Mundt: Kevin, we saw a little bit in that report, in general terms, the trend over the last forty to fifty years, from a more centralized form of care to a community-based care. I want to ask both of you in a moment about some of the ways in which that’s worked, but I think what we're hearing from the report -- as I saw you nodding your heads as you were thinking about some of the issues we're facing in Iowa -- that there's some things that we've not done exactly right over those past forty or fifty years. Your thoughts?
Concannon: Yes, exactly. As the author pointed out, the hope was in the '60s when the Community Mental Health Centers Act was created -- we currently have about 33 community mental health centers in our state here -- that they would receive extended federal funding over many period of years. That funding really is very short lived, and they receive a modest amount now. But principally, their funding comes from counties, from the Medicaid program, and some state funds, with a limited amount of additional federal mental health funding.
The advent of medications, basically psychiatric medications, to which I know Dr. Sieleni can speak to directly, was one of the principal reasons why many people could successfully either leave the hospital or never come to the hospital, but there are huge gaps.
Iowa is a state where we have 99 counties. We have a principally county based system of mental health care at the community level. Many of those counties have robust, what I would say rather full-service systems, but many have what I call mental health systems light, the very lean.
And we are particularly I think vulnerable in not having consistent emergency mental health care across the state, as well as we have a very varied system of mental health care for children. There are many challenges on that front.
And Dr. Sieleni I think day to day can speak to the fact that many people -- and I certainly subscribe to that belief -- that our correction system has become, by default, the nation's mental health system, not just here in Iowa but across the country.
Mundt: Dr. Sieleni, do you agree?
Sieleni: Definitely. There used to be approximately 560,000 people in state hospitals across the country. Now there's about 60,000 people. Most of those people have gone in the opposite direction, into corrections across the country. It's unfortunate because corrections was never geared, nor was it ever meant to take care of those type of people. And now it's a huge paradigm shift for people who have to work in corrections to now take care of the mentally ill.
Mundt: And the mentally ill, many of whom may -- I don't want to diminish the crimes that have been committed, but in some cases I've read that they're along the lines of petty crimes over a period of time and these individuals and they may not be aware of what they've done or the impact it's had on others. They're being put into a system where they're incarcerated along with others.
Sieleni: It is true. And in our populations currently -- and Iowa is keeping good records of our population -- we have a population of about percent 40 which are mentally ill in general. But we have a large population, about 28.6 percent, of which are seriously mentally ill. That means those are people who were probably at some point, a lot of times at the time of their crime, were pretty ill, were psychotic, were out of touch with reality and did indeed commit a crime. Some of those crimes were not as heinous as people would like to believe but, over a period of time, they've ended up in a correctional system.
Mundt: Are all criminals mentally ill?
Mundt: No. You said 26 percent.
Sieleni: 28.6 percent.
Mundt: 28.6 percent, that's higher than many of us would think.
Sieleni: It is and it's actually a little bit higher than the national average would be. The national average is somewhere between 16 and 20 percent. But as people are refining their data sets more and more -- and Iowa is fortunate enough to have electronic records, so we actually have a pretty good refined data system -- we're finding that the numbers are actually probably higher.
Mundt: Medication has played a role in helping a number of people leave the system. Did it also, in some odd way, contribute to some of the funding cuts that came later, when they saw success, they began cutting funds, congress or state governments?
Sieleni: I think the assumption was that people would do better on medications, that they could take care of themselves, that medication would be the panacea. Certainly during the 80s that was felt to be kind of true. The unfortunate outlook was that you can give someone a pill, but you have to help learn to live life.
A lot of people who were institutionalized has been institutionalized for years and years, and a lot of the community-based systems that have been successful have take people who have been locked up for years and put them in the community, but offered significant community support to keep them out of prisons and out of hospitals.
Mundt: Kevin, I saw you about to say something a moment ago.
Concannon: I was reflecting when dr. Sieleni was speaking, the mentally ill -- the people have almost been devalued. They've been stigmatized. And I think that has reflected itself in national policies.
I recall years ago "NAMI," the organization that Dr. Sieleni represents here in the state, advocated very powerfully nationally saying we need to put more research dollars into mental illness compared to some of the other biological illnesses because it affects so many people in our communities. We still see that stigma often attached to people.
I can recall associations with professionals, lawyers who said I'm not going to seek counseling because later on it may adversely reflect on my resume when I'm applying for a job and being considered for judgeship.
We wouldn't say that if a person had diabetes, but yet we still -- and the majority of people with mental illness are not violent, and we don't have to worry about their assaulting us. But these stereotypes develop and they hurt the cause greatly.
Mundt: DHA is undertaking a program to try to begin to change that. What is the game plan for beginning to change those issues?
Concannon: I think as was stated in the piece that we saw earlier, I think people need the relationships, the friendships. We need to personalize this so that it is very much the personal next door to you -- your brother, your uncle, your cousin, what have you -- and it's not a label, it's not a tag, so to speak, it's another human being, a person. Ironically, I think that's one of the pluses, if you will, of people being served in the community.
Years ago it wasn't all beautiful when everybody were sent off to an asylum. There were down sides to that clearly. And what we need to do -- we sort of have this American tendency to go one way or another, and we need something sort of in the middle where we have more capacity to serve people when they are going through a difficult period, but we also need to welcome them in our communities. They're among us right now. We need to support them.
We don't have adequate housing, as the piece pointed out. And we don't -- it varies -- the variability is tremendous from county to county in our state in terms of their capacity to provide service and care.
And the contrast I often think of, we do a better job as a state and as a society for people with mental retardation. Why is that? There are comparable needs often. And I think some of it is we don't have the judgmental approach toward people with mental retardation. We recognize that therefore the grace of god go I, that could be any one of us.
Yet we still have sort of, I think, primitive ideas about people with mental illness that somehow blame them, and we haven't put the financial resources in there to follow their needs or to meet their needs.
Mundt: Dr. Sieleni, I want to ask you a couple recommendations that Mary Beth Pfeiffer has made in her book. I'm sure she'll be talking about it at the conference coming. One has to do with moving the mentally ill to special prison units, where they can be separated from inmates. And she also said that mentally ill people should not be held in solitary confinement. Are those workable ideas in the Iowa system?
Sieleni: The first one of the many of these separates areas, currently the department of corrections in Iowa has what I call special needs units which house those people which are mentally ill. We have several of them across the state. Ideally that is a good way to do it. We've develop a continuum of care, though, where people go from being very sick to pretty well, and we would like to get them into the general population.
Certainly we would like to have people be able to function as they would in the community, which should be the goal, period, because a lot of these people have to go back into the community. Not all prisons are, shall we say, violent. So I think it is a good thing, actually, to move them across the continuum and start out maybe in a system whereby they might be alone. Her second recommendation was --
Mundt: It was about solitary confinement.
Sieleni: I firmly believe that keeping people in solitary confinement for long periods of time doesn't help. It makes it works. But the bottom line is you need to develop programs and treatment for people so that you can keep them out of solitary confinement and keep them functioning in the prison system. It's a problem and it's certainly something that can be worked on.
Mundt: I hate to say we only have just a few seconds left, about 30 seconds left. But I want to do get something in about children because this came up in the report. Something that is -- is there one thing that the state can start doing that gets us on a better path to dealing with children with mental illness?
Concannon: Well, we’ve already started. In the past year we have a new mental health waiver for children to receive long-term care who previously their parents terribly had to relinquish the custody in order to get longstanding or long-term public support. We're in the middle of that. We have about 540 children being helped by that. But we also have an initiative under consideration for the next legislative session that would put more mental health resources into schools. That's where kids are every day. I need to say one thing --
Concannon: Kids and adults, we have a serious work force shortage in mental health care in our state, starting with a shortage of psychiatrists, nurses, physicians, social workers, and others. And we need to address that as a state because, if not, we'll be worse off down the road.