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The jails are filling and Tennessee's managed care system is teeming with people in search of mental health care.

By David Madison

SEPTEMBER 13, 1999:  Dennis Gordon never meant to bother Dolly Parton. Several years ago, while living in a tent in Pigeon Forge, Gordon claimed to be "spiritually married" to the country music star and founder of Dollywood. He jogged along next to Ms. Parton while she passed on a float during a parade in the Smoky Mountain resort town and he once tried to barrow a van from Parton's theme park.

Then, on April 23, 1995, Gordon walked into the Circle E Western store in Pigeon Forge in the midst of a manic attack. He claimed to be the director of the Central Intelligence Agency and Parton's husband. The police were called and Gordon's manic condition escalated after he was taken into custody and reached the jail. According to testimony from officers, Gordon began making threats against President Clinton.

Gordon says his comments were blown out of proportion, but the former UT engineering student was still charged with a felony. It would become the best thing to happen to Gordon in his 15-year struggle with mental illness.

Between 1990-95, Gordon says he spun in and out of county jails around East Tennessee, never committing serious offenses—trespassing, mostly—and almost never receiving any help with his condition.

Once, says Gordon, he was misdiagnosed with depression and given a prescription that only intensified his mania. Then came the alleged threats against Clinton, a trip to the federal mental facility in Butner, N.C., and Gordon's first real shot at recovery.

"Thank God for the feds," says Gordon, who was diagnosed with bi-polar disorder at Butner. "They are trained to treat you like a human being. You don't get that treatment in the county jails."

His condition stabilized by medication and therapy, Gordon is now employed as a staff assistant for the Tennessee Mental Health Consumers Association. He wants to help others break a cycle that continues to ensnare an estimated 19 percent of the state's inmate population. The mentally ill have always trickled into Tennessee jails. But over the past couple of years, this population arrived in a gush, according to a statewide survey completed last November. It found that two-thirds of the state's jails have noticed an increase in the number of mentally ill offenders being put behind bars.

Compiled by a statewide task force working in conjunction with the TennCare Partners managed care group, the survey found that "slightly more than one-half of the Tennessee jails that responded have a program to divert mentally ill persons to treatment." That means nearly half of the state's jails are doing nothing to the stop the swelling flow of mentally ill offenders into the criminal justice system.

"You think there'd be another net, something besides jail," says Gordon, who shares a growing belief that the state's jails have become a dumping ground for the mentally ill. Along the way, beat cops, jailers, detectives, public defenders, and probation officers have become therapists by default. Fortunately for Knox County, there is one staffer specifically trained to assist the mentally ill in jail. In other counties, they must fend for themselves.

But at the federal level, where Gordon eventually found help, mentally ill offenders are being funneled toward treatment. That's not happening in Tennessee's county jails, where mentally ill inmates continue to revolve in and out of a system that's so mixed up, threatening the president may be the smartest move they can make.

"All you have to do is drive under any viaduct," says attorney and psychologist Eric Engum. "What you see are people who are untreated, unmonitored. And the world is viewed by these people as very, very threatening."

Engum, who evaluates the mental condition of defendants in courts all over East Tennessee, says the mentally ill "get put in situations they can't handle. Their internal controls are such that they can't put the brakes on."

So when someone in a paranoid state of mental illness is chased away from a storefront or questioned by a patrol officer, says Engum, minor conflicts often escalate into an arrest. In other cases, the illness clouds a person's judgment in the same way lung disease makes it difficult to breathe. The line between right and wrong vanishes amid delusions about everything from the CIA and to Dolly Parton.

In Blount County, mentally ill defendants parade through Public Defender Mack Garner's office like actors on a casting call. Their stories add to the stress of the job while supplying occasional doses of comic relief.

"There was this woman who's legendary in Blount County," says Garner. "She thought she was a dog and she would chase cars."

One defendant insisted all of his offenses should be excused because "Warner Brothers has declared me officially dead." Another claimed he was allowed to booze to the point of hysteria because Wal-Mart had issued him "a license to drink."

"There was one woman who called me up and said, 'Mack, my neighbor is a witch," continues Garner. "I asked, 'How do you know she's a witch?' And she said, 'Well, she has to be a witch because she's been flying around my house on a broom.'"

The public defender adds, "It's amazing how often we get this sort of person."

While many mentally ill offenders come from low-income backgrounds and are often substance abusers, Garner says his clients don't always match a predictable profile.

"It can happen to rich and intelligent and responsible people," says Garner, detailing the case of one, well-educated defendant accused of assaulting people inside fast food restaurants. At Wendy's, he allegedly attacked a cashier with a pair of scissors. At McDonald's, he's accused of hitting a nine-year-old boy for talking too loud in line.

In another case, says Garner, a man stands accused of kicking in his neighbor's door and brandishing a butcher's knife.

"Everybody agrees that this is a mental health case, but he's looking at major jail time," says Garner. "Even the victim knows this is a mental health case."

For those mentally ill defendants who stick to less serious crimes, Garner says there's nothing to stop them from repeatedly circulating through the system.

"Revolving door doesn't even describe the problem. It's almost as if they're knocking on the jail door as soon as they get out," says Garner, noting his experience with one repeat offender. "He's not afraid of going to jail. He's much more afraid of flying saucers."

Call her crazy, but Patricia Abbarno has noticed a correlation between patients not taking their medication and flying saucers, among other, less delusional signs of mental illness.

While running the now defunct Knox County Mental Health office, Abbarno, a social worker, would assist people who were just beginning to slip into psychosis. They'd stop bathing and eating. Their families would call, worried that they'd also stopped taking their medication.

If someone with an illness wound up in jail, like one inmate who set a mattress on fire while in custody, she'd assist with their care as well. But keeping people on their medication and out of jail was a major part of the mental health office's mission.

Abbarno says her office was closed by the county in 1996 following a combination of developments. "The whole delivery system changed," says Abbarno. Instead of relying on her office, she says, the county turned to the Mobile Crisis team of social workers employed through Covenant Health. This created a different screening process; one that went to work once situations became a crisis.

"We were a prevention," says Abbarno, who made this prediction when her office was closed: "All those people, they are all going to go to the jails... Everything changed and all the pieces fell apart."

Those pieces—the up front, diversion tactics away from jail, the services behind bars, and the so-called "aftercare" that should follow a mentally ill person's release from the Knox County Jail—have never been perfectly assembled in Knoxville or any other place in Tennessee. Like other states, Tennessee intended to build a safety net decades ago when its mental institutions began to scale back. But those plans remain bound in a straight jacket wrapped tight by budget constraints and conflicting ideas about how Tennessee's public health care system should be run. As a result, keeping the mentally ill out of jail is a challenge that continues to grow.

"Beginning with Sen. Robert F. Kennedy's 1965 crusade against the 'Snake Pits,' the big institutions for the mentally ill and mentally retarded came under intense scrutiny," announces the voice of mental health activist Doug McCormick. "With great fanfare, one by one the institutions announced they would be phased out. The money saved was earmarked for community care comprised of outpatient treatment, supportive housing, and assistance for independent living."

This "only partly materialized," continues McCormick's narration. A diagnosed obsessive compulsive who is now fully obsessed with getting the word out about his cause, McCormick assertively clicks through his Powerpoint, computerized sketch history of mental health care. Words read across McCormick's computer screen in a bedroom at Country Club Apartments in West Knoxville. Different messages appear on the screen and McCormick listens to his own clipped narration as it prods on toward a distressing conclusion: "The mentally ill are now trapped in a terrible limbo, caught between good intentions and broken promises."

In Tennessee, the state once housed and cared for 10,000 mentally ill patients in its five public hospitals. Now there are only about 1,000 beds in the state's institutions. That leaves thousands of "outpatient" consumers caught somewhere in between the snake pit asylums of the past and a system of adequate care that's never materialized.

"In a lot of ways," says Ben Harrington, director of the Mental Health Association of Greater Knoxville, "our system is dumping people into the jails."

Since the state began its managed care, behavioral health program called TennCare Partners in 1996, the number of mental health facilities in Tennessee has shrunk from 33 to 17. TennCare Partners asserts that this marks an improvement in efficiency and service, while its critics believe it shows how TennCare Partners has shifted its focus away from preventative care and toward what Harrington describes as "crisis management."

Once a patient is plugged into the TennCare Partners system, one-on-one sessions with psychiatrists and psychologists are abbreviated, says Harrington. TennCare Partners puts patients in contact with a case manager instead, who can offer group counseling, but little else. The system has also slowed the delivery of some medicines.

"You can attribute it to the system being awkward in a lot of ways," says Harrington, citing complaints about prescriptions requiring mounds of paperwork and patients who can't find transportation to their local clinic. "All that can lead to the client being extremely frustrated. You're fueling the frustration level of these folks."

As Dr. Clif Tennison, director of adult services at Helen Ross McNabb Center, puts it, "Prior to TennCare Partners, things were not perfect, but they were continuing to improve." Using grants from the Department of Mental Health and Mental Retardation, places like the McNabb Center found they could serve the uninsured with a fuller menu of services. Since the introduction of managed care, says Tennison, that service has become less complete.

"If you can't provide services adequately," says Tennison, "you're going to have more revolving patients, more homelessness, more incarceration."

Those who do wind up in the Knox County Jail are fortunate to have Rick Sawyer around. Sawyer, a social worker who works on contract from Helen Ross McNabb, screens inmates for mental illness and sets up formal evaluations to see if a person is fit to stand trial. He also assists those who need to remain on or begin taking anti-psychotic drugs while in custody.

Since TennCare Partners started, Sawyer says he's seen a rise in the number of seriously mentally ill entering the jails. The numbers have leveled off in the past year, he says, but the problem persists with as many as one in five inmates suffering from mental illness.

"They've reduced the outpatient service so drastically that people aren't getting the care," says Sawyer. "TennCare Partners is run by the bottom line. The state wants to save a few bucks."

But by not doing enough to stop the mentally ill from entering the criminal justice system, and then doing little to direct them toward care after they're released, the state is shifting the financial burden of mental health care on to the jails, says Sawyer. The cost: as much as $35,000 a year per inmate. Voices on all sides of the issue agree that medicine, counseling and other assistance designed to keep the mentally ill out of jail would cost the state significantly less.

Unfortunately, over the years, Tennessee jails have become not only money pits, but warehouses and incubators for the mental ill. After 30 days in custody, federal guidelines for TennCare Partners—like those for Medicaid—cut off care to inmates. Treatment is then left up to the individual counties. Some keep their inmates medicated, but according to the TennCare Partners survey, only 24 percent of the state's jails offer individual therapy for the mentally ill. This neglect allows inmates with schizophrenia or bi-polar disorder to drift deeper into their own illnesses.

Then one day, the jail door swings open and out walks someone with no medicine, no job, and often no friends or family.

"A jail releases like a jail, not a hospital. It's propping people up for revolving door syndrome," says Sawyer. "There are holes in the net. That is a major hole."

From her stately corner office at Lakeshore Mental Health Institute, Elisabeth Rukeyser looks out over the past and future of mental health care in Tennessee. The recently appointed commissioner of the state's Department of Mental Health and Mental Retardation can see Lakeshore's abandoned Lonas Hall building where patients once toiled for a lifetime in the back wards. Its dark corridors and zoo-like caging rise behind the trees just across Lakeshore's campus from where Rukeyser sits.

Out her window, the buildings offer a view of the past. In front of Rukeyser, resting on assembled pages of a report she recently compiled, is a glimpse of Tennessee's future. It's a calculated look at the growing mass of state residents seeking mental health care. The numbers are telling.

In the last year, 18,000 additional consumers entered the TennCare Partners system seeking care for serious mental illnesses. In Tennessee there are now 52,000 seriously ill consumers tapping into the system, and TennCare Partners has increased its spending by $106 million since 1998.

"We've been more generous than a majority of states," says Rukeyser. "But it's really hard to know how to get the best bang for the buck."

Dealing with the growing number of mentally ill in Tennessee's jails was one of the first tasks Rukeyser took on when the former president of the National Mental Health Association took over the state's department. She assembled a task force that is now looking for ways to keep the mentally ill out of jail and better serve those who do get locked up. Comprised of mental health professionals and representatives from law enforcement, the task force will offer the commissioner its recommendations by January. Until then, Rukeyser doesn't want to make any assumptions about why more of the state's mentally ill are winding up in jail.

"Until we find out what the real reason is," says Rukeyser, leaning forward to draw out her point, "we can't solve it."

A former sculptress who began her mental health career in London teaching hospitalized children how to play with clay, Rukeyser uses her hands to illustrate her points. One hand goes down and the other goes up as Rukeyser describes how over the years the number of mentally ill behind bars has risen while the number of patients in mental hospitals has dropped.

"You have to wonder if there is a link," says Rukeyser, who emphasizes, "I'm not convinced there is any one reason."

To critics of TennCare Partners, Rukeyser offers statistics showing fewer people being referred from the Knox County Jail to the state hospital at Lakeshore. That's significant, because over the last few years, the Partners program has identified a rapidly expanding number of people who were not receiving treatment before managed care came to their aid.

So far, says Rukeyser, there's nothing to suggest TennCare Partners is responsible for nudging more people out of doctors' offices and into jail cells. Rukeyser agrees that TennCare Partners has its problems, but "corrective pieces have come into place."

A piece providing inmates with standardized care, and another that supplies "aftercare" following their release, have yet to be formed. They could emerge from Rukeyser's law enforcement task force as lumps of clay. The commissioner will then busy herself sculpting the suggestions into solutions.

In the encouraging case of Dennis Gordon, a felony charge for threatening the president opened the door to therapy and treatment. Gordon was eventually declared innocent by reason of insanity. It's something he's not proud of and would like to have washed from his record.

But Gordon's story should be remembered because it shows how a run-in with the law can turn a mentally ill person's life around instead of sending it into further despair. While at the federal hospital in Butner, N.C., Gordon says he was playing chess with a fellow inmate when he recognized the upside of doing federal time.

"This guy was loose as a goose," recalls Gordon. "He needed help, so he says he sat down and typed out a threatening letter to a federal judge so he'd wind up at some place like Butner."

Gordon's story doesn't surprise Dr. Steve McNish, who says some mentally ill offenders have discovered the health benefits available inside federal facilities. The director of Midway, Knoxville's federal halfway house, McNish describes his experience with one offender who would run out of medicine and then "Bam, he'd threaten the president again." It was apparently the best way for this repeat felon to get the care he needs.

If the public wants TennCare Partners to step in and provide more intensive care for the uninsured, says mental health commissioner Rukeyser, then something must be done to boost state revenues.

"If there's no tax reform," says Rukeyser, "we are not going to be able to do what we do today."

Raising the sales tax or creating a state income tax are two options, but tax reform in Tennessee is a tar baby no agency is banking on. Mental health care advocates say there are several encouraging movements afoot, however, including a governor-appointed committee that is currently reviewing the state's mental health code and could push for increased services. A team of advocates and administrators is also gathering for regular pow-wows with the Tennessee Mental Health Council, which is looking for ways to improve TennCare Partners and divert the mentally ill away from jail.

Another new development, something called the Program of Assertive Community Treatment, is also in the works. Bids are being taken for a $1 million grant through Premier Behavioral Health that could be used to establish full, wrap-around care for up to 120 mental health consumers. If Knoxville receives the grant, service could begin by the end of the year.

"[The PACT program] plugs all the loopholes and the little cracks in the floor," says Gordon, who spent lots of time slipping through the cracks before his blow-up in Pigeon Forge landed him in a federal hospital.

"If I would have had this," says Gordon. "Man, I would not have had to take the walk I took."

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