For Wounds Long Unseen and Neglected

When individuals with mental illness live in underserved communities, without adequate mental health care, they often seek antidotes elsewhere: Many try to self-medicate with alcohol or illegal substances. Some resort to retail theft or other petty crimes to get by. For others, a mental health crisis may escalate to a point where they become a threat to themselves or others.

In Chicago, the police are the first to respond in nearly all of these instances, and in areas without easily accessible treatment facilities, police frequently transfer individuals with mental illness to emergency rooms or the Cook County Jail.

“The unfortunate problem is, the police across the country have become a very bad taxi service—or I guess we should now say Uber service—for people with mental illnesses,” says Mark Heyrman, a clinical law professor at the University of Chicago and former president of Mental Health America of Illinois. “What’s really often needed for a huge percentage of folks is some place to go to be safe for a while, and then be connected to other services.”

As part of a new push toward citywide behavioral health reform, the Cook County Health and Hospitals System (CCHHS) worked with Toni Preckwinkle’s Justice Advisory Council to introduce an alternative that’s more like what Heyrman describes. The twenty-four-hour Community Triage Center (CTC) in Roseland, which opened on July 26, aims to provide a stable and immediately available environment for individuals with mental illness and those recovering from substance abuse.

“If we have resources in the community that can provide immediate intervention and de-escalation, there will be less people that come into the jail,” says Cara Smith, a spokesperson for the Cook County Sheriff’s Office, which has been involved in the triage center undertaking. “There will be a new option for the law enforcement.”

According to Kenya Key, chief psychologist of Cermak Health Services (the CCHHS provider at Cook County Jail), the CCHHS chose Roseland as the site of the CTC after analyzing the home zip codes of people with behavioral health conditions brought to emergency rooms or detained at the jail, identifying the Far South Side as an area in dire need of expanded care.

“We believe the community stakeholders all see the need for a triage center in the area,” says Key.

The CTC staff includes on-call psychiatrists from CCHHS and licensed clinicians, social workers, nurses, and peer counselors contracted from Community Counseling Centers of Chicago. They offer care to self-presenting individuals regardless of insurance status, including those brought in by friends, family, or law enforcement, and those released from the jail. The triage process begins with an overall mental and physical health assessment, after which a patient in crisis is appropriately stabilized. Then, before release, the CTC staff assigns each patient a case manager and an outpatient behavioral health specialist for continued care. Unlike hospital visits, which may span multiple days with around-the-clock surveillance but involve little actual care, visits to the CTC are generally not meant to exceed twenty-four hours.

These resources come at a time when the city’s mental health services are having a crisis of their own. In 2012, Mayor Rahm Emanuel shut down six of Chicago’s twelve public mental health clinics, including four on the South Side. Since then, budget cuts caused two state-run mental hospitals to close, and even privately operated facilities that have been serving more low-income patients through the Affordable Care Act and the expansion of Medicaid have either reduced staff and programs or gone under entirely.

Smith says these closings have had a devastating effect on those who depended on these facilities for medication, rehabilitation, and therapeutic services over the past four years.

“There’s no capacity in the community, or very little, and so law enforcement, when faced with someone who’s in a mental health crisis, has virtually no option but to arrest them and bring them to a jail,” she says. “And we saw the population of mentally ill people in the Cook County Jail explode.”

According to Key, twenty to twenty-five percent of detainees at Cook County Jail receive psychiatric and substance abuse treatment from Cermak Health Services, but the Chicago chapter of the National Alliance on Mental Illness reports that up to sixty percent of all detainees have underlying behavioral health conditions—the jail has been called the nation’s largest mental health institution. Furthermore, jail conditions are often traumatizing and may hinder recovery, causing some vulnerable mentally ill individuals to cycle back into the justice system after release.

Key recognizes that these deep-rooted issues in Chicago’s behavioral health infrastructure will not be resolved easily, but she believes the CTC pilot marks an important first step in the direction of reform.

The CTC depends upon the cooperation of law enforcement for these interventions, which may present a notable hurdle given that Chicago police have been criticized for incidents of aggression against individuals with mental health problems. However, Heyrman points to research by Linda Teplin of Northwestern University that found that police are more likely to respond to nonviolent individuals in mental health crises without arrest or hospitalization when they have the option.

“The police have a great deal of discretion with many of these crimes, including trespassing, etc., to not take people to jail but to take them to the mental health system,” Heyrman says.

Plans for the CTC were first officially announced in late February of this year, though Preckwinkle and CCHHS CEO John Jay Shannon had been coordinating efforts after seeing research on the positive effect triage centers had had on other communities. San Antonio, Minneapolis, and Salt Lake City have all reported reductions in emergency room space occupied by mentally ill individuals, as well as multimillion-dollar savings, after implementing the triage center model.

“This is a game changer in terms of our long-term goals of creating healthier communities and addressing the unjust incarceration of people who are mentally and medically ill,” says Smith, the spokesperson for Sheriff Tom Dart. But she also says the collaboration between Dart, Preckwinkle, and CCHHS has further to go in its long-term plan to address behavioral health needs in underserved communities.

“We are trying to provide health care to people, many of whom never have had health care coverage and never have engaged in preventative health care before,” she says. “So it’s not going to happen overnight.”

Currently, the CTC in Roseland only has the capacity to serve a dozen patients a day, but if successful, the triage model could be expanded. Other recent mental health reform efforts have included more Crisis Intervention Team (CIT) training for police officers. The training is intended to teach officers how to respond to situations of mental health crises without excessive force or unnecessary detainment. The CCHHS has also developed a Behavioral Health Consortium through which six community providers collaborate to connect individuals to need-specific care, and has worked to further integrate behavioral health care with primary care providers and clinics.

“People should be cared for in their community. They should not have to turn to the criminal justice system to receive care,” says Smith. “We will not be able to end the criminalization of mental illness or unjust incarceration of mentally ill and vulnerable people until we have built capacity in the community to care for people.”