FULTON, Mo. — There is a corkboard in one of the buildings at Fulton State Hospital, the state’s largest in-patient psychiatric facility. On the corkboard, patients have posted their goals of what they’d like to accomplish during their recovery.
“I want to go home, rent a restaurant and get rich,” one of them reads. It’s posted in the Guhleman building, an intermediate security facility where patients are sent once they’ve recovered enough to leave the larger, maximum security Biggs Forensic Center.
Most of Biggs was built in 1937, and as Chief Operating Officer Marty Martin-Forman points out, it is no longer an environment conducive to recovery from a mental illness.
FSH represents perhaps a confluence of three major policy issues for the state of Missouri and its lawmakers: a nearly $1 billion bonding issue — struggling to move through an increasingly-conservative legislature and stalling in the Senate in the final days of the 2013 session — fluctuating budgets for the Department of Mental Health and the lackluster level of Missouri state employee pay. All of these issues converge in Fulton, where the hospital doors first opened in 1851.
‘I want to get out of this hospital’
It’s hard not to think of the Biggs Forensic Center as a prison from the inside. A huge bank of screens monitors dozens and dozens of cameras across the building and heavy, automatic sliding doors clang loudly as visitors are screened, searched and allowed in with security escorts. Bars and screens are on the windows and a 20-foot, two-layer fence topped with razor wire runs the entire exterior of Biggs. But FSH is not a prison. It is a treatment facility where individuals accused of criminal behavior but adjudicated mentally ill are sent.
“Can you imagine trying to get better, trying to improve and be treated for a mental illness, in a place like this?” Martin-Forman asks during a tour The Missouri Times participated in.
Martin-Forman might have been referring to the low ceilings, which measure at less than seven feet and are commonly ripped down by irate patients. She might have been referring to the hallways, which are so narrow that, with a pen in each hand, one could sign their own name on both walls at the same time.
She might have been referring to the intake area, where Missourians incarcerated in prisons that are pleading not guilty by reason of mental illness or defect are initially brought in. Here, orange jumpsuit and all, new arrivals sit in an open hallway with current patients passing by and describe their crime, their illness and their symptoms, all while staff and patients look on, unhindered.
“It’s just inhumane that this is how we treat these people,” Tammy Smiley, who runs one of the four wards in Biggs, said. “There is no privacy. These are clients, not prisoners, they are patients who need care, and this is not an environment that will encourage them to be honest and open with us and we need that to help them.”
Smiley also mentioned another frightening trend. According to her, it’s not uncommon for someone in the facility to be determined competent enough to stand trial, most in the state are sent to FSH to make that determination in the first place. But sometimes, as the result of slow processes or judge’s orders, competent, non-mentally ill individuals end up staying at FSH until their trial, sometimes for months at a time, leaving perfectly mentally healthy individuals in the constant company of those with sometimes severe mental illnesses and a history of criminal behavior.
“Now imagine you’re waiting to stand trial and adjudicated mentally sound,” Smiley said. “Most of these people have nothing to lose at this point, and it is not uncommon for that individual to then attack a staffer or a patient, out of both frustration and out of a desire to be re-examined and found mentally incompetent. That alone poses a huge risk to our staff and our patients and it is very common.”
In Biggs, the antiquated building was designed before basic innovations in psychiatric care came to light. The hallways are long and not centrally located near nurses stations, meaning more staff are needed to monitor patients, and the long, ominous hallways make staff tense, as attacks are not uncommon and response time, because of the building’s ancient layout, is not always swift.
“Walk to the end of the hallway and back,” Martin-Forman challenged. “Try it and tell me it doesn’t scare you a little.”
Smiley discusses attacks on patients and nurses, and how the layout of the building makes safety harder. While she does, a man at the end of the hallways does jumping jacks without stopping and another talks animatedly into the payphone. A third is pacing, ancient headphones wrapped around his head plugged into an even older Walkman.
They’re all crammed into a small day room and on bad days, or when new staff arrives, or new patients come in, the tension in the room is palpable. As for the hallways, a man is permanently stationed there with a large, black leather pad on his arm. This hall monitor is there to break up fights and eye the bathroom, which, unless you’re standing next to it, is completely hidden from the staff.
By 2009, Fulton State Hospital represented almost half of all state-employee workers compensation claims in Missouri. Martin-Forman says this statistic is largely the byproduct of a facility that is nearing a “breaking point.”
“There’s a new, modern state mental health facility in Oklahoma I recently toured and in one year alone, they cut their injuries and violent incidents in half, just by way of designing a building that is more conducive to our mission,” Martin-Forman said.
Conditions are frightening, according to Ron Lapp. Lapp is an electrician for maintenance and facilities at FSH and president of the local chapter of the American Federation of State, County and Municipal Employees (AFSCME) Council 1324.
“Right now, all of our maintenance is to keep up with our accreditation as a facility, not making significant improvements,” Lapp said. “You’ve got buildings ranging from the mid-1800s to the 1960s and on here, and it complicates the process greatly because each building is totally different.”
Lapp said the age of the buildings meant significant resources were spent on basic improvements to existing facilities, which prevents major changes in “brick-and-mortar.” It doesn’t help that Missouri state employees make the lowest average salary of any state in the nation, Lapp said. In fact, it’s a major hindrance to recruiting and retaining quality staff.
“We’ve been tagged as the most dangerous place to work in the state,” Lapp said. “And with our extremely low salaries, we have a lot of turnaround.”
In fact, wages are so low that a typical man working full time at FSH with a family of four makes under the federal poverty level, meaning that if state workers were eligible for Medicaid (they aren’t, because of their state-provided healthcare), Fulton employees would likely be in the program. This same man’s children are eligible for free and reduced school lunches, because of his wages.
One of the patient goals posted on the corkboard in Guhleman perhaps sums it up the best:
“I want to get out of this hospital.”
Fighting for funds
The Department of Mental Health as well as the FSH staff and administration know there is only one solution: major funding. Biggs is beyond repair and new designs are needed for a new facility. Even the basic design itself is severely fraud.
Lapp indicated the ‘T’ shapes formed by the Biggs building in several places cause blind spots for cameras and generally result long hallways and narrow, sharp corners — a major no-no in modern designs for mental health facilities — which put patients and staff at risk. These are walls that “can’t be moved,” Lapp said. Thought and practices relating to mental illness from 1937 are far more rudimentary than today, he said, and modern buildings can be designed that are much more conducive to the environment.
Recently, $13 million was allocated in the state budget to draw up plans for a new, modern design for a maximum-security facility in Fulton, which could house both Biggs and Guhleman patients beneath one roof. However, the $13 million was part of a more than $400 million budget freeze imposed by Gov. Jay Nixon in response to House Bill 253.
Nixon — who campaigned against the tax cut in HB 253 for most of the summer — said in a statement after touring FSH last month that if his veto was overridden, the $13 million allocated for FSH planning would not be released, effectively pitting HB 253 against the fate of a massive bond proposal that will likely come back before the legislature in 2014. The measure contained $211 million for improvements at Fulton, largely related to building a new primary facility to replace Biggs and Guhleman.
And these plans represent just a potential first step.
Administrators at FSH say blueprints will take approximately 18 months to finalize and once that is done, they still need to allocate more than $200 million to build the facility.
Rep. Jeanie Riddle, a Republican who represents Fulton, said she relies on budgetary experts to find that money, but also strongly backed the bonding measure as the “most logical way,” to get the funds together quickly.
“This is a human issue, that’s what I try so hard to communicate with people,” Riddle said. “It’s a human rights issue. Not just the human rights of these Missourians under the care of the state, but also the human rights of the employees working here who risk so much and who, when they get injured, have their entire lives changed because of that.”
Riddle has had trouble getting everything Fulton needs. The politics of HB 253, she said, have slowed down the process. Nixon and his fellow Democrats have long argued that the bill will result in less money for state services, including mental health.
She says she was disappointed that Nixon announced a withholding of FSH planning funds, and that politics is drowning out policy.
And yet if Nixon’s veto is sustained, the battle is far from won.
The massive bonding proposal, which received huge support from both sides of the aisle in the House and is backed by House Speaker Tim Jones, would be one of the state’s largest, and is sharply opposed by more conservative members of the Senate.
Sen. Brad Lager, R-Nodaway County, a longtime opponent of large bonding measures, doesn’t believe the state should borrow money to make improvements like those called for at Fulton. He favors an incremental approach, funding such projects as the state finds the money to do so.
But Riddle and Martin-Forman both say there is no time to wait.
The dietary building, where all of the food is prepared for the facility’s 350-plus patients, is in major disrepair.
“It’s falling down around our ears, we have maybe two or three years before we really don’t have a choice anymore,” Martin-Forman said.
The building has no air conditioning or heating. In the dishwasher room, temperatures hold steady at around 90 degrees all day. The kitchen’s themselves are littered with ancient equipment, including a mixer and an oven, which both come from a decommissioned battleship from the Korean War.
Sandy Dreyer, Director of Dietary Services, said much of the equipment, like the mixers and ovens, were so old that repairs were no longer possible. One of the ovens, an older model, broke down several years ago but continues to take up space, because the cost to remove it has never been met.
Above the kitchen is the gymnasium. You can’t get there by elevator because all the elevators in the building were permanently put offline a few years ago as a result of repairs becoming impossible on the ancient equipment.
There is no access to the gymnasium because of the discovery of asbestos, but the cost of removal is too high. Under these conditions, Dreyer and her staff prepare meals approved by physicians and sometimes meeting very specific dietary needs.
Like much of FSH, the space is too large. Since some of its buildings originally opened doors in the mid 1800s, FSH’s patient size has grown and shrunk, peaking at around 2,400 and now hovering consistently at around 350. Much of this was the result of deinstitutionalization, which swept the nation in the 1960s and 1970s.
But the extra space is energy inefficient, time inefficient and staff inefficient, administrators say. FSH doesn’t need all the land it has, and abandoned buildings are common on the grounds, which contains about 70 buildings in total.
Budget cuts, payroll woes
What it would cost to properly repair FSH is unknown. Riddle and Martin-Forman will tell you that $211 million would get a new building for psychiatric patients and lower costs. But that number doesn’t account for improvements to the dietary building, asbestos removal, improvements to other buildings not in need of total replacement or the demolition of the dilapidated buildings sitting empty on the grounds.
That $211 million wouldn’t add a dime to the salaries of state employees, whose turnaround at FSH is “unbelievable,” according to Smiley. It wouldn’t cover the ever-worrisome costs of ballooning workers compensation claims and it would do little for the resources of the Department of Mental Health overall.
Lapp says employees don’t come to FSH to get a job they can retire at anymore, and training new employees is costly.
Riddle says not only continued improvements to training, but better benefits and compensation are needed to attract better staff, and both agree higher salaries would ultimately keep personnel around longer.
And then there are concerns about other Departmental functions, resources, and training.
Will the Department of Mental Health — which has seen budgets fluctuate wildly in the last decade with only a recent resurgence of support for an increase — be able to properly manage a newer facility?
Nixon, in his State of the State address, called for $10 million more for the Department of Mental Health for the coming year and the legislature granted the increase. But the unity between parties on budget priorities, and the consideration of mental health as a priority itself, is a relatively new trend. At FSH alone, budget cuts in the 10 years since Lapp’s arrival permanently halved the maintenance staff for the facility.
Administrators and staff seem to agree that FSH is doing its best to accomplish its mission, but doesn’t work as well as it could to help people recover, and money is needed in all areas: for capital improvements, for the state workers risking their livelihoods there, for the Department of Mental Health to implement better practices.
And while support in the House for FSH repairs is huge, the human need is sometimes forgotten, according to Riddle.
“Everyone here, whether staff or patient, has human rights,” Riddle said. “And if we can’t care for our ill Missourians and protect those rights, then we really have to examine how we are doing things. The situation here is dire and we need fixes now.”
A human problem and a “logistical nightmare”
Ideal treatments would mean patients would stay for shorter periods as they recover and have more chances, while in treatment, to develop skills for the outside world. In the recreation room at Biggs — the only recreation room in the facility — a single washer and dryer are present where patients can learn the basics of doing their own laundry.
On the long, uniform tables in the room, thousands of white straps sit in piles. Here, patients make straps for masks related to construction and maintenance for the 3M Company. They are paid based on their work levels, which Martin-Forman called “amazing.”
“We have some patients who are still very ill, and who may still have a lot going on in their heads,” Martin-Forman said, “But, a simple task like this one actually improves their mood, they have a sense of accomplishment and pride because they did something. This program has worked wonders. It’s one of the ones we’ve kept for a long time because of the response we get from patients.”
But even here in the “rec” room, where Martin-Forman says recovery can begin, the room is aching for improvements. The air-conditioning system has been rigged in recent years because the room once didn’t have it. Fans are mounted on the walls, and in the back of the room behind a mesh cage, boxes are piled to the ceiling, because there simply isn’t room for storage.
Not far away, the cafeteria doesn’t fair much better. All the 180+ patients inside Biggs cannot eat at once, because the room is too small. There are shifts and on some days, lunch can take up to three hours from beginning to end.
When food is often directly tied to medication, and patient stability relies largely on routine and normality, a single patient can delay lunch for most of the others in the building, leading to fights and other incidents that ultimately put staff in danger.
“Imagine you’re ill, you’re waiting for lunch at 12:15 and someone ahead of you in line causes an issue that slows it down,” Smiley said. “Now, it’s 12:45, you’re hungry. You’re hot standing in line and you can’t eat because someone else is slowing the process down, and you’re in line with other patients struggling with their own illness. That situation can escalate and become very difficult to manage very, very quickly. It’s a logistical nightmare just to feed people.”
Administrators are quick to point out that they don’t control “the front door, or the back door” to FSH. Meaning it’s not up to anyone at FSH who is transferred into the facility’s care, or when someone gets to leave. As a hospital for the mentally ill, as well as serving as part of the Sex Offender Rehabilitation and Treatment Service and caring for a small number of the developmentally disabled, Fulton administrators will always have a patient list.
“They don’t go away,” Martin-Forman said. “We could do nothing about this place and let it all fall down, but these people, they aren’t going away. We’ll always have a need for a facility like this. We might be coming to our time here. This population will always be here. Let’s not forget that most of these patients are Missourians. They are ill and they have some basic human rights. We have to serve them.”