mental health.

The Benton county sheriff's department, formerly the location of the county jail where Jimmy Sons died, in Ashland, Mississippi. Photograph: Eric J Shelton/Mississippi Today

None of them thinks jail is the right place for people awaiting treatment for mental illness.

"We're not a mental health hospital," said Greg Pollan, president of the Mississippi Sheriffs' Association and the sheriff of rural Calhoun county in the north of the state. "We're not even a mental health Band-Aid station. That's not what we do. So they should never, ever see the inside of my jail."

Batts himself, who took Sons into custody in Benton county, said law enforcement officers across Mississippi "hate to detain people like that. But we're told we have to do it". He acknowledged that the facility "was substandard to begin with, not having the space and the adequate facilities to hold and monitor someone in that mental state – it just puts everybody in a bad situation." And he said he thought the state could provide alternatives to jail.

Some counties jail most people going through the commitment process for mental illness. Other counties reserve jail for people who are deemed violent or likely to hurt themselves. And at least a handful sometimes jail people committed for substance abuse – even though a 2021 opinion by the state's attorney general says that is not allowed under state law.

This happens because until people are admitted to a state hospital, counties are responsible for covering the costs of the commitment process unless the state provides funding. If a crisis stabilization unit is full or turns someone away, the county must find an alternative, and it must foot the bill.

Counties can place patients in an ER or contract with a psychiatric hospital – and some do – but many officials balk at the cost. Many officials, particularly those in poor, rural counties, see jail as the only option.

"You have to put them somewhere to monitor them," said Cindy Austin, a chancery clerk in rural Smith county, located in central Mississippi. Chancery clerks are responsible for finding beds for people going through the commitment process. "It's not that anybody wants to hold them in jail, it's just we have no hospital here to hold them in."

Timothy Gowan, an attorney who adjudicated commitments in Noxubee county from 1999 to late 2020, said people going through the commitment process there generally were jailed if they were determined to be violent and their family did not want them at home.

According to the Noxubee county jail docket, people going through the civil commitment process with no criminal charges were booked into the jail about 50 times from 2019 to 2022. Ten stays lasted at least 30 days. The longest was 82 days.

"Putting a sick person in a jail is a sin," Gowan said. "But it's the lesser of somebody getting killed."

Some counties rarely hold people in jail – sometimes because a sheriff, chancery judge or other official has taken a stand against it. Rural Neshoba county in central Mississippi pays Alliance, a psychiatric hospital in Meridian, to house patients.

The practice is not confined to poor, rural counties. DeSoto county, a populous, relatively wealthy county near Memphis, jailed people without charges about 500 times over four years, the most of any of the counties we analyzed. The median jail stay there was about nine days; the longest was 106.

The state and county recently set aside money to build a crisis stabilization unit – currently, the nearest one is about 40 miles away – but the county and the local community mental health center have not decided on a location, said the county supervisor Mark Gardner.

Some county officials say that keeping people out of jail during the process requires the state to step up. The state representative Jansen Owen, a Republican from Pearl River county who represents people during the commitment process, said he believes counties that spend "millions of dollars on fairgrounds and ballparks" could find alternatives to jail. But he also sees a need for more state-funded facilities.

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"You can't just throw it on the counties," he said. "It's a state prerogative. And them being held in the jail, I think, is a result of the state kicking the can down the road to the counties."

Wendy Bailey, head of the state department of mental health, said it was "unacceptable" to jail people simply because they may need behavioral health treatment. Department staff have met with chancery clerks around the state to urge them to steer families away from commitment proceedings and toward outpatient services offered by community mental health centers whenever possible.

The department of mental health says it prioritizes people waiting in jail when making admissions to state hospitals. The state has expanded the number of crisis unit beds from 128 in 2018 to 180 today, with plans to add more. And it has increased funding for local services in recent years in an effort to reduce commitments.

But Bailey said the department has no authority to force counties to change course, nor any responsibility for people going through the commitment process until a judge orders them into treatment at a state psychiatric hospital.

Locked in the 'Lunacy Zone'

Willie McNeese's problems started after he came home to Shuqualak, Mississippi, a town of about 400 people and a lumber mill, in 2007. He had spent a decade in prison starting at age 17.

He found the changes that had taken place – bigger highways, cellphones – overwhelming, said his sister, Cassandra McNeese. He was eventually diagnosed with bipolar disorder.

"It's like a switch – highs and lows," said Willie McNeese, now 43. "I might have a whole lot of laughter going on, trying to make the next person laugh. Then my day going down, I be depressed and worried about situations that nobody can change but God."

McNeese has been involuntarily committed in Noxubee county 10 times since 2008 and has been jailed during at least eight of them, one for more than a month in 2019 according to court records and the jail docket. During his most recent commitment starting in March 2022, McNeese was held in jail for a total of 58 days in two stints before eventually going to a state psychiatric hospital.

The old jail in Noxubee county, where Willie McNeese was incarcerated multiple times during civil commitment processes, including his first commitment in 2008. Photograph: Eric J Shelton/Mississippi Today

From 2019 to 2022, about 1,200 civil commitment jail stays in the 19 counties we analyzed lasted longer than three days. That's about how long it can take for people to start to experience withdrawal from a lack of psychiatric medications, which jails do not always provide. About 130 stays lasted more than 30 days.

McNeese said he spent much of his time in jail last year standing near the door of his cell, in what jail staff called the "Lunacy Zone", screaming to be allowed to take a shower. A jailer tased him to quiet him down, and his clothes were taken from him. For a period, his mattress was taken, too.

"It's a way of punishment," he said. "They don't handle it like the hospital. If you have a problem in the hospital they'll come with a shot or something, but they don't take your clothes or take your mattress or lock your door on you or nothing like that."

McNeese said he had inconsistent access to medication and received none during his first stay in 2022, which lasted 25 days.

The Noxubee county sheriff's department did not respond to questions about McNeese's allegations.

Staff from Community Counseling, the community mental health center where McNeese had regular appointments, could have provided him with medication, but McNeese said no one from the center came to visit him in jail. A therapist at Community Counseling said staff go to the jail only when they're called, usually when there's a problem jail staff can't handle. Rayfield Evins Jr, the organization's executive director, said when he recently worked in Noxubee, deputies brought people from the jail to his facility for medication and treatment.

Mental health advocates in Mississippi and other people who have been jailed during the commitment process said the limited mental health treatment McNeese received is common.

Mental healthcare varies widely from jail to jail, and no state agency sets requirements for what care must be provided. Jails can refuse to distribute medications that are controlled substances, which include anti-anxiety medications like Xanax. The state department of mental health says counties should work with community mental health centers to provide treatment to people waiting in jail as they go through the commitment process.

But those facilities generally do not have the resources to provide services in jails, said Greta Martin, litigation director for Disability Rights Mississippi.

Martin's organization, one of those charged by Congress with advocating for people with disabilities in each state, investigates county jails when it receives complaints. "We are not seeing any indication that these individuals are getting any mental health treatment while they are being held in these county facilities," she said.

McNeese said those jail stays added physical discomfort and pain to the delusions that got him committed in the first place. "Then you get to the mental hospital – they have to straighten you all the way back over again," he said.

Since being released from the state hospital last year, McNeese said, he has been doing well. He is now living in Cincinnati with his wife.

Scott Willoughby, the program director at South Mississippi State hospital in Purvis, said it can be hard to earn patients' trust when they arrive at the psychiatric hospital from jail.

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At his facility, patients sleep two to a room in a hall decorated with photographs of nature scenes. Group counseling sessions are often held outside under a gazebo. In between, patients draw and paint during recreational therapy.

Willoughby has spoken with patients who had attempted suicide and were shocked to find themselves in jail as a result.

"People tend to associate jail with punishment, which is exactly the opposite of what a person needs when they're in a mental health crisis," he said. "Jail can be traumatic and stigmatizing."

'I'm more scared of myself'

When Sons learned that he was going to be booked, he became anxious about being locked in a cell, Batts testified. So he was assigned to an area of the jail reserved for trusties – inmates who are allowed to work, sometimes outside the jail, while they serve their sentences.

On the afternoon of his first day in jail, Sons was sitting on his bed when a trusty named Donnie Richmond returned from work. Richmond said in a deposition that he asked a deputy who the new guy was.

"You better watch him," Richmond recalled the deputy telling him. "He kind of off a little bit."

Richmond offered Sons a cigarette and cookies and asked him why he was there. Sons took a cigarette and told Richmond the deputies had said he would hurt someone.

"He was like, 'Man, I'm going to be honest with you,'" Richmond testified. "'I ain't going to hurt no one. I'm more scared of myself, of hurting myself.'"

Sons was not placed on suicide watch. The jail's suicide prevention policy applied only to those who had attempted suicide in the jail, although the jail officials in the lawsuit over his death said they had an unwritten policy to closely monitor people going through the commitment process.

That evening, Sons told a jailer he was feeling anxious around the other men. He asked to be moved to a cell by himself.

A guard took him to a cinder-block cell with no windows. There was no television and nothing to read. He was given a blanket.

A security camera in Sons's cell was supposed to allow jailers to watch him at all times. But jail officials said in depositions that no one noticed anything unusual the next morning.

The door of the Benton county jail cell where Sons was held. Photograph: Obtained by Mississippi Today

At 11.28am, Sons rose from his bunk bed, walked to the door and placed his ear near it. He went back to his bunk, fashioned a noose and tied it around his neck. He sat there for three minutes before hanging himself, according to a narrative of the video in court records.

He stopped moving at 11.38am. A trusty serving lunch peeked through a tray opening in the door 48 minutes later and saw his body.

Sons's father sued Benton county, the sheriff and several of his employees over his death. The defendants denied in court filings that they were responsible, but the county's insurance company eventually settled the case for an undisclosed sum. (All that is publicly known is that the county paid a $25,000 policy deductible toward defense costs.)

Sheriff's department staff said in depositions they had kept an eye on Sons, but they could not watch the video feed constantly. Lawyers for the defendants said there was no evidence sheriff's department employees knew someone could kill himself in the way Sons did.

Sheriff A A McMullen, who is no longer in office, acknowledged in a deposition that "any mental commitment is a suicide risk", but he said he was not sure it would have made a difference if Sons had been placed on suicide watch.

"You could write up the biggest policy in the world and you couldn't prevent it. There's no way. God knows, you know, it hurts us," he said. "If they're going to do it, they're going to do it."

McMullen could not be reached for comment for this story.

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In an interview, the jail administrator Kristy O'Dell, who joined the department after Sons died, said the jail still holds two or three people going through the commitment process each month.

John S Farese, an attorney for Benton county, said that the county, like others, "does the best they can do with the resources they have to abide by the laws" regarding commitments. He said the sheriff and the county will try to adapt to any changes in the law "while still being mindful of our limited personnel and financial resources". He declined to comment on the specifics of the Sons case, which he did not work on.

Murray, Sons's mother, was at a grocery store around noon the day her son died. As she picked out a watermelon, she thought about him, a fitness buff who loved fruits and vegetables. A strange thought crossed her mind: "Jimmy's never going to eat watermelon again."

When she got home, she got the call that he was gone.

John Sons, Jimmy's half-brother, wrote in a text that the family is left with "complete and total guilt for putting him in the prison and always the wonder if we would not have done that move, if he would be with us today".

But Richmond, the trusty who briefly shared a cell with Sons, testified that it was jail staff who "messed up".

"He hung himself," Richmond said. "I say this. God forgive me if I'm wrong. We couldn't have saved that man from killing himself, but we could have saved that man from hanging himself in that jail."

● In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.Org, or text HOME to 741741 to connect with a crisis counselor. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.Org or jo@samaritans.Ie. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.Org

Inspired By Crisis And Controversy, Minnesota Health Orgs Work To Improve Access To Mental Health Care And Reduce Hospital Stays

Late last summer, the story of a 10-year-old boy with autism and severe mental illness who'd spent seven months boarding in a Carver County emergency department awaiting mental health treatment made national headlines. Providers around the state knew something had to be done to improve access to mental health care in Minnesota. 

In response, a group of providers, hospital administrators and public health experts set up a weekly group call with the purpose of making change happen. What they quickly realized was that they needed to create a system to better match patients with available mental health care, said Todd Archbold, chief executive officer of Prairie Care, a Twin Cities-based provider of residential and outpatient mental health treatment for adolescents, young adults and families, who was on the calls. 

Archbold recalled one discussion about an aggressive 13-year-old in foster care who needed treatment. Mental health providers shared the number and kinds of inpatient beds they had available, often to the surprise of hospital administrators, he said.  "They were saying, 'There are available mental beds out there and there's this 13-year-old stuck in my hospital for two weeks? What's happening?'"

The first phone calls were "awkward and wonderful at the same time," Archbold said. And things started getting done.

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"Suddenly there was this coming together of two communities who hadn't worked together intentionally before," Archbold said. "We were learning to talk the same language. It evolved into a real grassroots effort. People were showing up to help. There were very compassionate-but-frustrated providers saying, 'This is awful. We have to carve out time from our day to make something happen.'"

Todd Archbold

Eventually, Archbold said, Prairie Care was able to get a grant from the Minnesota Department of Health to create an online portal to match hospitals with mental health care providers. "Hospitals can now enter de-identified information about their patients 24-7," he explained. "We configured the system so we're capturing the right data and getting the information we need to respond in a timely manner." It's kind of like a matchmaking app, Archbold said: "It matches the provider and the patient so a busy ER worker doesn't have to remember all of the mental health facilities in the state when they are looking to place a patient." 

This "beautiful and simple" system, Archbold said, is a key improvement: "We've had 100 kids who have been connected to care who previously would've sat in ERs or been discharged back to home while waiting for another crisis to occur," he said. "We've saving lives. We're getting kids and families out of ERs." 

This new matching system is one of several changes that have been taking place over the last few years to make Minnesota's mental health care system more accessible and open to people around the state. While many Minnesotans in mental health crisis still struggle to find the help they need, insiders say that in many key areas, progress is being made. 

Sue Abderholden, executive director of NAMI Minnesota, pointed to a number of changes made in latest legislative session that were designed to help Minnesotans more easily get the mental health care they desire, even if there's still more work to be done. 

"People always want to know the one thing we can do to make things better for people with mental illness," Abderholden said. "The truth is it is not one thing. It is multiple things." 

'Value-stream' process, outpatient expansion

One thing Allina Health has been trying to change is how to serve people with mental health needs who arrive in the system's 12 emergency departments, said Joe Clubb, Allina's vice president of mental health and addiction services.

"We recognized that we were overwhelmed with the number of patients that needed mental health care," Clubb said. "We'd had significant wait times for mental health care." 

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Since recognizing the problem five years ago, Allina staff started tracking all of the steps that happened from when a patient in mental health crisis entered an Allina ED to when they finally got treatment for their concern. Clubb said the process revealed gaps and repeated steps that slowed the process for patients and made the experience of getting mental health care feel frustrating and exhausting. 

Joe Clubb

In response, Clubb said, Allina "launched a value-stream process — a concept that comes out of the automotive industry," that encouraged staff to look for waste in their process and improve efficiencies. What they landed on was a more team-focused approach to ED-initiated mental health care.

Rather than following the old model, Clubb said, where the patient comes into the ED and waits hours to see a nurse, then a physician then a mental health professional, Allina emergency staff now conduct a team assessment: "When a person in mental health crisis comes into our ED, we do an overhead page. The team comes together. We assess the situation, and then determine how best to treat the patient." 

Another approach that Allina has taken to mental health care is moving more patients away from inpatient hospitalization and into day-hospital programs. These programs, which typically require participants to spend a significant part of their daytime hours in group and individual therapy while allowing them to spend nights in their own home, have proven to be less expensive and just as successful for many people with mental illness, Clubb said. "We've recognized that inpatient care is not always the best option for people."

With that conviction in mind, Clubb added, "We have significantly expanded our partial hospitalization and day treatment programs and our outpatient addiction programs. We've built more options for patients at Allina that are alternatives to going to an inpatient bed." 

While some people need inpatient care, Clubb said the outpatient experience is less disruptive while still being impactful in the treatment of mental illness. Allina now has more mental health patients in their day hospital programs than in their inpatient hospitals. "We have 250 inpatient mental health beds," Clubb said. "We've decided to maintain that number, not decrease or grow it, and then grow the heck out of our day hospital programs." 

Allina behavioral health leaders have leaned heavily into this approach, with a 30% increase in outpatient programs in 2021 and 15% more in 2022. Today Allina offers outpatient mental health slots for some 750 children and adults across the state, in the Twin Cities and in Faribault, Cambridge and Hastings. "We are trying to bring those services to where people live so they don't have to travel long distances," Clubb said.  

New care options available

Another health system that's undergone drastic changes In the past few years is M Health Fairview.  Some moves — like the closure of St. Joseph's Hospital in downtown St. Paul and its addiction treatment Unit 2700 — caused controversy. Others — like repurposing the hospital as a Community Health and Wellness Hub — won praise. 

Some more recent changes at the health care organization have helped to reduce wait times for patients in mental health distress, said Lew Zeidner, M Health Fairview vice president for mental health and addiction. 

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"Part of what we've been trying to do is reduce some of the strain of the delay and identify patient needs accurately," Zeidner said. One strategy the organization has adopted is creating an EmPATH unit alongside the ED at M Health Fairview Southdale Hospital in Edina. The unit, designed to offer focused, alternative treatment to patients in mental health crisis, has been successful, with fewer people lingering in the system's EDs, reducing hospital admissions, and getting the care they need in a more calming, relaxed environment. 

Lew Zeidner

Before EmPATH, Fairview Southdale admitted about 45% of patients who came to the ED with mental health or substance use into the hospital, Zeidner said. Today, he said, the overall number is 18%, with only 11% admitted after EmPATH and 21% admitted after traditional treatment in the ED.

"The EmPATH provides a more ideal space in which to manage a crisis, the staff are all mental health professionals and there is more time to deescalate the crisis, manage medications and connect them to the next level of care," Zeidner said.

The COVID-19 pandemic caused a big jump in demand for ED treatment from people seeking care for their physical health, Zeidner said, but despite the chaos this caused, M Health Fairview was still able to reduce wait times for behavioral health visits: "With the EmPATH unit, we've been able to more accurately identify who needs outpatient vs. Inpatient care and direct people to the right care." 

With a goal of easing the transition to psychiatric care, Zeidner said M Health Fairview also opened something called "a transition clinic, focused on bridging from the identification of need to the appointment with a psychiatrist." The transition clinic, located in the Community Health and Wellness Hub in St. Paul, is open every day, he said, so behavioral health staff can help patients manage their medications, identify needed medication changes and support them until they get an official appointment with a psychiatrist or are referred for partial hospitalization. 

For cases that don't originate in the ED, most of M Health Fairview's clinics now have mental health providers on staff, so primary care physicians can easily help their patients build connections for care. 

Having easy access to a mental health professional allows "primary care docs to make an introduction on the spot, or to drop in and say, 'I'm working with this person. They seem to struggle with anxiety or sadness while they were here today. Can you help them make connections for mental health care?'" Making early identification and treatment of mental illness convenient can help to nip a problem in the bud, before it reaches a point where a patient and their family feels they have no other option but to head to an ED. 

Sometimes when a person is admitted to the hospital for another issue, like a surgery or a birth, physicians or other caregivers notice a mental health issue that needs attention. Zeidner said M Health Fairview has recently created a consult liaison service, where clinicians can identify symptoms of potential crisis and intervene by making connections to mental health providers during the course of treatment. 

"We're having clinicians ready to see patients while they are already in the hospital so they can clearly identify symptoms and intervene early so patients can be treated before the situation becomes a crisis," Zeidner said.  

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