By Barry Blackwell, M.D.

Milwaukee, Wisconsin

The woes of mental health care in Milwaukee have deep and tangled roots, many of them fed by overt and covert discrimination, stigma and deafness to the lived experiences and plight of people and families struggling to cope with the social consequences and inadequate treatment of their ailments.

The largest city in the State of Wisconsin, long (but no longer) known for a progressive political climate has become the place where treatment of those with mental illness is viewed as seriously flawed while the capital Madison, 90 miles to the northwest, is seen as among the most enlightened. How did this come about, are we on the cusp of final remediation and, if so, what must we do to secure and preserve its success?

The ingredients of this tragic saga are threefold and go back over 6o years; the illnesses, their treatment and the politics and economics involved. Each can be viewed separately but are realistically intertwined.

The Illnesses

The worst forms of mental illness are cruel. They can impair thinking, feeling and behavior, beginning in late adolescence or early adulthood and intermittently persisting for a lifetime. Their early onset often disrupts education, emancipation from parents and formation of intimate supportive relationships. Intellectual difficulties, social deficits, stigma and discrimination create employment and economic problems. Taken together the burden on families is often considerable and may become unbearable. The most severe forms can erode a persons ability to see themselves as sick or in need of help, leading to bizarre or frightening behaviors, reluctance to take medications or even, in rare instances, to violence or suicide. All of these handicaps feed stigma and discrimination.

The Treatments

Until the early 1950s treatments were mostly harsh, primitive or largely ineffective, including shock therapy (ECT), insulin coma, surgical lobotomy and psychoanalysis, often accompanied by lifelong incarceration in asylums. The imagery this created deepened social ostracism towards people with mental illness.

The discovery of chlorpromazine in 1952 was followed within a decade by other antipsychotics, antidepressants, minor tranquilizers and mood stabilizers. The result was a dramatic shift from asylums to care in the community during the 1960s. Resources recouped by closing asylums were seldom if ever transferred to provide care in the community. This led to a cycle of relapse, re-hospitalization and release; the so called revolving door.

This was contributed to by realistic but seriously under estimated shortcomings in the available drug treatments. Initially regarded as curative they were mostly palliative, often at the expense of side effects that lowered quality of life and sometimes shortened it due to incapacitating medical complications (diabetes, metabolic syndrome, Parkinsonism, dyskinesia and cardiac conditions). Professional and public over optimism was fed by misleading mega million dollar advertising by the pharmaceutical industry and their corrupting influence on medical education and practice.

The Politics and Economics

From the early 1970s national attempts were made to legislate improved community mental health care at the local level, supported by federal funding. But these became diverted to caring for the worried well who were more easily treated at lower cost and with more success than those with serious mental illness. Perhaps this triggered an important development when patients themselves banded together to start the Fountain House movement in New York. They purchased a property and opened a self-managed daytime community devoted to support each other, developing skills and preparing for employment. The movement spread throughout America and around the world, including the highly successful Grand Avenue Club in Milwaukee.

Among the greatest impediments to effective treatment into the early 21st Century was insurance discrimination. Both government and private insurance was either absent or severely restricted and, even when available, most severe mental illness was excluded as a pre-existing condition due to onset early in life.

When a new Behavioral Health Complex on Watertown Plank Road (a long way from the central city) was opened in 1979 by Rosalyn Carter, it was a state of the art facility with collaboration between the County and MCOW for staffing and management. Unfortunately Medicaid legislated that institutions with more than 16 beds (IMDs) were not eligible for reimbursement and mandated that people with mental illness should be treated in general hospitals where treatment might evoke less stigma, while providing proximity to medical treatment for frequently occurring co-morbid conditions.

Medicaid rates for inpatient care were inadequate, particularly for psychiatric disorders; matters were made worse by Managed Care restrictions and federally mandated brief stays (DRGs). Not surprisingly, during the late 1980s and 1990s, six inner city general hospitals merged, closed or eventually went bankrupt. Two remaining hospitals both closed their inpatient psychiatric units while the Medical College of Wisconsin (MCW) never had a general psychiatric inpatient program.

Outpatient care was also difficult for indigent or uninsured patients to obtain; Medicare rates were so low, most psychiatrists refused to accept them.

This economic environment placed an increasing burden on the County BHD and its services, recreating a scenario reminiscent of the 1960s: an inefficient revolving door between inadequate outpatient care in the community, resulting in repeated re-admissions via the crisis service to hospital beds. The overburdened inpatient services relinquished their national quality accreditation (JCAH) for economic considerations and became plagued by repeated episodes of suboptimal care, including several fatalities that attracted press attention and public blame.

This situation added to the unique (unwelcome) burden placed on law enforcement, as mandated first responders in crisis situations and enhanced the unpleasant experiences of people shackled in the back of a police car on their way to an overcrowded and sometimes poorly staffed inpatient unit.

Finally, inability of the County to bill Medicaid for inpatient services had serious implications for indigent uninsured patients treated at the BHD who were billed for services they could not afford and which may have led to less than ideal lengths of stay.

These adverse economic circumstances created a growing awareness of the problems at the leadership level of the County and BHD based on the local experience and coincided with a national move to transition mental health care from institutions to the community. This was ideologically and economically driven, leading in 1992 to the development of a Milwaukee Master Plan for remediation. It was also synergistic with a growing grass roots movement to empower consumers, family members and advocates seeking a stronger voice in decisions and services. This included a Statewide Recovery Movement, the establishment of a Mental Health Task Force (a coalition of individuals and providers of care), and a federally funded Disability Rights of Wisconsin Organization. The BHD created paid positions for consumer advocates and peer supports in its own programs and those it supported in the community.

Over the last 25 years, politics has played a vital role in the ebb and flow of the promising ideas generated in the 1990s. Politics are governed by forces related to economics and control. The County Executive and Board of Supervisors strive to maintain a balance between quality of services and the cost the public must bear via the tax levy. This in turn is related to politics and the relationship between the County Executive and the Board, as well as the leadership or creativity of BHD administration and their openness to input from the grass roots and advocacy organizations.

The Ament administration provided a congenial and constructive period brought to an abrupt end by the pension scandal. It was followed by Scott Walker and became fallow, driven underground by tension between a Republican Executive, a predominantly Democratic Board of supervisors and their own disagreements about implementing the Master Plan. This would inevitably involve substantial job loss following the predicted closure of the BHD, anathema to supervisors whose re-election depended on the donations and votes of their employee-constituents. In addition they were not well informed or skilled in mental health issues.

When Walker moved on to become governor of the state, new County Executive Chris Abele inherited the existing political and economic dynamics. Aware and approving of the need for change, a new Redesign Plan was drawn up. Although dressed in democratic clothes, Abeles controlling administrative style worsened the tension between Executive and Board. When the Board began to veto his administrative appointments, he resolved the issue by political force, persuading the Legislature (with Walkers acquiescence) to reduce the number of supervisors, radically cut their salaries and strip them of responsibility for mental health affairs. Mental health oversight of his plans would be provided by a new Mental Health Board with members nominated by the Executive and Board supervisors, but initially appointed by the governor.

These changes enabled Abele to assume total control and speed up plans, close the BHD and ultimately sell the facility to offset the cost of funding a complete transition to community care. By the end of 2015, the BHD will have closed its two chronic care facilities, and Abeles administration has just released a 260-page Request for Proposals (RFP) to hire a health care organization to provide all the crisis, emergency and inpatient care when the existing inpatient facilities are closed. This initiative is triggered in part by frustration over failure of the local general and psychiatric hospitals to collaborate with the County although Aurora, Rogers Memorial and MCW-Froedtert remain potential competitors, if they choose, with any out of state for-profit health care organizations that apply and which would be required to build and staff its own new facilities.

Clearly Abeles management style is producing long awaited changes, but with it come drawbacks and concerns. He awarded his Director of Health and Human Services a remarkable $50,000 dollar pay increase, who in turn selected a new head of BHD who is an expert in quality improvement but has no experience in mental health, and who appears to be equally controlling. The new Mental Health Board, selected for its expertise, is being treated as a rubber stamp. Interaction between this board and the existing advocacy organizations has been minimal and discouraged. The Board has no staff assigned or designated and has been overwhelmed by vast amounts of information at very short notice (Including the 2015 budget) that it is expected to approve with minimal input and no changes. The few suggestions members have made have been largely unfulfilled. Since all have full-time jobs elsewhere and their service is unremunerated, energy and innovative ideas seem to be dwindling.

Most troubling is that the responses to the RFP are to be evaluated by a group of experts selected and appointed by Abele with no capacity of the Board to make changes in its composition or members. This is a fatal flaw. Similar experiments elsewhere in community care around the country that are further advanced show a tendency for conflicts to occur between quality and cost of services in which political forces almost inevitably operate in favor of curbing the former at the expense of the latter.

This outcome was recently illustrated when the state legislature, supported by Abele, planned to introduce legislation that would bring Milwaukee into line with all other Wisconsin counties by replacing law enforcement as first responders to mental health crises with teams of mental health professionals. Plans were quietly scrapped because it was too expensive.

Abeles management style and disinclination to raise taxes to adequately fund responses to the RFP may inevitably lead, over time, to drowning out the voices of consumers, advocates and providers of service committed to quality.

The Mental Health Task Force, Disability Rights Wisconsin, mental health professional organizations of all stripes, NAMI and the Grand Avenue Club, as well as all other advocates and consumers, should unite and fight hard to ensure they have a voice in the selection of which RFP responder is selected and, equally importantly, remain involved in sustaining the quality of services over the 20-year term that the contract guarantees.

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Last edited by Tyler Schuster.   Page last modified on July 23, 2015

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