Jails ‘de facto’ mental health providers
- Published: August 29, 2019
The fourth in a series of articles looking at the proposed expansion of the Greene County Jail, and the economic, social and human issues surrounding incarceration in the county.
• Read the first, second, third and fifth articles in this series.
Several years ago, Yellow Springs resident Jim Stone had a terrifying experience in Greene County Jail. Picked up by police for being rowdy in a Xenia bar, Stone, by his own account, was handled roughly by police and taken to the downtown jail.
Things got worse from there.
A former professor at Central State, Stone has bipolar disorder. He was experiencing a manic episode that night, he explained in an interview with the News this spring.
“My mood was elevated and I was also scared,” he said. “I shouted and screamed. I was very, very angry and resentful.”
Jail personnel responded with force, according to Stone.
Officers put a woolen sock over his head, punched him in the shoulder about eight times and tasered him, he said. He felt frightened, angry and confused.
“It was brutal,” he recalled. “I’ve been through some rough stuff but nothing like that.”
According to Stone, he was held in an isolation cell for two nights. To the best of his recollection, he did not receive his medications during that time. A phone call from his psychiatrist facilitated his release to Miami Valley Hospital, where he stayed for 10 days.
Reflecting on the experience in a follow-up interview with the News this week, Stone said he doesn’t entirely blame police and jail staff, given his own disruptive behavior.
“Some of what happened is understandable,” he said. “But they didn’t have to treat me as roughly as they did.”
He paused and added, referring to the incident’s emotional impact, “It left scars.”’
In this fourth article in the News’ series on the proposed expansion of Greene County’s jail system, we take a closer look at the changing role of jails in mental health treatment, including in our local facility. There is a growing consensus among national and local mental health experts that mental illness is better treated outside of jail, yet people with mental illness disproportionately fill our nation’s jails and prisons. Efforts nationally and statewide to create alternatives to jail for people with mental illness implicitly raise the question: are bigger jails needed, or could stepped-up efforts to keep people out of jail translate into smaller jail populations, and smaller jails?
‘De facto treatment facility’
Two million people with mental illness are booked into jail each year, according to the National Alliance on Mental Illness, or NAMI, a grassroots mental health organization.
“In a mental health crisis, people are more likely to encounter police than get medical help,” NAMI states on its website.
Partly as a result, mental illness and substance use disorder are prevalent among people in jail.
While county-level statistics aren’t available, statewide numbers suggest that 30% of Ohio’s jail population have mental illness, with 75% also having a substance use disorder, according to the Mental Health and Recovery Board of Clark, Greene and Madison Counties, or MHRB.
Nationwide, a seminal 2006 mental health study by the U.S. Bureau of Justice Statistics found that 64% of jail inmates had a mental health problem, as defined by a recent history or symptoms of mental illness.
This rate was highest among jail inmates, as compared to people in state and federal prisons.
According to the same study, rates of treatment, including use of prescribed medications, was significantly lower in jail than prison.
For those who have been in the mental health field for decades, there’s a terrible irony apparent in the high rates of those with mental illness behind bars.
“When I started my career, there were corrections wings in state mental hospitals,” said Leon Anderson, a sociologist and mental health researcher who lives in Yellow Springs. “Now we have psychiatric units in prisons.”
He added, “It just flip-flopped.”
Retired longtime mental health counselor Joe Cimoch, also of Yellow Springs, made a similar observation.
When state mental facilities were closed in the 1980s, government funding for community-based services failed to materialize, he explained. Lacking access to mental health services and experiencing other problems like homelessness and substance dependence, people with mental illness began to filter into jails and prisons.
“The cost of care shifted to the legal system,” he said.
Yet jail is an unsuitable and even dangerous setting for a person with mental illness, according to mental health experts.
“Oftentimes, it can do more harm than good,” Dr. Greta Mayer, CEO of our area’s Mental Health and Recovery Board, or MHRB, wrote in an email this week.
“Individuals are often not receiving the treatment that they need, and as a result, they often end up getting worse, rather than better,” she continued. “Those with mental illness often stay longer and experience higher rates of recidivism.”
Mayer registered her strong concern regarding jails as a setting for mental health treatment.
“It is absolutely unacceptable that our prisons have become de facto treatment facilities for those living with mental illness,” she continued. “Jail staff are under resourced to handle these significant medical concerns.”
Shortcomings at local jail
Greene County Jail is a case in point. An outside assessment of the jail’s medical and mental health operations suggests that the jail falls short in its current mental health services to inmates.
The assessment was conducted last fall by Falcon, Inc., a company that provides correctional mental health assessments. It is included in the May 2019 final report prepared for Greene County by consulting firm HDR. That report offers a comprehensive picture of the jail’s existing facilities and recommends that the county rebuild and expand its jail.
The mental health portion of the report notes shortcomings in the jail’s suicide prevention system, intake process, data collection and clarity of policies and procedures related to mental health services, among other areas.
The report’s language is strongest in the section on suicide prevention.
“A complete re-examination of this policy is strongly recommended. The jail’s current suicide prevention policies and procedures does not align with the compliance indicators recommended from NCCHC (National Commission on Correctional Healthcare),” the report reads.
Greene County Jail is currently accredited by the NCCHC.
“While the county incorporates components of best practices set forth by NCCHC, they should ensure processes for these components are in place, executed and enforced,” the report reads.
More training for jail staff, clearer policies related to suicide watch and better housing options for those on suicide watch are among the recommendations the report makes.
Nationally, suicide is the leading cause of death among people in local jails. More than a third of those who die in jail die by suicide, often within the first seven days of being admitted, according to 2014 data from a U.S. Bureau of Justice report.
Suicide rates are higher in jails than prisons, the report reveals.
Nationally, the recent suicide death of financier Jeffrey Epstein in a Manhattan jail has shined a spotlight on suicide in jail.
“His death sheds light on how dehumanizing and stressful for mental health being incarcerated is,” observed mental health researcher Anderson last week.
Data collected over the first nine months of 2018 in Greene County Jail suggests that as many as seven suicide attempts were made in the downtown jail during that time. No suicide attempts were recorded at the lower-security Adult Detention Center. However, this data may not be accurate, the HDR report notes. The nursing director “was unable to determine or guarantee the accuracy of the data and further reports that they are unable to quantify the number of inmates on psychotropic medications,” according to the report.
Based on information gathered during this reporter’s recent tour of the downtown jail, the facility has a total of 11 isolation cells used both for disciplinary purposes and for temporarily housing those with mental health symptoms.
“The rooms are the same, but the purpose of being there is different,” jail administrator Major Kirk Keller explained.
Those who are on suicide watch may be placed in the former “drunk tank,” also known as the “glass house” for its glass windows facing out to the corrections officer’s post.
This room is used for mental health observation until a mental health counselor can evaluate the individual, according to Major Keller.
The local jail has a nursing director on staff, and for at least 27 years has contracted with Xenia-based agency TCN for mental health services. Two full-time equivalent counselors split duties between the downtown jail and the Adult Detention Center. Between the two facilities, the jail population averages about 320 people on any given day. There is also a TCN crisis counselor available 24/7 to assist officers and inmates, according to Keller.
One positive noted by the HDR report was that mental health staffing levels appear to be “consistent and appropriate for a jail population of their size.”
The report adds, “Worth noting is that TCN mental health staff report comfortably completing all their daily duties without stress of backlogs or delays to inmates accessing care.”
Responding to a News question about the report’s findings, Keller wrote in an email that there were no unmet needs “from the perspective that we assess and provide the needed mental health treatment through our relationship with TCN.” However, Keller noted a larger unmet need related to the lack of mental health facilities.
“The sheriffs have had to do their best to provide for mental health treatment within their jails because of the lack of alternatives,” he wrote.
And he emphasized that the proposed new jail would expand treatment options for those with mental illness and substance use disorders by turning the current Adult Detention Center into a treatment and rehabilitation center.
Behavioral issues in jail
Overlapping with mental illness is the issue of behavioral issues in jail.
“Mental health issues can show up as behavioral problems” both in and out of jail, according to retired mental health counselor Cimoch.
People with serious mental health issues may act out in jail, though it’s more common for those with mental illness to be victimized inside jail and out, Cimoch said.
He described working with mentally ill clients who had been “badly beaten up” by other inmates and jail personnel.
“I’m sure they acted in ways that were provoking,” Cimoch reflected. “But that still doesn’t make it right.”
Data from the 2006 U.S. Bureau of Justice Statistics study adds to Cimoch’s observations.
Mentally ill inmates were twice as likely to be charged with violating facility rules and three times as likely to be injured in a fight while in jail, the study shows.
If an inmate’s mental illness is unknown to corrections officers, the problem might be amplified, with symptoms of the illness being interpreted by officers as resistance or misbehavior, according to Cimoch.
“Jail personnel aren’t trained to deal with mental health issues,” he said.
In Greene County, a brief medical intake is part of the booking process. The intake is administered by corrections officers. The intake combines basic medical and mental health questions, but there is no separate intake for mental health, according to Keller. Those booked into jail may be referred for follow-up with one of the jail’s mental health counselors based on officers’ observations of their behavior and perceived mental state.
In response to “aggressive or threatening behaviors” by inmates, officers use de-escalation techniques, starting with communication, Keller wrote in an email. Officers are provided with specific training to assist people in mental health crisis, he added. A “time-out” in a holding cell may follow, or a restraint chair if a person is being physically combative, he said.
“If a person is physically combative, we will apply the restraint chair to have them sit still and settle down. This involves multiple officers holding on to a person to keep them from punching or striking,” he wrote.
The local jail recorded a total of 190 use-of-force incidents by jail officers in response to inmate behavior last year, according to the jail’s 2018 “response to resistance” report.
The use of the restraint chair is the most common, with 80 instances, followed by the escort position, with 32, and the display of an officer’s taser, with 29 instances. Corrections officers carry tasers but rarely use them, Keller clarified.
The jail’s 2018 response to resistance report records nine instances of a taser being used.
The most common inmate behaviors that elicited officer responses included not responding to commands, with 56 instances, followed by pulling away from officer, with 45 instances.
Major Keller emphasized that officers seek to use force as little as possible.
“We do everything we can to never go toe to toe with them,” he said, referring to inmates.
Corrections officers are trained to be professional and polite, he said, noting that many come to the profession from retail environments including Petsmart, Burger King and Walmart.
“I try to teach my folks in this occupation as corrections officers you always have to be on guard. That doesn’t mean you can’t be polite and caring,” he said.
To many mental health experts and advocates, the most pressing need related to mental health and jail is to help those with mental illness avoid it.
Former Ohio Supreme Court Justice Evelyn Lundberg Stratton retired from the bench seven years ago in part to help tackle what she sees as an epidemic of mental health issues among people in Ohio jails. In her earlier work as a common pleas court judge, she saw many of the same defendants with mental health issues cycling in and out of her courtroom.
“When I was a judge I had the foolish thought that if I put them in jail, they’d get treatment. Now I know it was the worst thing to do,” she said in a recent interview with the News.
Stratton now directs Stepping Up Ohio, part of a national NAMI initiative. Her expression of its mission is succinct: “To divert people with mental illness from jail.”
Forty-seven of Ohio’s 88 counties have signed onto the initiative, which brings together community groups, county and jail officials, families and others with a stake in reducing the numbers of people with mental illness in jail. Stepping Up Ohio provides information and technical assistance to participating counties to help them implement strategies and programs toward this goal, according to Stratton.
In our area, Clark and Montgomery counties have joined. Greene County has looked into it, according to MHRB’s Mayer.
“There is consensus among our leaders to keep those with mental illness and addiction out of jails,” she wrote this week. “However, the problem is with finding sustainable funding sources to invest in comprehensive, effective treatment alternatives” for those who would otherwise be in jail.
One such alternative is mental health courts.
Anderson, the Yellow Springs-based sociologist, is an expert on such courts. Similar to drug courts or veterans’ courts, they are specialized dockets that take cases involving offenders with mental illness. Offenders are given the option of treatment in lieu of conviction. Provided they meet certain benchmarks in recovery, their charges are dismissed.
Anderson sees mental health courts as a crucial “go-between” for the mental health system and the criminal justice system.
“It’s hard for there to be linkage between these two systems because of differences in their philosophy and approach,” he said.
Mental health courts, dubbed “hugging courts,” are sometimes criticized as being too lenient, but in reality, offenders spend more time under supervision with this model — and have a better chance of getting the help they need, he said.
Ohio is second in the nation in numbers of mental health courts, though Greene County does not have one.
Recalling Stone’s story, such an alternative might have helped him avoid jail — not once, but twice.
Court records show Stone was arraigned after his release from the hospital, with a court date set for several months later. When Stone failed to make his court date, police showed up at his Yellow Springs apartment with a warrant for his arrest. According to Stone, he spent another four nights in jail, his mental state deteriorating under the stress of confinement, although this time he was able to access his medications and was placed in a cell with other inmates.
When his case came to court, the judge reduced the more serious of his two original charges, menacing, to a lesser charge of disorderly conduct. Stone was placed on probation, an alternative to more jail time, and paid over $700 in fines and fees, court records show.
One year after the original incident, he was released from probation. But in some respects, the experience wasn’t over. He remained angry and scared.
“They did me a lot of damage,” Stone said.
Finding ways to avert such damage, while more appropriately focusing resources on helping people with mental illness has got to be the future of mental health care — “if we want to have a positive future,” Cimoch observed.
Anderson agreed. While he is a proponent of mental health courts, he also sees the irony of providing mental health resources to people after they commit a crime, yet failing to adequately support people who need help outside of — or before they’re involved in — the criminal justice system.
“There’s so little that I see that gives people the opportunity to be their better selves,” he said.
And this lack relates directly to jails and their current, unfortunate role as mental health treatment centers.
“If there were better mental health care facilities, would the need for expanded jails be reduced?” Anderson reflected. “There’s every reason to think the answer is yes.”