Grading the States 2006: Montana - Narrative
Montana is a profoundly beautiful state with a strong culture of self-reliance. It also is a vast and relatively poor state, a combination that leads to chronic shortages of healthcare providers, low pay, and a constant challenge to provide quality services. The state also has a significant Native American population, posing its own set of unique challenges to the mental healthcare system.
Montana is the only state in the country that has as many Assertive Community Treatment (ACT) teams as employees of the state mental health agency (5). It also can be credited for taking steps to address structural problems within the oftentimes complicated mental health system. It has a competent data collection system. Services have recently been aligned with Medicaid spending through three regional nonprofit agencies, taking into account local decision making. On the latter initiative, the jury is still out on how well it will work.
What is appalling is the lack of adequate psychiatric hospital beds in Helena, especially when one considers the lack of day treatment programs. Consumers report long hauls in shackles in the back of police cars taking them to the distant state hospital. The practice is not only an assault on individual dignity, but a burden on sheriffs, who are themselves victims of the system's inadequacies. Statewide, there is a need for more inpatient beds - the supply of which is shrinking.
Criminalization of mental illness is tied to capacity issues. If there are not beds in hospitals, it is easier to put people where there are beds - in jails and prisons. Jail diversion programs are needed in Montana. The absence of housing options, providers, and Crisis Intervention Teams (CITs) help fill homeless shelters as well.
ACT teams in Missoula, Bozeman, Billings, Great Falls, and Helena reflect a sensible deployment and a significant achievement. From the perspective of an overall system of care, however, without beds, the ACT teams are like an airplane trying to fly on only a wing and a prayer. Big Sky horizons need to be broader.
Alcohol abuse and co-occurring disorders have been a major problem for Montana, causing the state to consult national experts and develop a plan to address the problem. At a larger level, the Montana legislature has made efforts toward reducing its many highway deaths by outlawing open alcohol containers in vehicles. With alcohol and depression oftentimes underlying suicide, Montana has realized that it has to try to curb the high numbers of suicides in the state. NAMI applauds this first attempt to do just that.
Families and consumers help to get things done in the Big Sky State. It is difficult to see how progress is made at all, given the tiny infrastructure in the state. With such a small existing infrastructure, consumer and family involvement is essential to develop appropriate services. NAMI Montana's advocacy in helping support the development of ACT teams statewide, the first Crisis Intervention Training (CIT) for law enforcement officers in Helena, and consumer and provider education programs has been instrumental in creating services that really work for the people they are intended to help.
Montana's mental healthcare system has the feel of a rural "barn raising" philosophy - people working together with their limited raw materials. Yet if you are a Native American Indian consumer, you may not be connected. There has been little success in bringing this population sector to the table. While this is a challenge with a difficult history, Montana could be a leader here, given its relative success in being consumer- and family-driven.
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