Maryland’s poor treatment of those with severe mental illness was exposed last month when Judge Gale Rasin held the acting state health secretary and four other top state officials in contempt of court. The judge found that these officials had willfully disregarded orders to increase the number of psychiatric hospital beds available for criminal defendants, some of whom had been languishing in jail for weeks waiting for treatment.
To those of us who have been paying attention to the failures that characterize Maryland’s “treatment” of people with the most severe mental illnesses, this otherwise shocking decision came as little surprise.
Unfortunately, Maryland has long failed to embrace policies that would ensure that mental illness is treated as the medical condition it is, rather than as a concern for the criminal justice system. Adding to this tragedy, the state is woefully unprepared to meet the demand for treatment, both before and after people with severe mental illness are criminalized.
In part, this is because, for years, the state has hemorrhaged needed state psychiatric treatment beds while population growth has outpaced availability.
As my organization, the Treatment Advocacy Center, reported, between 2010 and 2016 Maryland closed more than 10 percent of its state hospitals — a loss of 108 beds. And what beds remain have largely been given over to forensic patients, who receive care only after they are arrested.
Consequently, since 2005, Maryland has seen a 250 percent increase in pretrial competency evaluations, a procedure by which the court assesses an arrested person’s mental illness and ability to participate in legal proceedings. During this evaluation period, defendants are directed to forensic patient beds — the same, limited number of beds that these people occupy after trial — effectively creating a game of musical chairs with treatment beds, one in which everyone loses. In 2014, the Old Line state reported the third highest rate of such forensic patients in the country.
This is not an isolated problem. Last year, we identified nearly 2,000 inmates across the country in local jails waiting for slots at public psychiatric hospitals. We also estimated that the number of available hospital beds per capita in the United States dropped 17 percent since 2010, leaving it at 11.7 beds per 100,000 population — fewer than at any time since the nation stopped treating mental illness as a crime in the 1850s.
Maryland’s mounting bed loss crisis has left state officials completely unprepared. It compounds this misery by being one of only three states in the country without an assisted outpatient treatment law.
Assisted outpatient treatment programs have a proven record of success at providing care to people who have a demonstrated difficulty adhering to treatment on a voluntary basis and have experienced recurring negative outcomes because of it. In states like Ohio, New York and California, results show these programs can significantly reduce rates of hospitalization, arrest and incarceration.
While not a panacea, an assisted outpatient treatment program could alleviate mounting systemic pressure before tragedy strikes. The establishment of such a program could also have helped avert the state’s current legal predicament by providing treatment before a scenario escalated to arrest and/or hospitalization. A bill was authored in the last legislative session to authorize the creation of this type of program, but it was stymied by a lack of political will.
There are no easy, immediate solutions to the myriad challenges posed by untreated mental illness. Any solution will require decision makers to have the courage to recognize the system’s many existing shortcomings and to take difficult steps to serve this vulnerable population. However, as the judge’s decision makes clear, the problem of providing adequate treatment cannot be solved by simply locking people up and throwing away the key.
John Snook (firstname.lastname@example.org) is executive director of the Treatment Advocacy Center, a national nonprofit that works to eliminate barriers to treatment for people with severe mental illness.