Consider the case of a 60-year-old patient I will call “Library Man.” While at the public library, Library Man took off most of his clothes and was talking loudly to no one in particular. The police were called, of course. He was charged with disturbing the peace and brought to my jail.
Jails basically have three types of housing areas. First are dormitory-style rooms with 60-100 residents. Library Man cannot be housed there—the young aggressive inmates would prey on him. Second are smaller cells that hold two to four inmates. The problem with these cells is that even if the jail could guarantee gentle cell mates, it would be hard to monitor Library Man in such cells. Such cells tend to be in out-of-the-way places and have small windows on the doors. The only place that Library Man can be reasonably housed in most jails is “Special Housing,” which refers in this case to a single-man isolation cell with lots of plexiglass to allow easy observation. Such rooms are designed to have nothing that someone could use to harm themselves, so they are made entirely of concrete and steel—even the bed. This is where Library man ends up—basically in a large concrete box.
Unfortunately, this is not a good place for Library Man to be. You may have guessed that Library Man is a homeless schizophrenic who had gone off of his meds. He is harmless–certainly not a danger to himself or to others. In his psychotic state, he does not understand why he was arrested and jailed. Library Man would benefit from familiar surroundings and normal social interaction with people. He will get neither of these in the alien and sterile environment of his concrete isolation cell.
I should make it clear here that I am not criticizing the jail. The jail medical and mental health personnel will do what they can to help Library Man. He is going to get back on his medications. If necessary, jail personnel will coordinate commitment proceedings. The jail social worker will work with outside psychosocial rehab services to help transition him back into the community. Library Man was eventually released after three weeks in jail.
My point is that Library Man should never have gone to the jail in the first place. He is a harmless (though disruptive) mentally ill man. The jail was never designed to house the seriously mentally ill, such as Library Man. The reason that Library Man came to jail is that in my state, as in many others, funding for mental health services was severely cut several years ago. As a direct result, Library Man and many others lost access to mental health services. Consequently, my jails saw a marked increase in the number of mentally ill patients like Library Man being brought there.
The police officer who responded to the call from the library actually recognized that Library Man was mentally ill. But the local for-profit psychiatric facility would not take Library Man. The state psychiatric hospital is full and would only take him after a long commitment process anyway. There is a local Crisis Center, but they are not staffed to handle someone as sick as Library Man. The only option left to the police is to take Library Man to jail. And the jail has nowhere else to put Library Man except the concrete cell of Special Housing.
Sadly, Library Man is not an isolated case. Another recent patient housed in Special Housing was a developmentally delayed woman who had hit one of her caregivers at her shelter home. She is an adult in body but probably only 8 years old or so in on a functional level. She also does not understand why she is in a cold concrete room. “I want my Dad!” she wails. The jail staff try to calm her down with coloring books and Pikachu stickers during her several days stay in jail.
Jails and prisons have become the resource of last resort for the mentally ill just like emergency rooms have become the resource of last resort for people who cannot afford health care. It should not be this way of course. A concrete room at the jail is not the right place for people such as Library man or Developmentally Delayed Girl to be. It is not in their best interest. It is not a wise use of the jail facility or staff.
And it is expensive! Multiply the cost of housing Library Man times the hundreds of thousands like him incarcerated in our jails and prisons currently. That money would easily pay for effective community programs to keep the mentally ill out of incarceration.
What’s the solution to this problem? I confess that I don’t have the answers. The first step, though, is to recognize that a problem exists. What happens inside the walls of a jail is often invisible. It needs to be made public. Is this really what we want?
This article was originally published on MedPage Today, found here.
No, you are not wrong. You hit “the nail on the head”. As you say, this issue is SOLUTION. Only can our legislators effect a real change. As medical professionals, it is our responsibility to get the information to them and vote those into office who are responsive; and vote those out who are not.
Thank you for this post. I am glad to see that jail medical staff agrees with what we in the general public already know to be true.
Thank you Sara!
I am in an admin position at a county jail and you are right on. It has been and probably always will be the dumping ground.
I have created a training class to help prevent these types of issues. Deny the inmate if he is not stable.
Chicagoans with mental illness end up in jail through a chain of small decisions by different local officials. Police officers can choose to take a mentally ill person home, to the hospital, to a shelter, or to jail. Prosecutors can choose whether or not to bring charges. Judges can choose to set higher or lower bail amounts, thereby determining whether poorer defendants can avoid pre-trial detention and keep their jobs and housing. But once a person reaches the jail, the local sheriff can’t simply decline to take them into custody.
Clearly the best ‘solution’ is for people like ‘library man’ to have appropriate community care. It seems that the community mental health agencies do not have the capacity to respond to this type of situation. They should – so, the question is why not??
Suggest that there are several parts to this issue. NIMBY is one – police / jails have little impact on the mental health system – its not in their wheelhouse. ER treatment is not the best (wrong place) but has more impact – but many are unwilling to accept the task – due to the lack of resources. One great factor is the lack of ‘political will’ and not just by the politicians. Over time; a state wide DHS & DOC project, a bridge position (PhD hired by both); community based Intensive Case Managers with a primary objective of caring for those with mental illness; and despite the effort of many from all organizations involved – the problem remains. Examples of additional issues: there is no waiting list at the forensic service – because we won’t establish one; the client does not meet criteria – despite the fact that the facility clinician agreed that each point of the presentation was valid; the beds at the forensic service are occupied by those determined to be NGRI (long term) and / or competency assessments; we can’t meet the clients needs – despite the fact that the client was discharged from there just yesterday. [repeat – no political will to address the issue]
Suggest that one possible solution would begin by establishing the true need – obtain and document accurate statistics of those established diagnosis, a collision with law enforcement and need for specialized care. Once the need is determined; create a facility(ies) [!not jail!] that is established for the purpose of housing these individuals and base the available space on 20% over the maximum number identified as in need (per month). Then staff with a view towards – assess, stabilize and discharge to a stable placement.
That idea was ‘floated’ with one jail and with a complete plan – place, staff, purpose and data – charging a slightly higher boarding fee would result in payment for the whole idea with some left over – again no political will.