During the last eight years, the number of Marshalltown Community School District students referred for mental health support has seen a significant increase. Roughly 25 percent of students in the district have various mental health conditions, said Matt Cretsinger, the school district director of special services.

“As you follow the information being shared by national medical and mental health professionals, the district is preparing for an increase in the number of children needing mental health care,” Cretsinger said. “We want to be prepared, similar to how we prepared and responded after the tornado struck our community. So if the need is there, we’re in a position to respond immediately.”

Across the district, Cretsinger said the primary issues students deal with are anxiety, stress and everyday life pressures.

“No matter the student’s situation, we are able to focus on teaching them problem-solving strategies for managing their emotions,” Cretsinger said. “The approach is called Collaborative Problem Solving by Dr. Stuart Ablon.”

Contributed photo — Inmates at the Marshall County Jail in December. The sheriff’s office frequently deals with inmates who have mental illness. Hoffman said the jails have become repositories for the mentally ill.

The Collaborative Problem Solving approach is something school district officials have spent a significant amount of time learning. It is neurobiologically-grounded and guides care and empowerment of children. The approach helps identify skills children are lagging and then helps them learn those skills.

“The approach helps us teach our students the skills they need to cope with many of their unique situations,” Cretsinger said.

Students are able to get help from the district and mental health partners — Center Associates, Grace C. Mae, YSS of Marshall County, Life Connections and Midwest Counseling. At Center Associates, 49 percent of patients are under the age of 18.

However, getting access to those providers is an issue identified by Woodbury Elementary counselor Heidi Williams.

She said depending on what agency a family chooses to work with, there can be situations when mental health professionals are booked for long periods of time and families have to wait for services to begin.

Contributed graphic More than 500 residents of Marshalltown participated in the UnityPoint Community Health Needs Assessment at the end of 2019 and listed access to mental healthcare as an important aspect of making the community healthy.

Sometimes, there are situations in which families only speak Spanish and it can be difficult to find Spanish-speaking providers or agencies with interpreters.

“This has been somewhat improved in the past few years and I think that many agencies are aware of this need and are working hard to better meet it,” Williams said.

Finding quality mental health professionals is challenging, Cretsinger said, and when the need for being fluent in another language is added, it becomes more difficult.

“These barriers make it more challenging for mental health agencies to hire enough qualified professionals to consistently meet the needs of our students and families,” Cretsinger said. “They do an excellent job connecting with families and working on getting services to them as quickly as possible in spite of these challenges.”

Getting mental health service to people is not an easy task. There is a lack of mental health resources in Marshalltown, Marshall County and the state of Iowa. There are not enough providers, not enough inpatient beds, not enough funding to handle the rising needs. ATTRIBUTION

Contributed photo Jennifer Daniel of Rapha Reins Ranch, an equine therapy facility in Marshalltown, works with Marshalltown youth. In the Marshalltown Community School District, 25 percent of students are receiving mental help.

The lack of resources and the problems in a complex system is something that is apparent to residents of Marshalltown, as getting access to mental health care was listed as a top concern in a UnityPoint Community Health Needs Assessment released at the end of 2019.

Challenges persist in finding providers

Center Associates is challenged with finding providers. Paul Daniel, the executive director of Center Associates, said the facility is one to two clinicians short of a full-service shop.

“We are struggling to get licensed mental health counselors,” Daniel said.

That struggle is not limited to Marshalltown. Daniel said many rural-based facilities are facing the same challenge.

“Mental health is so rewarding,” Daniel said. “It is a calling and you need a passion for it. As long as I have been here, it has always been a challenge to get care to rural Iowa. Mental health needs are on the rise. There is a mental health provider shortage. We need more providers. The supply is low but the demand is high.”

Not only does Center Associates have to deal with a lack of providers, but also the lack of inpatient care and available beds. Sometimes it is criteria that gets in the way of getting someone in to a facility.

“For example, if a person is suicidal, they are taken to the emergency room and are assessed,” Daniel said. “They need to go to a hospital but there are no beds. I think we do not have enough beds available even if they meet the criteria. People who are having episodes, for example, schizophrenia, may not meet the criteria. If somebody is coming in and seeing things, hearing things, are they psychotic? Absolutely. Are they wanting to kill themselves? Maybe not. So, they do not meet the criteria. They are given a shot and hope the psychosis goes down.”

Sen. Jeff Edler (R-State Center) said the lack of beds is a complex issue.

“People who say there is a lack of beds need to understand how it looks; they need to understand the push of the federal government,” Edler said. “There has been a large shift from institutional care to caring for people in communities.”

Having more programs in the communities that can provide immediate care is something Marshalltown Police Department Chief Mike Tupper would like to see. He wants law enforcement to have immediate access to mental health resources so people don’t have to wait hours or schedule an appointment to see a provider two weeks from when help is needed.

Law enforcement tasked with crisis

Marshall County Sheriff Steve Hoffman said roughly 40 percent of inmates in the Marshall County Jail have mental health problems.

“Nationally, that percentage is 44, so I am not surprised we are in the same ballpark,” Hoffman said.

All of the inmates with mental illness are also on prescriptions, which means jail staff are handling how and when to provide them with their medications.

“It is unfortunate we have had to task our jail staff with acting in a capacity of mental health professionals when they are lay people with additional training,” Hoffman said. “We are not necessarily resolving, curing or treating mental illness so we rely on collaborations to connect individuals with services that can help them.”

Sometimes, the sheriff’s office has to request assistance from the Central Iowa Community Services (CICS) Mobile Crisis Response Team.

“Recently an inmate was released by court order that staff realized was having a potential mental health crisis,” Hoffman said. “We called the Mobile Crisis Unit who then gave them to a ride to get further evaluation.”

Hoffman had to utilize the crisis unit recently when he encountered an individual on the highway.

“This person was in the hospital the week prior and had experienced a trigger,” he said. “Through the phone, I contacted the crisis line and was able to get her to a point where she stabilized.”

Tupper said his officers encounter people with mental illness multiple times per day and officers can be found frequently at the hospital as they wait for a person who was arrested to get a mental health evaluation.

“It is not uncommon for officers to be at the ER for six, eight, 10 hours or more,” Tupper said. “They are there more than once per week, between six to eight times each month.”

The police chief said too often law enforcement is looked at to provide mental health care help, but they are not mental health professionals.

“Folks deserve mental health services,” Tupper said. “Too often we’re pushing these problems onto law enforcement. That’s not fair to people who need help. It’s not fair to our cops. It’s not fair to our community. I would implore our elected representatives to find more funding for these programs that make a difference.”

Sometimes officers deal with the same people repeatedly, in what Tupper described as a revolving door situation. A person gets arrested, goes to jail, does not get the necessary help, gets out and the cycle repeats itself.

“If we want criminal justice reform, we need to start putting resources in our communities that will help people deal with their demons and challenges so we can avoid putting them in jail,” Tupper said.

Hoffman has been a longtime advocate for jail diversion to an appropriate resource for non-violent people who are reasonably suspected of having mental illness.

“Unfortunately, jails across the country remain repositories for the mentally ill with disparate periods of incarceration,” Hoffman said.

Tupper said jail is not the place for people dealing with these challenges.

“Our jails throughout Iowa and the country are becoming the largest mental health institutions and that’s wrong,” Tupper said. “If there is a solution it needs a collaborative approach. It’s going to require more financial resources.”

In the state of Iowa, sheriffs are designated officials to execute mental health and substance abuse committal orders.

“The committal process needs work in that many people believe that when a person is committed, they are receiving the help they need,” Hoffman said. “Many people that are committed, never have a hearing. If it was an emergency committal order, once they are stabilized, the attending physician can release the person and there is no mechanism for follow-up care. The cycle repeats.”

State access centers stalled

Hoffman said one thing that would significantly help the sheriff’s office is a no-reject access center, which is a facility that would not be able to deny service to a person who does not need inpatient psychiatric treatment. The center would take care of people on a short-term basis. That person also cannot be discharged based on the severity or complexity of mental health issues or multi-occurring needs.

House File 2456, signed by Gov. Kim Reynolds in March 2018 calls for six centers to be built with 16 or fewer beds each. The centers are to provide immediate assessments, detox and crisis observation and stabilization.

“If these centers come to fruition, where an individual may be triaged, stabilized and an appropriate level of care follows, I think that is a meaningful step toward reducing the cycle,” Hoffman said.

Edler has been working in the legislature to improve the mental health system in the state.

“I made a promise to the sheriffs to address the issues they are facing,” Edler said. “When I tell somebody I am going to do something, I try to follow through. I have made a lot of progress, but it is not something that can be done overnight.”

Edler said there are no access centers according to the definition of the Iowa Department of Human Services and he is focusing on making them a reality. Benefits of an access center would fall on law enforcement, families and businesses.

The biggest problem in making access centers comes to fruition is making sure there is support for them.

“That is the biggest thing,” he said. “We need to wrap up a set of services and make sure we do it efficiently and effectively and we have to live within our means on the function of budgeting. We need to have support services, which is why I am working on all things simultaneously.”

He had a big role in passing House File 2456 into law. He introduced Senate File 2252 and Senate File 2351 which was passed as House File 2456. Edler said one of the biggest differences between the Senate version and the House version is the Senate version would have allowed regions more flexibility on the spend down requirements.

However, the access centers have not received funding yet.

State regions struggle with funding

Funding for mental health services is something Jody Eaton, the CEO of the Central Iowa Community Services mental health region, deals with frequently.

Eaton suggested each individual community should reach out to providers and see if there are opportunities to fund something not funded by the region.

The region helps secure financing for services — crisis, treatment, support, education and coordination — but funding is limited. Each mental health region in Iowa receives property tax dollars, but legislation was passed in 2019 that requires cash flow amounts of regions to not exceed 40 percent of expenditures. Plus, Eaton said regions do not have the ability to raise money, which is something she hopes is addressed by the legislature.

Providing funding for these lacking resources will not only help facilities bring in providers, but will help people, which is what Eaton desires.

“The stigma of mental health has lessened but it is still there,” she said. “If people have questions, they can call us and they can let us lead them. It is not an easy system to access but we can lead you. We can help you find the right service. Ask legislators to support steady and adequate funding. That is the most important thing.”

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