Editor’s note: This is the fifth installment of the

Minding Mental Health series,

in which Forum reporters are diving into how mental illness affects different parts of the community.

FARGO — When 911 calls come into the Red River Regional Dispatch Center for an individual who is having a mental health emergency, it is almost always police officers who respond to the call rather than a behavioral health specialist who is trained to deal with such a crisis.

Local law enforcement, service providers and health care professionals agree that approach has contributed to a growing and troubling problem.

The

Fargo Police Department

alone took just over 2,700 such calls last year. Chief Dave Zibolski said roughly 15 individuals were responsible for more than 400 of those calls, each of which averaged over an hour with multiple officers responding. The department’s intelligence analysts estimated the total working hours spent on those calls alone were the equivalent of at least three full-time officers.

There is also unanimity that the available treatment and service options for those in crisis are inadequate.

What the solution to these problems ought to be, however, is less clear.

Zibolski sounds the alarm often: a small handful of individuals — many of whom are not committing a crime — are the source of some of his department’s most repeated and resource-heavy calls.

Even if a nuisance crime were being committed, Zibolski acknowledged that taking the person to jail would likely only exacerbate the crisis, and that there certainly isn’t any good treatment behind bars.

“We’ve identified a big gap in the whole mental health piece,” Zibolski said while

presenting the department’s annual report

in early March. “We don’t have a long-term mental health treatment facility for the portion of those folks who have severe, chronic mental health issues who I think, by anyone’s review, should not be walking around on their own in our community because they are not getting treated.”

He has repeatedly called on the state Legislature to step in to help establish and fund such a facility.

Cass County Sheriff Jesse Jahner has echoed Zibolski’s concerns.

“At times we have individuals we know need to get out to the State Hospital, but instead they just sit in jail because there’s not a spot available or before we can arrange to get them there. Then they complete their jail time and are back out into the community before they are able to get that help — and law enforcement just comes right back into contact with them. It’s a revolving door,” he said.

For decades, there has been a push in the U.S. to “deinstitutionalize” — shuttering long-stay, often compulsory, psychiatric hospitals in favor of community-based care for individuals with severe mental illness. But in recent years, the pressures that approach has put on law enforcement have been widely acknowledged.

“Deinstitutionalization did not solve the problem,” Zibolski told The Forum. “It helped in some areas but it caused this problem. Nobody wants to touch it. But now there needs to be the political will to do so or we’re not going to fix it.”

Pam Sagness, who runs the Behavioral Health Division of the state Department of Health and Human Services, said it’s a fair discussion to have.

“The criminal justice system did become the de facto behavioral health system after deinstitutionalization, because we did not have the right services in place,” she said. “But, I don’t think it’s a black and white question of ‘did deinstitutionalization work or not?’ There’s a spectrum: if services aren’t in place, it doesn’t work. But we are trying to build those missing services. I don’t think anyone is defending the current state.”

Beth Olson runs the Presentation Partners in Housing Navigation Program, which works to move people from homelessness to housing.

“When we started the program in 2016 we asked: who are the people in our community who everybody thought could never be housed? That they were too ill, too sick, too mean, too noncompliant? What would happen if we just offered them housing and support? Spoiler alert: we found that people can be incredibly successful,” she said.

Olson pointed to a 2023 PPIH study as evidence. It tracked 30 program participants before and after they received housing. Emergency room visits and ambulance trips decreased about 65%. Jail and detox visits were down 86% and 90%, respectively. The study found overall use of the city’s emergency services went down 81%, and that housing those individuals saved Cass and Clay county communities $620,000 last year.

The Navigation Program is based on a national model called Housing First, which prioritizes providing permanent housing to people experiencing homelessness, guided by the principle that people need basic necessities like food and a place to live before attending to anything else like employment or mental or substance abuse issues.

The architect of Milwaukee’s successful Housing First efforts

recently visited Fargo

and met with stakeholders about doubling down on efforts like the Navigation Program. Olson said increased investment in Housing First strategies could further help alleviate the burden on first responders.

“The police, I don’t envy them. It’s a terrible job to have to show up for people when all the systems around them have left them behind. The police are the only ones who are truly mandated to show up to that call, and the things that they deal with are so inappropriate for a police officer to ever have to be dealing with,” she said.

Olson said what might look like severe mental illness to an officer might not actually be.

“A lot of symptoms are due to the issues these people are facing, purely by being on the street, unsupported and disconnected, and are way less about mental health and addiction than you would imagine. When you’re homeless, just surviving is a 24/7 job, and the things that people have to do to survive can be pretty traumatic,” she said.

Chandler Esslinger is a community liaison within Fargo Cass Public Health’s Harm Reduction Division. She said the Housing First approach has been proven to result in less law enforcement calls.

“The vast majority of people who have a mental health issue are housed, but their housing buffers them from the public nature of a crisis most of the time. Especially when we’re talking about repeat users of the system, when they have nowhere to go and their only option is to have a mental health crisis in public, they’re likely going to continue to rotate in and out of that system. What we see is when people — especially who’ve been chronically homeless — once they have the dignity of housing, a lot of those mental health issues are just less,” Esslinger said.

Sagness said a lack of beds for inpatient care is not the issue in North Dakota. The state’s inpatient psychiatric capacity is nearly twice the national average, according to the most recent data. Instead, she said, the beds aren’t always located in the places where they are needed, and they aren’t necessarily populated with patients who need them, at times depriving those desperately in need of that higher level of care.

The State Hospital in Jamestown is a facility that specializes in court-mandated, forensic care for individuals with complex needs that the private sector or their local community cannot meet. Fargo’s Prairie St. John’s is another of the state’s largest providers of inpatient, acute mental health care and, Sagness said, an important part of any solution.

Forum file photo

But, she said, what may look to law enforcement like a severe mental health crisis deserving of the level of care the State Hospital and Prairie St. John’s provide, might not fit the parameters behavioral health professionals must use to commit someone against their will.

“Unless they can meet the standard of showing that someone is going to harm themselves or someone else, they cannot justify taking away someone’s rights and freedoms. A psychiatrist has to be able to defend that decision in court,” she said.

More appropriate for the kinds of cases the Fargo police are dealing with, Sagness said, could be a residential level of care known as intermediate care facilities.

Such facilities are community-based, home-like settings with 24-hour care from doctors and other behavioral health staff. They are a benefit of Medicaid and are designed to give people adequate and continuous support and services. In Fargo, Fraser and CHI Friendship both operate intermediate care facilities but they are specifically for people with intellectual disabilities. The North Dakota Legislature would need to codify intermediate care facilities for behavioral health, Sagness said.

Esslinger said solving the problem is not just about adding levels of care — it’s about a proper response.

C.S. Hagen / Forum file photo

“We’re all acutely aware that there is a portion of people who are just not being well served by the status quo, and we’re butting up on the limits of what that current system is capable of serving,” she said.

She said it starts with a systems change based on a best practice model from the Substance Abuse and Mental Health Services Administration, called the mobile behavioral health crisis response toolkit.

“It represents the gold standard for what we could achieve in our community,” Esslinger said.

She said the toolkit relies on three guiding principles: having a centralized call-in location which triages mental health calls, having an designated response team in lieu of a police response when appropriate and having proper levels of care available based on the response team’s assessment.

“If everybody was using the same entry point in the same system, it would divert a lot of folks who are currently utilizing higher levels of care which require more expensive, restrictive resources even though they don’t need them, and open up those spaces for that small portion of people who do,” Esslinger said. “We need to prioritize the least restrictive, most integrated level of care at every opportunity possible.”

Some measures have been put in place to try to stop mental health calls from overwhelming law enforcement.

Southeast Human Service Center, the regional hub of Health and Human Services, is working with Fargo police to develop a co-responder pilot program in which licensed behavioral health providers would accompany officers on mental health calls.

Neighborhood Services Capt. Chris Helmick said the Fargo Police Department has also been collaborating with Sanford, Essentia Health and Prairie St. John’s developing a work plan to address the needs of those individuals who have the highest number of mental health calls for service.

Most recently, Fargo Cass Public Health implemented a downtown-specific response. As of May 1, a neighborhood response team of three harm-reduction advocates is now out walking between the hours of 10 a.m. and 6 p.m. in order to build relationships and help diffuse potential crises before they require law enforcement intervention.

“We wanted to be more responsive to the needs of both people who may be experiencing a crisis and people who may be interacting with somebody who’s experiencing that crisis, including business owners and visitors and residents downtown,” Esslinger said.

In an interview with The Forum on May 16, Zibolski said he is focused on persuading legislators to fund a residential facility that is intended for compulsory commitments of 48 hours or more in Cass County.

Zibolski was also skeptical that some of the new approaches will make much difference for the population he is most concerned about.

“These are people with severe, chronic mental health issues which are not going to be solved by a mobile crisis unit,” he said.

Zibolski acknowledged that housing could be a part of the solution, but not without an initial mandatory mental health stabilization period.

“Even in the Milwaukee example, they held people in mental health facilities first and got them evened out and then moved them into housing. They just didn’t go from the street to housing,” he said.

Despite different proposed approaches, Esslinger said she believes there is positive movement toward finding a solution to care for those who have severe mental health crises.

“One of the things I really love about our community is that the problems that we’re trying to solve are solvable, because the populations of people who need this dedicated type of resource and infrastructure are very small,” she said. “Helping 15 people identify what the appropriate level of care is and ensuring that care exists is doable. That’s what gives me hope about this situation.”

More from the ‘Minding Mental Health’ series

In the Minding Mental Health series, Forum reporters are diving into mental health topics in our communities. Issues surrounding mental health touch our homes, classrooms, athletic venues, criminal justice system and beyond. Continue reading to learn more about the people behind the issue and how the metro area hopes to address mental health challenges. Have an idea for a story? Email news@forumcomm.com to share it with us.