JACKSON – Melody Worsham has voluntarily committed herself six times in Mississippi hospitals for a mental health crisis.

Still, despite working in the Gulf Coast’s mental health system, Worsham has never gone to a state hospital for mental healthcare.

“I’m terrified of them,” Worsham said. “I would never want to be (there) and I’ve made efforts in the past to stay out of them.”

Worsham’s testimony tied up the Department of Justice’s witnesses Wednesday advocating for changes in Mississippi’s mental health system. The federal government argues that Mississippi’s system relies too heavily on institutions and not community-based care.

Worsham told the court she had a diagnosis of schizophrenia and worked as a certified peer support specialist for the Mental Health Association of South Mississippi, using her experience to help others in recovery.

“There’s a lot of people out there that don’t have a voice and I’d like to be a voice for those people,” Worsham said. “People with mental illnesses, for a long time, have not had a voice and a lot of traditional providers don’t get it.”

Worsham described a day Center she worked at, saying she’d seen clients make progress, return to work, marry and live their lives.

“Not everything needs hospitalization. Not everything is an emergency,” Worsham said. “When I go to a hospital, I’m losing all power over myself. And that itself is traumatizing.”

Worsham testified that she believed the state needed to expand community-based mental health services, such as peer support specialists.

Even in the Gulf Coast, a more populated area of the state, Worsham said mobile crisis centers had encouraged to drive herself to a hospital mid-crisis or call police rather than respond themselves.

When a peer support specialist at South Mississippi State Hospital calls Worsham about a patient’s release, there’s no formal process for establishing continuing care.

“She can’t tell me who that person is or what kind of help they might need,” Worsham said. “And I can’t communicate with her whether or not they show up.”

Worsham said that though Mississippi had 238 certified peer support specialists, they were mostly clustered — with some specialists handling large areas alone.

Another witness testified in federal court on the importance of community-based care and modifying mental healthcare systems for rural areas.

Robert Drake, of the Geisel School of Medicine at Dartmouth College, testified about his experience modifying mental healthcare in New Hampshire and Vermont in the early 2000s.

“If we discharge patients from hospitals without having appropriate housing, without having appropriate services and support, without having appropriate insurance (and) without having appropriate jobs,” Drake said. “It’s very difficult for them.”

Plaintiffs asked Drake to share a lasting image of what he saw during his studies of Mississippi. Drake said he recalled seeing a group of men in a day room at a group home in North Jackson rocking, shaking and drooling.

“And it reminded me of state hospital units that I’d seen in the 1970s,” Drake said. “It makes me sad that situations like that persist in the United States.”

U.S. District Judge Carton Reeves asked Drake to expand on conditions in the 1970s.

Drake said people, at the time, thought severe mental illnesses were deteriorating conditions, not realizing the effects of over-medicating and stagnant environments.

“Rocking, shaking and drooling are all symptoms of over-medicating,” Drake said. “We didn’t realize then what we were seeing was mostly the symptoms of bad treatment.”

The state’s defense repeated their argument from Tuesday, trying to pin down what exactly DOJ expected from the state.

“One of the issues in the case is whether services are universally available (across the state),” James Shelson, an attorney representing the state, said. “Do you have an opinion on what (that) means?”

“I’ve done a lot of work in New Hampshire and Vermont – which, by the way, is the most rural state – and I know it’s difficult to have services uniform across the state,” Drake said. “I think we’re referring to quality rather than the specific form of services. That’s what states aspire to.”

Shelson read from a 1998 article Drake wrote with colleagues about case management.

“It is becoming increasingly clear that there is no single community care model that is equally appropriate across all services settings,” the article said. “For example, resources and characteristics of rural communities place different demands on service systems compared to urban communities.”

While Drake acknowledged the difficulty with isolation, lack of qualified medical professionals and other obstacles of mental healthcare in rural areas, he also highlighted some advantages.

“When I moved from Boston to New Hampshire, I spent the first two-to-three years saying, ‘Where are all the really sick patients?’” Drake said. “Dense, noises, highly populated areas are really toxic for people with serious mental illnesses and rural areas have a lot of advantages.”

Drake said patients in rural areas could escape to a quiet pond, away from people, during difficult times.

“You can’t do that in Boston. That person is likely to be walking down the street talking to themselves,” Drake said. “I actually think the advantages outweigh the disadvantages.”

Shelson pushed Drake to define how the state could transition to a different model, characterized as “responsible deinstitutionalization.”

He referred to Drake’s report, submitted to the court.

“Many states have closed hospitals but failed to set up community-based services simultaneously. Other states established community-based services but failed to sustain them when budget crises appeared.”

Drake acknowledged the critics of deinstitutionalization, for the reasons above.

When states closed beds first, some states didn’t increase services but, when reversed, hospitals found other populations to fill vacant beds, Drake said.

“It’s been done differently in different states,” Drake said.

When Shelson pushed about the potential cost of a transition, Drake said that was beyond his expertise.

“I’ve helped many states design their systems but I’ve never been the one to deal with the cost or fund raise,” Drake said.

Todd McKenzie, an expert for the court in statistics and biostatistics, analyzed the results of a questionnaire for 154 individuals who had experience with state hospitals.

Nearly all respondents, 99 percent, said they were not opposed to community-based services. All said that with community-based services they would have avoided or spent less time in the state hospital.

About 85 percent were categorized as being at serious risk of institutionalization at a state hospital.

The defense pointed to several counties, more than 30, that didn’t have any representatives in the sampling and asked about the statistical significance.

“To me, that’s not surprising,” MacKenzie said.

MacKenzie said it wasn’t statistically significant “unless there’s some reason that those counties that are not represented are different from the counties that are.”