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Sue Aberholden

NAMI Director: Five Top Issues in Minnesota’s Mental Health System

Our mental health coverage in 2024 is made possible by the Minnesota Association for Children's Mental Health.

For several years we have been connecting periodically with Sue Abderholden, director of the National Alliance on Mental Illness Minnesota chapter to learn more about the status of mental health care in Minnesota — where the pain points are, what legislative policy and funding is needed, and what successes community leaders are engaged with. This is from our most recent conversation, in January 2024, talking about the issues she sees as a long-term voice in mental health advocacy. We asked what we should be doing stories about, and what conversations we need to be having statewide. This is an excerpt from our discussion.


Sue Abderholden, director of National Alliance on Mental Illness Minnesota. Photo Sarah Whiting


Issue #1: Early Intervention

Some of the children that are boarding in the emergency room have very complex mental illnesses. When you have children who are young and have very aggressive behaviors, it seems difficult to figure out why and what can be done.

The mental health system isn’t helping children who have an autism spectrum disorder and an intellectual disability. Mental health treatment involves a lot of talking and expressing your feelings. If you have low verbal ability, it’s pretty hard, honestly, to be engaged in typical mental health treatment. 

We identified back in 2009 that these kids with more complex needs require different treatments. We still haven’t solved that problem. We need to, because we’re seeing more kids with these types of disabilities and mental illnesses. There aren’t really many places for them to go.

In terms of aggressiveness that can lead to inappropriate or criminal behavior, again, we are not doing enough early intervention. There is a program in Ramsey County,  called ACE: All Children Excel. These are kids under the age of 10 who would have ended up in the juvenile justice system if they were old enough. They intervene with the child and their family and turn things around.

There are also early childhood mental health programs to help very young children — some who have been kicked out of child care — that help the child and the family. But these types of early intervention programs are limited.

It is also true, for decades, that more than 70 percent of youth in the juvenile justice system have one or more mental illness diagnoses. I think that has to be part of the conversation. We aren’t intervening early so that these youth are in the mental health system instead of the juvenile justice system. 

When we look at who is in jail and in prison, people who are homeless, it is often people with schizophrenia, schizoaffective disorder, bipolar disorder. I get irate about it — how can we not invest at the early onset of these illnesses in evidence-based programs that work? 

The whole issue of having a locked facility is complicated, too. When you have kids or adults that you’re worried about elopement, you need a locked facility. Medicaid makes it hard to have a locked facility, and I think that’s problematic. I kind of think we should be able to allow locked residential spaces to support these kids and adults.

We haven’t built the places that the kids need. We haven’t put enough money into it. And we haven’t provided early intervention. 

Issue #2: Youth Anxiety

I think we can blame quite a bit of the spike in youth depression and anxiety on the pandemic, in terms of isolation. School-aged youth are supposed to be connecting with their peers, apart from their parents. 

Social media definitely has a role to play. We do know from the student surveys that suicidal ideation is much greater for females than males, and much, much greater for LGBTQ kids. Those are pretty serious things that we need to look at. 

I was talking to someone from Greater Minnesota, where there was a greater view that schools should not have closed. I said we also have to recognize that anxiety and depression went up around the world, not just in the U.S., not just in states and communities that closed their schools. It went up everywhere. 

It wasn’t just the isolation during COVID, but it was also the deaths. The number of people from BIPOC communities in particular who died was greater than the white community. Many children in BIPOC communities lost someone. Death is a traumatic event.

Kids were worried about their parents who were working essential jobs where you couldn’t work from home. There was a lot of things that were scary for kids. Especially if you didn’t have the resources — food scarcity, having limited space in your home, everyone trying to get onto the Internet to do e-learning.

Most adults felt depressed and anxious during the pandemic for at least a day or two. The kids felt it even more — they don’t have as many tools in their toolbox.

Some of the strategies that people kind of dismiss — like teaching kids mindfulness at a very early age, breathing to calm yourself down — those are really important skills. 

Early intervention is critical. And frankly, with legalization of cannabis, we’re going to see more young people experiencing psychosis. We have the first episode of psychosis programs, but we only have about half of the ones that we need.

Issue #3: Voluntary Engagement

If you’re over the age of 18, you get to make your own decisions unless you are under guardianship. It’s pretty hard to get guardianship for someone with a mental illness. Guardianship is about people who cannot make decisions; it’s not about making decisions you disagree with. Even if you had guardianship, you can’t force involuntary medication — you would still have to go through the courts. So it doesn’t always help you as a family member. If you are 18 and over, you’re an adult, you get to make all those healthcare decisions. 

Ages 16 to 18 is trickier, because you can actually consent to outpatient and residential treatment. What we’re seeing in some hospitals is that from 16 to 18, they can make a decision about getting treatment, which means if they refuse treatment, we’d have to do a commitment — except a lot of counties won’t do a commitment for someone under the age of 18. So we have these young people having psychotic episodes in the hospital, refusing treatment. And they’re in limbo, basically.

But the commitment law is pretty clear that if the person is under 18, parents can give consent, unless hospital lawyers are involved who don’t think parents can give consent. It is problematic. If they were 19, refusing treatment, they would get committed. So how can you say that between 16 and 18 you can’t be committed, that we’re going to allow them to make the decisions?

We’re not quite sure what to do with this issue, to be honest. The ombudsman’s office and I have been meeting on it, trying to figure it out — we think the law allows people to do this, and we’re really not sure why they’re not. 

Why do we have to wait till someone is a danger to themselves or others? How can we possibly walk away from someone that we know is struggling? If mental health professionals ask them if they want treatment and they say no, then the professionals are supposed to walk away.  We need to frame this conversation differently in communities.  

We have a bill that would try to engage people in treatment — going out over 90 days to develop a relationship and work to get them into treatment. Peer specialists would be very effective with this. The language is in the statute but no county is doing it. We need funding. 

Yes, we don’t know how to prevent schizophrenia, or bipolar disorder, and a lot of that is genetics, but we can prevent it from becoming disabling. We can make sure that these young people go on to have fulfilling lives. That’s one area I think hasn’t gotten enough attention. 

Issue #4: Workforce

What we really lack is the people to do the work.

We need to strengthen our peer specialists programs. Peer specialists are an important part of the workforce. Even though they’re not clinical, there’s a lot of good things that they can do.

The mental health programs that are now in school is, I think, a model for the rest of the country in terms of how we do it. Because we don’t give the money to the schools — we give it to the mental health providers to co-locate, and keep a firewall between the education and healthcare records.

They can bill public and private insurance and use grant funds to pay for children who are uninsured or underinsured. The therapist sees the child in their natural milieu. Therapists can help the teachers figure out what to do.

When my kid was in therapy, I had to drive from Saint Paul to pick her up in Minneapolis,and then drive her to Uptown for therapy and then drive her back. That was almost four hours out of my day. Not every work place allows parents to take that time off work. This way, you don’t have to worry about it. The therapist is right in the school. If you want to take your kids to private therapists, you can do that, but it just makes it so much easier when the therapists are in the schools.

The program is in about 70 percent of school buildings now. But usually by November or December, they’re booked. A lot of those school providers say they can’t even hire people. So I do think we need more people, and people from more diverse cultures, to be able to meet the needs, along with teaching kids strategies to help anxiety and depression. We felt like we were starting to catch up a little bit before COVID hit. 

Plus the workforce is largely women. A lot of women dropped out of the workforce during COVID. I know women therapists, or those who identify as women, who are only doing tele-health now. But when we want people in the schools, they need to be there in person. 

We keep adding money to the loan forgiveness program. That covers all mental health professionals and licensed alcohol and drug counselors. It does work. We have supervision grants — money that goes to community health clinics or culturally specific providers to pay for supervision, to help people get licensed. We have a lot of people who don’t get licensed because they can’t afford to pay for the supervision. 

We’ve also changed the laws so that, especially for rural Minnesota, the supervision can be by tele-health, so you don’t actually have to drive 90 miles to be with your supervisor. We also paid for BIPOC mental health professionals to become supervisors, so that more people from BIPOC communities can find someone of the same race or culture to learn from. That’s been pretty effective. 

The legislature also just funded a new program where pediatricians and family practice doctors will train next to psychiatrists, so that they’re increasing their skills to treat depression and anxiety in kids. There are just not enough child psychiatrists. I think we’re paying for five psychiatry residency slots in Minnesota, so we’re adding to what the federal government currently pays for.

So, I think we’ve done quite a few good things, in terms of trying to address workforce, but there’s more to do. As one example, low rates under Medicaid for mental health treatment and services makes it hard to recruit and retain a workforce. Programs are closing down due to lack of staff.

Issue #5: Crisis Response

Who responds to an emergency crisis call is still very important, and muddled depending on where you live. There are mental health professionals, social workers, police officers — they all have different roles. 

We strongly support having a mental health response to a mental health crisis. There are mobile mental health crisis teams covering all 87 counties in Minnesota. Police departments are starting to embed social workers in their departments. 

In the ideal world, we would want police to contract with the current crisis teams. We understand our statewide crisis teams can’t always respond quickly. The total statewide funding for crisis teams is still less than the budget for the Saint Paul Police Department, for example. But at least if the police, who have the money, contract with crisis teams, there is continuity of care, and HIPAA is being followed..

We clearly define in law what our crisis teams can do, but we don’t define what an embedded social worker does in a police department. Who is responding to a crisis? Who is responding after the fact? We’ve muddied the water. Just because you hire a social worker doesn’t mean they’ve actually had training on how to deal with de-escalation and crisis intervention. Crisis teams are required to have training on these issues. 

The records issues are clearly covered by HIPPA as part of the crisis team. They’re not covered by HIPPA as part of a police department. In Anoka, they were happy to share information about people’s diagnosis with landlords so that they could evict them. So we want to create one system that is protected by health care standards.

The goal is not to build the police departments to be able to handle mental health crisis. The goal is to build our mental health system.

Optimism

At a NAMI Minnesota event, a speaker offered a hypothetical anecdote. Two different ambulances pull up at a hospital, one with somebody that’s having a heart attack, and one that arrives with someone in a mental health crisis. Everybody knows exactly what the protocols are for the heart attack patient. For the other patient, there’s not a particular protocol. The speaker believes we are 20 years away from being as capable in mental health as we should be. We asked Abderholden where she is on the optimism scale.

I’m more optimistic, and that’s because we’ve seen more hospitals create psychiatric emergency rooms. When someone is having a mental health crisis, they don’t need all the bells and whistles that are in a normal emergency room. If you have a psychiatric ER through the same door, the patient can be invited to go into an adjacent space where it is quiet. It is staffed with mental health practitioners and professionals who know what to do. 

In one hospital, they actually are starting to provide treatment in the ER, especially for kids, since they might be there for a while. Instead of just having them sit there waiting for an opening somewhere else, they’re actually starting treatment. Not every ER knows what to do. 

There’s no reason why we can’t create a separate wing of rooms that are for people who are having mental health crisis.

UPDATED 2-12: How to Get Involved

  • Legislative agenda: The Mental Health Legislative Network’s (MHLN) Mental Health Policy bill (HF 3495) streamlines mental health service regulations to increase access to services and allow providers to focus on quality care. The changes are very technical in nature. You can read the bill here.
  • There is also a bill in process that would change limitations that some police and school officials objected to after passage in 2023 of legislation that limits their ability to put children in a choke hold that restricts their ability to breathe. The bill would again allow school officers, including police officers and security guards, to use prone restraints in schools. Prone holds restrict breathing and puts pressure on the abdomen, head, or neck; and can involve straddling a student’s torso. NAMI has objected to this proposed change; the letter submitted to two committees is here. Find our story about this political issue from fall 2023 here.
  • Sign up for the NAMI Minnesota weekly Legislative Update to learn what is happening at the state capitol and when your voice is needed. namimn.org
  • Attend the “39 Years of Voice & Vision” event hosted by Minnesota Women’s Press on April 13 to participate in the next step of a statewide initiative to have conversations about re-imagining public safety. Invitation-only to Badass members. Easy to join!