The phrase “school to prison pipeline” is a familiar one to people who pay any significant attention to social systems. In essence, this describes the way children (especially children of color) are often, whether intentionally or incidentally, pushed out of school by overly punitive policies and many times end up embroiled in legal problems that set their lives’ trajectory. The term suggests a certain methodology and design to this phenomenon that may be more narrative than truth but still underscores a disturbing reality.

A similar fate threatens those who, by choice or by decree, find themselves at the mercy of what passes for mental health care in much of the United States. In most cases, people experiencing an acute mental health crisis have two options: try and manage it oneself or take a gamble at a hospital emergency department. Neither of these choices are ideal, the former because most people suffering severe mental health problems are unable to manage their condition alone, the latter because the majority of this country’s emergency departments are ill equipped to handle psychiatric emergencies. In a revenue driven healthcare system, the prospect of handling behavioral and psychiatric emergencies is not an appealing one as many such patients are uninsured, underinsured and/or unlikely to pay the sizable bills psychiatric hospitalizations usually incur.

The emergency department in the typical US hospital is reasonably prepared to address a wide range of medical conditions. ED staff are trained and ready to respond to heart attacks, strokes, severe respiratory distress and traumatic injuries. These departments generally have the people and the tools to at least stabilize a patient, even if they are ultimately transferred to a higher level facility for more specialized care. Mental health crises can manifest in a wide variety of ways — a patient may arrive violent, angry, despairing or perhaps emotionless or even manic. They often arrive under the influence of alcohol or other substances; many come after days or weeks of medication noncompliance; some are brought in escorted by law enforcement armed with firearms, restraints and a court order, a practice known as involuntary commitment. Faced with so many possible presentations, control becomes the focus of the hospital staff as it might be hours or days before an actual behavioral medicine practitioner is able to perform a proper assessment.

For those arriving to the emergency department of their own volition, there might be some hope at the end of the ordeal. Those patients are more likely to participate in the interviews and therapies and their personal investment makes it more likely a plan of care will succeed. For the rest, those who had no choice or voice in their hospitalization, the likelihood of long-term success in therapy is far less certain. That uncertainty is what usually sets the stage for a lifetime of hospitalizations, incidents, commitments, medication changes and difficulty navigating the corridors of society. This is the other pipeline, a pipeline that may not lead to prison but still results in marginalization and constant struggle to maintain oneself in an environment that sees one more often as a threat or an aberration than an individual needing assistance.

The system is good at stabilizing and medicating, but its most serious weakness is the inability to promote and ensure long-term compliance with the therapies it initiated. At some level it is not the system’s responsibility to monitor patients once they have left the hospital, but it does seem like a system ostensibly providing ‘care’ would be more willing to take on more of that responsibility in the absence of family or other caregivers. But providing long-term support and access to clinical resources is an expensive proposition, one that healthcare systems and government bodies are reluctant (even averse) to embrace. So, we continue to see mental health treated as a public safety issue rather than a public health issue. Patients, and those that try and support them, remain torn between the desire to do something beneficial and the fear of doing something that might involve incurious magistrates, insensitive cops and a behavioral health apparatus that sometimes seems more like a trial run of prison than a place of healing and guidance.