First in a four-part series

For rookie patrolman Tim Cotten of Hampden it was an education about the multitude of holes in Maine’s mental health services.

On a Sunday in 1989, Cotten apprehended an out-of-town resident claiming to be Jesus Christ. The out-of-town resident, who was visiting relatives, had ripped the phone out of the wall after a family member dialed 911. While his family cowered in the bathroom, he then threatened to chop down the door with an ax. Then he ran from the house on his way to a local church service, and crashed his car into another vehicle.

Cotten thought he had apprehended a dangerous psychotic who needed to be institutionalized. “I just couldn’t believe what happened,” he says today.

At Eastern Maine Medical Center, the man alternately acted politely, screamed obscenities and threatened people. Cotten handcuffed him to his bed while hospital officials figured out what to do.

EMMC refuses to admit patients to its psychiatric ward involuntarily. Bangor Mental Health Institute (BMHI) also refused to take Cotten’s prisoner, saying it would be a conflict of interest because he had once worked there, and also because he now lived in southern Maine, outside its jurisdiction.

Calls to Augusta Mental Health Institute, Maine’s other public psychiatric hospital, were likewise futile. AMHI admissions staff wouldn’t take him because he needed weekly medical treatments for a chronic condition.

Efforts to call an after-care social worker, who had helped the man several years before after he had been released from BMHI, were unsuccessful because she had an unlisted telephone.

“No one in the emergency room at this time could believe that no one would take this man to commit him. Basically it was a pass the buck type of thing,” said Cotten.

The patrolman was forced to arrest the man on trumped up charges and incarcerate him in the Penobscot County Jail for the night. The next morning the charges were dropped, and he was released by a judge even though he still exhibited obvious mental problems.

Hampden police felt obliged to keep him at their station most of the day until EMMC agreed to admit him because he needed medical treatments. Finally, a mutual agreement was reached, and he was admitted voluntarily to the hospital’s psychiatric ward.

Cotten saw first hand many of the cracks in the state’s mental health system. He discovered there are no special places to take people having mental crises. He saw how difficult it can be to get people with serious mental problems admitted to state mental hospitals, and how jails and shelters are used instead.

Such experiences are increasingly commonplace, say observers. While dedicated professionals conduct a daily battle to help the growing legions of the mentally ill on the streets of Bangor and other Maine communities, gaps in services, some growing bigger, make it all but impossible for many seriously mentally ill to get adequate care.

In BMHI, patients are subjected to a minimum level of treatment and supervision. Out on the streets, however, mentally troubled people are guaranteed neither a home nor food, health nor safety. A few roam the streets filthy and confused, forgetting or refusing to take their medicine, unable to find their lodging if they can afford any, the butt of public fear and loathing.

Deinstitutionalization, the policy made possible by powerful mind-altering drugs a few decades ago, has virtually emptied asylums. In the early 1970s, BMHI had 1,200 inmates cared for by about 400 employees. Today there are 270 cared for by 550 employees.

Most people mention two major gaps — the lack of crisis stabilization services to deter BMHI admissions and help the large number of people the hospital won’t admit, and the lack of housing, especially supervised housing outside of institutions. Day programs and supervised job programs are also in short supply, they say.

The inadequacy of supervised housing and crisis services has contributed to at least three deaths in the last few months.

Craig Hinson, charged in the Sept. 7 strangulation murder of his uncle, had been evicted from a supervised boarding home for the mentally ill a couple of days before in Bangor. After several brushes with police and unsuccessful requests to have his mental condition evaluated, Hinson was taken to Monson by his mother where he allegedly killed his uncle in the belief that he was wrestling with the devil.

Julie Comer, a BMHI patient who had been living with her disabled mother prior to her last hospitalization, fled the institute in February and was found frozen to death two days later. Facing a mental crisis, Comer had a choice between little or no treatment, and being locked up at BMHI, a place with unpleasant memories. Critics charge that had some sort of supervised but less restrictive setting been available her death would not have occurred.

Jeannie Azzarello, an ex-BMHI patient who had been wandering the streets of Bangor homeless, hungry and having hallucinations last summer, was found near death Sept. 24 in a room in a Bangor boarding house where she lived alone. She died from not taking her insulin for diabetes. A last-minute communications breakdown among BMHI, EMMC and Community Health and Couseling Services personnel prevented her from being evaluated for admission to BMHI.

Patchwork system

Responsible for heading off such disasters is a patchwork system of competing local agencies responsible to a similarly divided state government hierarchy.

Maine, like other states, has evolved two systems of mental health care, concludes a report by the Maine Health Policy Advisory Committee. One is composed of local agencies, dominated by large regional bureaucracies like Community Health and Counseling Services of Bangor that serves thousands of clients including about 650 severely mentally ill people. The other system is run by the state in its two mental hospitals.

The relationship between the state’s mental hospitals and community mental health centers is “antagonistic” or “non-existent” depending on who you talk to, concluded a Boston consulting firm for the Maine Public Health Association. The consultant also noted an ongoing “turf war” between the state’s Departments of Human Services and Mental Health and Mental Retardation, whose programs jointly affect the mentally ill.

“The state’s eight (community mental health centers) are, in fact, the heart of Maine’s problems; for at least 10 years they have operated a system independent from the hospitals and essentially unregulated by the Department of Mental Health and Mental Retardation. They have their own supporters in the Legislature and so have been able to resist all efforts to integrate them into a broader public psychiatric care system,” concluded a report produced by the Public Citizen Health Research Group and the National Alliance for the Mentally ill.

“The historical turf battle between the state institutions and community-based service providers is still alive throughout the state of Maine,” wrote one local service provider last year. Robert Croce, an administrator at Community Health and Counseling Services of Bangor, complained that in starting a half-a-million-dollar day-hospital for former patients at BMHI instead of out in the community, state officials were violating their own policy of encouraging community services.

The program is much better staffed and financed than programs with similar aims in the community, prompting critics to charge that it exemplifies how the state has a double standard when it comes to funding hospital and community programs.

The program is one example of state spending priorities that have created a threadbare community mental health system. Maine’s expenditures per 1,000 residents are the highest in New England for state hospitals, and the lowest in New England for community services, according to the Maine Council of Community Mental Health Services. That’s despite the fact there are hundreds more seriously mentally ill people living outside the hospitals.

At the state level, communication is poor. “There’s a major communications problem between the Department of Human Services and the Department of Mental Health and Mental Retardation. They obviously don’t know what each other is doing which makes it hard on the receiving end,” said Bonnie Brooks, executive director of Opportunity Housing Inc., a Bangor housing developer for the mentally ill and retarded.

Communications at the local level is often fragmentary as well, and ex-mental patients are the victims. “There’s so little cooperation between agencies,” said Susan Brainerd, director of the Greater Bangor Area Shelter. “I end up with folks with severe psychological needs that I’m not aware of. … Oftentimes the excuse for that is the need to maintain client confidentiality.”

Funding inequities

The system has spawned a funding hodgepodge fueled by the political clout of competing programs. “The money doesn’t follow the clients. It follows the good old boys,” said Charles Tingley, a Bangor psychologist who contends his rehabilitation programs have been snubbed by the state after years of conflict with them.

“We build these agencies like a house of cards, and lose sight of the individual needs of people,” said Brooks, of Opportunity Housing Inc.

The haphazard funding system is reflected in the fact that some areas of the state get more money per capita than other areas, and hence have more services.

For example, in 1991 Region II (Penobscot, Hancock, Washington and Piscataquis County) received $2.70 per citizen for crisis intervention compared to $4.34 in Region I (Aroostook County) and $3.52 in Region III (Kennebec and Somerset counties). For housing it received $1.22 per citizen compared to $4.49 in Aroostook and $3.77 in Region V (Cumberland and York counties).

Local officials blame lack of funds and state priorities for the differences. But Robert J. Harper, director of the Bureau of Mental Health, said the differences among regions have as much to do with choices the big community mental health centers and other agencies have made in deciding whether to apply for the funds that are available.

When Maine is compared to the rest of New England, further gaps are evident. “…in services for seriously mentally ill individuals (Maine) is not close to the level of neighboring New Hampshire, Vermont, Connecticut or Rhode Island,” concluded the report of the Public Citizen Health Research Group and the National Alliance for the Mentally Ill last year.

Money is not the only important variable. Of the four states, only Connecticut spent more per capita on mental health services than Maine.

Future unclear

The future for mental health services in northern and eastern Maine is unclear. They will be affected by such factors as the current state funding crisis, the implementation of the AMHI Consent Decree and the opening of a new psychiatric hospital with 100 beds next year in Bangor.

The AMHI Consent Decree, a court order precipitated by poor conditions at AMHI, ordered drastic changes — more deinstitutionalization — but this time with accompanying community services. All areas of the state will be treated equally, as if the decree applied to more than southern Maine, said Harper. But plans do not address historic inequities in services, he said.

“We intend to fully fund the AMHI Consent Decree and make sure Bangor is treated well,” said Gov. John R. McKernan.

The Department of Mental Health and Mental Retardation has proposed spending $1,221,529 for community services in northern and eastern Maine in fiscal 1992. There’s still no money for any new services in either northern or southern Maine in the governor’s budget proposal, but McKernan said he intended that “most of it” be funded.

Such promises have a hollow ring to some in the Bangor area. The state’s budget crisis has engendered an air of pessimism.

“The budget at this point is driving policy,” said Sen. Stephen Bost, D-Orono, a member of the Legislature’s Human Resources Committee.

“The reality is that (things) are not happening. The shelter is functioning as an old fashioned settlement house. We’re putting our fingers in all kinds of places in the dam,” said Brainerd of the Greater Bangor Area Shelter.

“The situation has gotten a lot worse,” said Dennis King, a vice-president of Eastern Maine Healthcare, the parent corporation for EMMC.”People are anxious. They don’t know what’s going to happen. Are they going to lose BMHI?”

“Downsizing” at BMHI has already begun. BMHI closed its discharge unit Feb. 1, and seven patients were released to the community. Many jobs have been cut, but a proposal to close the hospital’s half-way houses was shelved.

While officials say there are no immediate plans to scale down BMHI further, a recent state report called for closing it and replacing it with a 50-bed institution.

Observers at EMMC, the Greater Bangor Area Shelter and other agencies sense admissions have been tightened, especially for the most severely mentally ill who have not benefited from treatment in the past, and for alcoholics.

“Yes, it’s harder to get patients into BMHI,” said Lynn Gagnon, head nurse in EMMC’s emergency room. “It’s harder to get them through the system and treat them.”

Superintendent N. Lawrence Ventura denied that standards have changed. Admissions have actually increased, he said, but “more active treatment” in the past couple of years has shortened stays and reduced readmissions.

Meanwhile, the finger pointing continues. “The whole system blames somebody else,” said William Donahue, a BMHI social worker.

Tomorrow: Police and the mental health system.