About five years ago, Diego (not his real name) was arrested by police after he broke into a church on Saipan and damaged some items inside. He was soon brought to the Commonwealth Health Center’s psychiatric ward after it was determined that he was suffering from a psychotic episode, with hallucinations and paranoia as his main symptoms.
After three days at the hospital—the maximum amount of time that one can be committed at the psychiatric ward—Diego was let go. It appeared that he had improved, thanks in large part to the treatment he got at the hospital. However, once he was out again, he neglected his treatment and soon began exhibiting the behavior that got him in trouble in the first place. About a month later, he hanged himself.
An examination of how the Commonwealth takes care of its mentally ill shows a fragmented system that, instead of fostering a system of treatment, empowerment and inclusion, perpetuates a vicious cycle that have them cycling through the police, prison, the hospital, and then release, only to go through the same cycle again when their conditions worsen.
The problem becomes magnified when the individual’s mental illness deteriorates to the point of violence, when families have no recourse or options on whom to approach for help.
Esther Muña, chief executive officer of the Commonwealth Healthcare Corp told Saipan Tribune that in the event a person with mental illness becomes violent, the first recourse is to call the police.
“The Department of Public Safety is responsible for safety so they should be called. The people who are being violent have to be protected as well, so it’s DPS and not CHCC’s [responsibility]. When anyone is violent, you should call DPS or call 911. DPS will then determine if the patient needs to be brought to CHCC. Our staff may need to be protected too. We cannot care for individuals if our staff is in danger as well,” she said.
Cops lack training
DPS Commissioner James C. Deleon Guerrero said giving police this responsibility is also problematic since, as a law enforcement agency, DPS lacks sufficient training when it comes to dealing with mentally ill individuals who are violent.
“Right now, honestly, our department I think is still ill-prepared to deal with these type of individuals,” said Deleon Guerrero.
He said the question for police officers is how to confront a mentally ill individual who is being violent in a manner that subdues their violent behavior yet still respect their rights.
At the moment, Deleon Guerrero said the department is working with the Community Guidance Center on how to deal with mental issues.
“In particular, our focus right now is to see how we can align or leverage their counseling services for out law enforcement officers,” he said.
Deleon Guerrero said they are looking at having someone at the CGC provide some kind of training or be able to access somebody who has the necessary skills to train CNMI police officers on how to deal with mentally ill people with violence tendencies.
The commissioner said there are certain triggering mechanisms that authorize them, for example, to bring an individual straight to a psychiatric ward.
“We usually bring them to the emergency room, and the doctor does the evaluation and admit them to 72-hour involuntary commitment. But whenever we do that, normally what has to happen is that somebody from the family has to sign off for that individual to be admitted at the psychiatric unit,” he said.
Deleon Guerrero said they also exercise a degree of caution when it comes to dealing with these types of individuals.
“There’s normally a lot of communications prior to just arresting them,” he said.
He said whenever they bring such a person, for example, to the Department of Corrections, the next step would be to communicate with the prosecutor’s office, and have the person brought before the court, which then determine whether or not that person should be brought to the hospital for psychiatric evaluation.
A permanent solution
There appears to be no permanent solution, though. Once the person is released after the 72-hour hold at CHC, their treatment stops and they relapse again.
According to Muña, if a patient or person with mental illness is arrested, it will be the decision of the court whether to refer them to the hospital. If transferring custody of the patient to CHCC, a psychiatrist’s evaluation is needed.
“We don’t put involuntary hold unless the doctor orders otherwise. In other words, we just don’t, because patients have their rights. Everybody has a civil right to be free. If people are admitted into the in-patient ward for psychiatric evaluation, it has to be for acute reasons,” Muña said.
“Our obligation is if the patient is admitted by the order of the physician and that is if you’re going to hold the patient for a 72-hour period it has to be justifiable. After the 72 hours, the patient has the right to walk away,” she said.
Besides the lack of long-term options for treating a patient with mental illness, there are also no permanent psychiatrists at the hospital. Guam-based Dr. Laura Post visits once a week to provide psychiatric treatment.
“We do have a psychiatrist from Guam who comes weekly who can treat their conditions. We also have our 24/7 emergency room physicians that can obtain telephone consults from this psychiatrist on those days when she’s not available until the psychiatrist returns and is able to provide a face-to-face evaluation and management,” Muña said.
She said they are looking into providing full-time psychiatrists and are also working on reopening the Transitional Living Center for patients who have behavioral health issues.
“We feel that behavioral health, in order to treat it, we have to make it accessible and we need to provide it. We need to provide those services. Opening TLC is significant as it is where they can have access to nursing care, and what activities will they have,” Muna said.
Numbers and statistics of patients currently in the psychiatric ward is confidential.
Who pays?
Muna said that Medicaid usually pays for these patients. Those who have Medicaid will often pay for acute care; however, it is a lot different for chronic care.
“They usually have Medicaid, probably or might also qualify for Social Security Income for disability. Medicaid, in my understanding, if they are SSI patients or recipients, Medicaid automatically renews them,” Muña said.
‘We are all the same’
James Rayphand, executive director of the Northern Marianas Protection and Advocacy Systems Inc., which advocates for all persons with disabilities, said the way they handle a person with mental illness depends on what the individual needs.
“We advocate for them to receive better treatment and not get abused or neglected. So we are basically the promoters of those who have mental health illnesses. We are all the same and basically those with mental illness, we aggressively advocate for them and work with other agencies as well,” he said.
NMPASI legal counsel Jeanne Rayphand said that what their agency wants to see is the government to be fully trained in handling people with mental illness. She cited Kaye Christian’s case as an example. When Christian was forcibly removed from her home on Rota two years ago, she filed a lawsuit against several government agencies and officials and later won a settlement agreement.
With Christian it wasn’t about her mental illness, yet the government deemed otherwise when she was removed from her home. It was all about how she, as a patient with mental illness, was mistreated by the government and this led to a lawsuit and then a settlement agreement for involuntary commitment back in 2011.
“You may see people with mental illness in the community, some walking around, because you don’t want them to be deprived of their freedom,” Jeanne Rayphand said.
She also noted that years back Dwayne Sibetang went to the hospital but was refused admission because of his mental illness. He then left the hospital and killed someone.
“The police and CHCC staff need to be trained and organized when it comes to treating or encountering a person with mental illness,” Jeanne Rayphand said.
“Budget-wise, they need to have two full-time psychiatrists. Right now only one psychiatrists, Dr. Laura Post, visits the CHCC,” she added.
Muña and Jeanne Rayphand, however, agree that there should be an effort between the community and agencies in forging and coordinating an action plan that will take care of patients with mental illness.
Northern Marianas Protection and Advocacy Systems, Inc.