Should Police Be Handling Mental-Illness Cases?

The majority of police officers in 45 percent of agencies surveyed haven’t been trained to handle mental-heath crises. In Eugene, Or., a nonprofit handles such cases, amounting to 17 percent of police service calls last year.

The calls come to police departments with growing regularity: a man in mental crisis; a woman hanging out near a dumpster at an upscale apartment complex; a homeless woman in distress. In most cities, police officers respond to such calls, an approach experts say increases the risk of a violent encounter because they aren’t always adequately trained to deal with the mentally ill. At least one in every four people killed by police has a serious mental illness, says the Virginia-based Treatment Advocacy Center. In Eugene, Oregon’s third-largest city, when police receive such calls, they aren’t usually the ones who respond, the Wall Street Journal reports. The first responders are typically pairs of hoodie-wearing crisis workers and medics driving white vans stocked with medical supplies, blankets and water.

They work for a nonprofit called Cahoots—which stands for Crisis Assistance Helping Out On The Street. Started by social activists in 1989, Cahoots handled 17 percent of the 96,115 calls for service made to Eugene police last year. In 2017, police officers spent 21 percent of their time responding to or transporting people with mental illness, found a survey of 355 U.S. law enforcement agencies by the Treatment Advocacy Center. More police departments are training their officers in techniques to deal with the mentally ill. Los Angeles, Houston and Salt Lake City pair officers with mental-health workers with police officers. Still, the center found that in 45 percent of the agencies polled the majority of officers haven’t received crisis-intervention training. Public anger over police killings has pushed law-enforcement leaders in California to discuss how to replicate Eugene’s program in their state, said Brian Marvel, president of the Peace Officers Research Association of California.


Rural Jails Struggle to Cope with Rise in Mentally Troubled Inmates

The growing population of offenders with mental health or substance abuse issues is a nationwide problem, but it’s especially challenging in rural communities. One Wisconsin jail has risen to the challenge.

When someone is booked into Polk County jail in rural Wisconsin, the first step is a screening process to determine the individual’s medical and mental health care needs. The information from that screen is reviewed by the jail nurse and jail sergeant, who determine if the jail nurse needs to follow up.

Once in the general jail population, the inmate can submit a nurse call slip for non-emergency mental health concerns, and the nurse or jail staff member will follow up as needed. An urgent mental health need is handled through a request by call slip to a nurse or staff on regular rounds.

Many big-city jails, which are now the main source of medical help and counseling for the mentally ill, have used similar strategies to deal with a growing roster of inmates who need special medical help.  But the approach has now spread to smaller rural jails in states like Wisconsin.

“Our jail staff is excellent in recognizing symptoms of mental health and of untreated mental health issues, notifying me, and addressing those issues,” said Donna Johnson, the Polk County public health nurse, who has worked in the county jail for 20 years.

Rural jails often bear the brunt of what has become a growing national problem. A 2016 survey of 230 jail staff members across 39 states found that 96 percent reported having inmates with serious mental illnesses during the previous year.

Three-quarters of the jails reported seeing more or far more seriously mentally ill inmates compared to five to 10 years ago.

More than 80 percent of people incarcerated in the Polk County Jail have mental health needs, according to Johnson.

“For the people we’re seeing with serious and pervasive mental health issues in the jail setting, methamphetamine (addiction) is by far the greatest issue that we’re dealing with,” she said.

According to the federal Substance Abuse and Mental Health Services Administration (SAMHSA),  the toxic effects of substances can mimic mental illness in ways that can be difficult to distinguish from mental illnesses.

Substance-induced mental health disorders involve psychiatric symptoms that are caused by using a substance. People can also have co-occurring mental disorders, where they have a mental illness and a substance use disorder.


The 160-bed Polk County Jail in rural Wisconsin has seen a rise in inmates suffering from mental health and substance abuse issues. Photo courtesy Leader-Register.

Rob Drew, captain of the Polk County Jail, estimates that around 70 percent of the county jail’s inmate population would benefit from some type of mental health care, be it from a counseling session or meeting with a psychologist.

“We have a fairly low number of people that rise to the level of being suicidal, but the number of people that could benefit from general mental health services is very high,” said Drew, who oversees the county’s 160-bed jail.

Drew said it is difficult to calculate the specific amount of people in jail with mental health needs due to the variation in inmate mental health needs, which aren’t tracked with jail records.

Polk County’s Johnson says that the mental health of those in the county jail has always been a concern, but it has dramatically changed over the years.

“It used to be a rare occasion when we had someone who displayed [suicidal tendencies] … (and was in need of) psychiatric services,” said Johnson.  “Now it is really the norm,”

Looking back to the first methamphetamine epidemic that occurred about 20 years ago, Johnson says that they had people in the jail displaying acutely psychotic behavior where they experienced both auditory and visual hallucinations.

“We see that on a chronic basis now,” said Johnson, who believes the mental health issues the county is experiencing right now are largely due to methamphetamine and alcohol use.

“Alcohol remains our Number One issue,” said Johnson. “It (alcohol) doesn’t get as much attention because it’s legal.”

The American Psychiatric Association reports that chronic heavy methamphetamine use can cause temporary paranoid delusional states that may last for weeks, months and even years. Symptoms can also include dementia, psychotic episodes, and evidence of “bipolar” disorder.

Heavy long-term alcohol use can cause brain damage that causes symptoms of dementia that are not entirely reversible even with sobriety.

However, most substance-induced symptoms begin to improve within hours or days after substance use has stopped.

In 2017 the Leader-Register reported that Polk County leads the state of Wisconsin in per capita criminal prosecutions of methamphetamine. That year there were 184 individuals arrested for methamphetamine alone with 393 drug charges against them.

The Polk County behavioral health unit pychiatrist, Dr. James Rugowski, visits the jail once a month for about five hours to handle medication assessment, management and to assess individuals’ mental health needs.

Crisis workers connect incarcerated individuals with behavioral health services before they are released from jail, so there is a continuation of care. Before their release individuals who are identified in need get help processing their (medical assistance) BadgerCare application from a county health department staff member.

“When they walk out of the jail doors, they can have their BadgerCare application already processed so they have insurance to cover their mental health services, medications and medical needs,” said Johnson.

Stark and Johnson also provide suicide and mental health training to jail staff.

“From administration all the way down to the line staff, we all strongly believe that it’s equally as important to care for [inmates’] mental health as it is to care for their physical health,” said Johnson.

The county offers a crisis call line through Northwest Connections, a third-party organization contracted by the county’s mental health unit to handle the county’s crisis call work. This allows the county 24/7, 365-day coverage for crisis calls and is used in the jail.

“The officer can bring the inmate to the phone and give the call taker a synopsis of what’s going on and the inmate will speak to the crisis call person and they determine the appropriate care for them,” said Drew.

Challenges they still face include serving non-county residents, and a lack of resources for proactive care and the continuation of care outside of jail.

“I do think we are doing a really good job of managing what we have with the resources that we have available,” said Drew.

“More resources would be nice, but you can only play with the cards you’re dealt.”

Johnson has found connecting individuals from outside of Polk County to services once they leave jail a challenge, because not all counties have the same services or resources.

“I can’t always have an appointment scheduled for them when they walk out the door, whereas I can if they are a Polk County resident,” she said.

Barriers for individuals continuing their mental health care outside of jail include finding housing and transportation to appointments. Those that are enrolled in BadgerCare can access the state’s nonemergency medical transportation services.

However, in Johnson’s experience, that extra step of organizing transportation can become a barrier for some people.

Polk County has one transitional housing facility for those returning to society after incarceration called the Serenity Home, but its future at its current location, in the old county jail, is uncertain.

“It has been a godsend to have them where they are, but unfortunately the county board opted not to renew their lease when it is up,” said Johnson.

The Serenity Home, operated by the Salvation Army, is located across the street from the Polk County Jail and neighbors the county’s behavioral health unit.

Looking to the future, Johnson and Drew are hopeful about the potential to better serve individuals incarcerated in the county jail who have mental health needs.

Recently, the county’s community services unit proposed two positions to expand behavioral health services. The positions are an additional half-time jail nurse, specializing in mental health services, and a full-time nurse practitioner for the behavioral health unit.

Drew supports both positions.

“If that comes to fruition, which I am hoping it does, I think it will be a really good model for other counties to provide more preventative care,” said Drew.

Danielle Danford, a staff writer for the Leader-Register, is a 2018 John Jay Rural Justice Reporting Fellow. This is a condensed and slightly edited version of a story written as part of her Fellowship project. The full story is available here.


Oregon Hid High Recidivism Among Criminally Insane

Oregon releases people found not guilty by reason of insanity from supervision and treatment more quickly than nearly every other state in the nation, but they commit far more crimes after their release than the state has previously led the public to believe, a news investigation has found.

Oregon releases people found not guilty by reason of insanity from supervision and treatment more quickly than nearly every other state in the nation, but they commit far more crimes after their release than the state has previously led the public to believe, according to a joint report from ProPublica and the Malheur (Ore.) Enterprise. The speed at which the state releases the criminally insane from custody is driven by both Oregon’s unique-in-the-nation law and state officials’ expansive interpretation of applicable federal court rulings. Release decisions are made by the Psychiatric Security Review Board. The five-member panel of mental health and probation experts has custody of defendants found not guilty by reason of insanity and oversees their treatment. On its website, the board assures Oregonians that repeat offenses by people it supervises are exceedingly rare events, with only 0.46 percent of defendants committing new crimes each year.

The reality is that about 35 percent of those let out of supervised psychiatric treatment were charged with new crimes within three years of being freed by state officials. Between Jan. 1, 2008, and Oct. 15, 2015, the state freed 220 defendants who had been acquitted of felonies because they could not tell right from wrong or control their actions. About a quarter of them, or 51 people, were charged with attacking others within three years. Twenty-five were charged with lesser crimes. Eighteen others were charged more than three years later, including 12 people for violent incidents. They were charged with felonies about as often as people freed after serving prison terms — both 16 percent — according to the news organizations’ analysis and the Oregon Department of Corrections. The review board made similar findings in an internal report almost three years ago, but never shared it with the public or with other state agencies.


Media Called Out on Linking Shooting to PTSD

Did the mass shooting in a California bar stem from the shooter’s combat-related post-traumatic stress? Too many reporters jumped to that conclusion, a media critic writes.

In a rush to explain the unexplainable, journalists have written multiple stories that draw unfounded conclusions linking the combat experience of last week’s Thousand Oaks, Calif., mass shooter to post-traumatic stress disorder, Columbia Journalism Review reports. In an opinion column, CJR‘s Andrew McCormick cites stories published by CNN, Reuters, the New York Daily News, the Los Angeles Times and The New York Times that took unconfirmed reports about the shooter’s mental condition and broadly suggested a causal link to the shootings at a country bar in which 12 were killed.

“Even if the former Marine had been diagnosed with PTSD,” McCormick wrote, “it would offer little explanation for Wednesday’s events. PTSD is not a guaranteed pathway to violence, much less homicide; while PTSD can result in increased anger and aggression, those suffering from PTSD are more likely to to withdraw than to lash out at others, according to the American Psychiatric Association. The image of the veteran as a haunted killer, stamped indelibly into the zeitgeist, is a myth. As Elspeth Ritchie, a retired Army colonel and psychiatrist with experience in treating the condition, told The Washington Post, something like a mass shooting usually results from a psychotic episode, in which the perpetrator loses touch with reality, not PTSD.”


‘Kindness of Strangers’ a Last Resort for the Rural Mentally Ill

In rural Nebraska, police and medical providers have teamed up to divert troubled individuals from the justice system, but it’s still a struggle to get adequate resources.

Even though more services are becoming available to divert the seriously mentally ill from the justice system, rural communities are struggling to find the resources they need to bring those services to the people who need them.

Transportation, for instance, can make the difference between success or failure.

“We have no public transportation here,” said Pamela Hopkins, a Fremont, Neb., lawyer who is running for Dodge County Attorney. “Many of these people are unable to drive, for one reason or another, whether it’s because they use alcohol as a substitute for their treatment and they lost their licenses because of that, or they’re too poor to have a car.

“They’ve got to depend on the kindness of strangers.”

Without ready access to counseling or treatment often located far from their homes, defendants might otherwise find it hard to prove to judges that they are serious about addressing their problems.

Nebraska, like many states with large rural populations, is at the sharp end of the challenges of dealing with mentally troubled individuals. Most of the state is experiencing a shortage in mental health and psychiatric providers, according to the state’s Department of Health and Human Services (DHHS) Office of Rural Health.

Linda Witmuss, deputy director of the DHHS Division of Behavioral Health, acknowledged that the system needs to undertake a “richer review of data” to better determine how the state’s finite resources should be allotted to meet the need.

But she argues that mental health reforms launched by the state in 2004 have led to more services at the community level.

“There’s always room for more services—don’t get me wrong there,” she said. “ (But) all of our rehab options (and) services, including expansion of medication management, came about as a result of that reform.”

In 2004, the Nebraska legislature passed Bill LB1083, which was designed to reduce the use of inpatient psychiatric services at the state’s three Regional Centers in Lincoln, Norfolk and Hastings, and invest more in outpatient and community-based services that could help those struggling with mental health in their own communities.

The reduction of inpatient beds was consistent with nationwide efforts to move away from institutionalizing the mentally ill and instead treat them in their communities. But those interviewed by the Tribune say that the infrastructure for community care was slow to materialize, and it still isn’t adequate for those who may be in need of more intensive care.

“There’s a lot of people who aren’t even leaving their homes to get the services that they need because they’re just homebound because of their anxiety,” said Hylean McGreevy, a licensed mental health practitioner and alcohol and drug counselor at Methodist Fremont Health’s Behavioral Outpatient Services.

“They’re not functioning well and they fall through the cracks.”

According to numbers provided to the Tribune by the Nebraska Jail Standards Board, of 1,225 individuals discharged from the Regional Centers in a four-year period following mental health reform, nearly 500, or around 40 percent, ended up in the county jail system at least once.

About six percent ended up in the prison system.

Collaboration Between Police and Health Providers

The challenges often begin at the street level, where rural law enforcement encounters individuals in desperate straits.

“There is a lot of stress on the community,” said Fremont Police Lt. Kurt Bottorff. “Times are hard for certain people — the stress builds up and that’s where some mental health breakdowns can take place.

“Their behavior ends up being a law violation and they’re sometimes jailed because of it, instead of addressing the core problem.”

Under a pilot program that started in July, the Fremont Police Department became one of only two departments in the state to hire a crisis response co-responder—a licensed mental health practitioner who works directly in the police department two days per week, responding to 911 calls alongside officers when she believes mental health is an issue in the complaint.

The pilot program, funded by a two-year grant from the Behavioral Health Support Foundation and operating in collaboration with Lutheran Family Services, aims to help keep those struggling with mental health issues out of the criminal justice system or avoid involuntary hospital stays, and to connect them with community resources.

Until recently, even the nearest medical services were a 40-minute drive away, in Omaha.

Now, mental health practitioner Rachel Wesely can respond at her own discretion instantaneously, from within the department, and can follow up with callers after law enforcement leaves.

‘When people are released (from jail) into the community, and they don’t have the supports in place, it becomes a revolving door.’

But as concern mounts about a growing number of mentally ill individuals entering the criminal justice system and winding up in county jails, local stakeholders are taking a more focused approach to line those individuals up with more appropriate services.

“There’s a need for access to treatment in jails and when individuals are incarcerated, it’s not getting filled,” Wesely said. “Sometimes when people are released back out into the community (and) they don’t have the supports in place, it kind of becomes a revolving door.”

Medication and services can be expensive. Many lack insurance to help cover costs, though some programs offer sliding fee scales, which can adjust payments based on income and family size. In recent years, co-pays and deductibles have become more expensive even for those who have insurance, providers say.

Additionally, treating mental illness is more complicated than treating physical ailments, and ensuring compliance to treatment plans poses challenges, providers say. Psychiatric treatment requires significant “trial-and-error” to find the right medications, doses and strategies. That means lots of time spent taking medications that may ultimately need to be adjusted or changed, and that may carry unpleasant side effects that deter compliance.

It’s a process that requires patience and follow-up. And ensuring that patients comply with their treatment plans, remain stable or avoid self-medicating with illicit drugs and alcohol is a challenge that’s only exacerbated by barriers like access and affordability.

“Let’s just use a hypothetical,” said Dodge County Attorney Oliver Glass. “I can’t afford my medication, my medication makes me feel strange anyway, but I do know that when I self-medicate with street drugs or alcohol, that’s going to make me feel better at least.

“And that’s when, at least in my experience here, a lot of crimes are committed.”

Intensive Care Challenges

The Regional (Health) Center has some space available to the regions for more intensive care. It houses individuals who have been ordered by a court to receive a competency evaluation or restoration, as well as individuals committed by a local mental health board. The latter process only occurs if an individual in crisis refuses to be voluntarily committed and is put under an emergency protective custody.

But wait times to get into the often crowded Regional Center have gone up, officials say.

Witmuss of the DHSS said that the state is looking into the need to increase capacity, but cautioned that opening new beds alone wouldn’t solve the problem.

“We have a lot of complex cases,” she said. “When you can’t discharge folks, then you can’t admit folks, either.”

Mental health programs and services are funded through Medicaid as well as the state’s behavioral healthcare regional system. Providers contract with one of the six regions, which then funnels funding from DHHS’ Division of Behavioral Health, federal block grants and county-level matching funds.

But grants and pilot programs, like the Lutheran Family Services’ co-responder program, are only guaranteed for fixed periods of time. Agencies and organizations are always shifting their appropriations to keep up with where the demand is highest, which can lead to changes in program availability.

Meanwhile, at the local level, stakeholders are giving new focus to the issue. Providers are exploring more innovative solutions to staff shortages, such as Telehealth, which would allow for remote counseling or med management.

Last year, Behavioral Health Care Region 6, which encompasses Douglas, Dodge, Cass, Washington and Sarpy Counties, hired Vicki Maca as a full-time employee, dedicated to trying to keep mentally ill individuals out of the criminal justice system.

That hiring decision was spurred by a nationwide initiative involving the National Association of County Officials, the American Psychiatric Association and the Council of State Governments known as the Stepping Up Initiative.

The initiative is a data-driven effort to reduce the number of people with serious mental illness booked into jail, shorten their average length of stay, increase the connection to care for those individuals in jail and reduce rates of recidivism.

While other behavioral health care regions are engaging with the Stepping Up Initiative, Region 6 is the only one that’s hired a full-time employee devoted to the topic.

But officials and providers remain optimistic. Rachel Wesely, the co-responder at the Fremont Police Department, law enforcement’s enthusiasm and willingness to cooperate with the co-responder model has led to success, she said.

Lt. Bottorff agrees.

“What I’m seeing now is reduced calls for service for the same problem,” he added. “There are times when we get so bombarded with the same situation—they didn’t have the tools to fix their problem.”

James Farrell, a staff writer for The Fremont Tribune, is a 2018 John Jay Rural Justice Reporting Fellow. This is an edited version of  Part Two of a series exploring the intersection of mental health and the criminal justice system in rural Nebraska. To see the full version, click here. Part One can be accessed here. Readers’ comments are welcome.


Rural Jails and Mental Health: The Hardest Challenge

Jail officials in rural communities frequently cope with staff shortages, overcrowding and budget shortfalls—all of which make it especially difficult to meet the needs of mentally ill inmates. One official in northeast Nebraska says the problem is the worst he can remember in nearly four decades.  

“There is nothing, nothing worse than seeing someone in jail for a misdemeanor nonviolent offense who has a mental illness,” said Vicki Maca, director of criminal justice/behavioral health initiatives for a region that encompasses northeast Nebraska.

They’re not in a therapeutic, trauma-informed environment,” she added .

And staff shortages are making things worse.

As Nebraska wrestles with shortages in psychiatric providers, officials are concerned that individuals struggling with mental illness are becoming increasingly entangled in the criminal justice system, frequently winding up in county jails.

And those jails, particularly in more rural communities, face unique challenges in meeting the complex needs of mentally ill inmates, according to mental health providers, jail administrators, county officials and criminal defense attorneys.

At these jails, there is no full-time staff devoted to mental health needs, as there is in the state prison system—which, while facing its own challenges with crowding, has a mental health unit.

The restrictive jail environment isn’t conducive to individuals struggling with mental illness, officials say. Yet those individuals face greater challenges moving through their criminal proceedings—such as long waitlists at the state’s Regional Centers, which conduct court-ordered competency restorations—which lengthen their stays.

Officials worry that challenges in providing continuous care out in the community increase the likelihood that mentally ill individuals may find themselves back in jails multiple times.

At the Saunders and Washington County jails, officials believe that mental illness is playing a far larger role in inmate populations than in the past.

“I’ve been doing this for 37 years, and I don’t ever remember the number of people with mental health issues being as dramatic, or significant, as large as it is right now,” said Captain Rob Bellamy, head of corrections in Washington County.

A 2006 report from the Bureau of Justice Statistics found that 64 percent of inmates in local jails across the country had some sort of mental health problem. The Virginia-based Treatment Advocacy Center estimates that 16 percent of inmates in jails and prisons have a severe mental health illness, such as schizophrenia or bipolar disorder.

More recent, localized data on mentally ill inmates is hard to come by. But generally, rising jail populations are becoming a greater concern for area counties.

The average daily population of Dodge County inmates at the Saunders County jail, which holds inmates from Saunders, Dodge and Sarpy counties, has increased from 61 to 81 since 2012, growing to encompass more than two-thirds of the total jail population, according to Jail Administrator Brian Styskal.

Washington County, meanwhile, is constructing a new, $24.5 million justice center—complete with a 120-bed jail—to accommodate a growing population that routinely exceeds its 17-bed capacity, and requires housing inmates in other counties.

Officials attribute jail growth to a number of factors, such as changes in sentencing laws and rising drug use, which is often coupled with mental illness, especially when individuals face obstacles in receiving proper medication or treatment.

“A lot of crimes are committed are when folks that I know, because I’ve dealt with them over the years, I know they have mental health issues, and doctors and psychiatrists have told me that,” said Dodge County Attorney Oliver Glass.

“I can tell you from my experience that a lot of [mentally ill individuals’] criminal activity occurs when they are self-medicating with alcohol or illegal street drugs.”

A rising population also leads to rising costs. To house its inmates in Saunders County, Dodge County pays a baseline cost of $64.50 per inmate per day, Styskal said, and that doesn’t include additional expenses, such as medical costs, which have been rising. This past year, the county spent $346,569.58 on inmate medical costs, more than double the original budgeted amount of $140,000.

That expense has increased every year since the 2013-2014 fiscal year, when it was just below $30,000. Medical costs have increased in Washington County as well, Bellamy says.

Mental health can play a big role in driving those costs.

A 2017 suicide in the Dodge County jail accounted for $114,000 after the inmate was flown to Lincoln for emergency medical treatment.

But even more alarming than the burden on counties’ budgets is the concern that jails are not an appropriate environment for the mentally ill.

“They’re in a jail, they’re having limited contact with other people, they may or may not be on their meds, they’re not getting support from family and friends like they may need, they’re not maybe seeing the mental health people as frequently as we would all like, ”  said Maca who coordinates mental health services for Behavioral Region 6, which covers five Nebraska counties, including Dodge and Washington.

The jails also lack re-entry planning services, Maca said, which are available in the prison system or in larger jails, like in Douglas County. Those services could help line up mentally ill inmates with the resources they need out in the community to stay out of jail: counseling, substance abuse treatment, housing, vocational training and more.

Through Region 6, Washington and Saunders are currently exploring the possibility of adding those services, though there are challenges at the jail level. In prisons, release dates are based on fixed sentences that are easy to predict. For jail inmates whose cases are being processed at varying lengths, preparing such services can be more difficult, Maca said.

Both jails have access to mental health crisis intervention services, which can respond in emergency situations. But those services are provided from outside the jails by local community-based programs, such as Blue Valley Behavioral Health and Lutheran Family Services.

Managing psychotropic medications in the correctional setting is also a challenge, as the medical practitioners from Advanced Correctional work to verify that prescriptions are accurate and that medical and mental health needs are legitimate.

Area defense attorneys are often concerned about how medications are doled out, especially at the larger Saunders County jail. They grow concerned that their clients are being forced off stabilizing medication “cold turkey.”

“That kind of confinement, and that kind of treatment of them really exacerbates some of their mental illness, especially when you restrict them on their access to meds going in,” said Fremont attorney Richard Register, who also sits on the county mental health board, which determines whether mentally ill individuals should be committed to state hospitals.

Generally, getting incarcerated poses frustrations for individuals who are on medications, especially if those medications have withdrawal symptoms, said Lindsay Kroll, Crisis Response Supervisor at Lutheran Family Services in Omaha.

Even in the period of time it takes to verify prescriptions, those symptoms can begin to manifest, she said.

Jail administrators, meanwhile, have to ensure that they are meeting inmates’ medical and medicinal needs while guarding against the potential that medications may be abused. With substance abuse becoming increasingly prevalent, jails need to ensure that prescriptions are legitimate, that needs are real and that inmates struggling with addiction aren’t seeking to compensate for lack of access to street drugs, Styskal argued.


“It makes it a problem for our contract medical provider where, their license is on the line for whatever they prescribe, so they have to be definitely cautious and make sure there is a medical need versus a medical want,” Styskal said.

And often, at the request of attorneys, judges will intervene, signing orders compelling the jails to prescribe those medications, Styskal said, though he believes that those decisions are often made without considering the full history of the inmate and the possibility that they may seek to abuse those medications.

Additionally, inmates with mental health issues often spend longer times in jails than other inmates. Among other contributing factors here in Nebraska is the lack of available inpatient beds at the state Regional Centers—inpatient psychiatric institutions that also provide court-ordered competency evaluations and restorations, when a defendant appears incompetent to stand trial.

Meanwhile, wait times for admissions at the still fully operational Lincoln Regional Center have increased. Mentally ill defendants ordered to receive competency evaluations can be put on long waitlists, awaiting court-ordered resources that must occur before their case can proceed.

The average wait time for a bed at the Regional Center in 2018, through Sept. 30, is 85 days—more than double what it was in 2014. Dodge County inmates have waited for anywhere between 30 to 100 days, said County Attorney Glass. In Washington County this year, one inmate spent more than 10 months waiting for a competency evaluation.

“That’s frustrating from the jail and the jail administrators’ perspective because apparently, the system recognizes that he has a problem that needs to be treated, but yet he continues to be warehoused in a jail because there’s, obviously and apparently, there’s nowhere else for them to go,” Bellamy said.

The Regional Center conducts competency evaluations both inpatient and outpatient, according to the state’s Department of Health and Human Services. The number of those evaluations are up: in 2018, through Sept. 30, there were 223 competency evaluations compared to 138 in 2016. Most of those were conducted in an outpatient setting.

But the higher number of calls means more individuals found to be incompetent to stand trial, which puts them on the waitlist for an inpatient bed for competency restoration, which can only be conducted at the Lincoln Regional Center, DHHS said.

Still, officials and attorneys say that the biggest frustration is the barriers to care outside of jail, like expensive medication or a shortage in psychiatrists. And for those who face those barriers, the criminal justice system may be their first exposure to treatment. Fremont-based attorney Leta Fornoff has seen that firsthand.

“I can say that there have been people that I have represented before that have wished to be incarcerated so that they can get the help they need,” Fornoff said.

“Now that’s few and far between, but it has happened.”

James Farrell is a John Jay Rural Justice Reporting Fellow. This is an edited version of a story published this weekend in the Fremont Tribune, first in a two-part series exploring the intersection of mental health and the local criminal justice system. The full version is available here.


Experts Link Mental Health Issues to Spike in Honolulu Police Shootings

The number of police-involved fatal shootings in 2018 has doubled to six, the most ever in recent history, prompting concern among criminal justice experts about whether they’re seeing an overall trend of more violence in the Aloha State. 

When  Hawaii’s new police shooting board began its work this summer, it already had a full plate.Four fatal shootings were waiting to be reviewed by August, with three of them involving the Honolulu Police Department  (HPD). 

Two months later, the number of HPD-involved fatal shootings in 2018 has doubled to six, the most ever in recent history, prompting concern among criminal justice experts about whether they’re seeing an overall trend of more violence in the Aloha State. 

It is not known if any of the six men killed were using drugs or alcohol at the time of their deaths. HPD has declined to provide details because the cases are still under investigation and they declined requests to be interviewed about the shootings for this story.

For years, the police department has tried to address encounters officers have had with mentally ill and drug-addicted individuals. In 2006, the HPD began consulting with three on-duty psychologists when encountering someone who appeared to be mentally ill. By 2008, HPD officers had placed about 26,000 calls to the on-duty psychologists. This year, the department has been part of a new initiative to divert the mentally ill who have not committed a crime but appear to be in crisis.

Launched in April, the Law Enforcement Assisted Diversion program has yet to divert anyone. Out of the HPD came the Crisis Intervention Team (CIT) training. The concept has worked well for police departments that had growing numbers of officer-involved shootings. In Miami, for example, fatal shootings have gone down since 2010 and the number of mental health-related calls resulted in far fewer arrests, also saving millions of dollars for taxpayers.


Experts Link Mental Health Issues to Spike in Honolulu Police Shootings

The number of police-involved fatal shootings in 2018 has doubled to six, the most ever in recent history, prompting concern among criminal justice experts about whether they’re seeing an overall trend of more violence in the Aloha State. 

When  Hawaii’s new police shooting board began its work this summer, it already had a full plate.Four fatal shootings were waiting to be reviewed by August, with three of them involving the Honolulu Police Department  (HPD). 

Two months later, the number of HPD-involved fatal shootings in 2018 has doubled to six, the most ever in recent history, prompting concern among criminal justice experts about whether they’re seeing an overall trend of more violence in the Aloha State. 

It is not known if any of the six men killed were using drugs or alcohol at the time of their deaths. HPD has declined to provide details because the cases are still under investigation and they declined requests to be interviewed about the shootings for this story.

For years, the police department has tried to address encounters officers have had with mentally ill and drug-addicted individuals. In 2006, the HPD began consulting with three on-duty psychologists when encountering someone who appeared to be mentally ill. By 2008, HPD officers had placed about 26,000 calls to the on-duty psychologists. This year, the department has been part of a new initiative to divert the mentally ill who have not committed a crime but appear to be in crisis.

Launched in April, the Law Enforcement Assisted Diversion program has yet to divert anyone. Out of the HPD came the Crisis Intervention Team (CIT) training. The concept has worked well for police departments that had growing numbers of officer-involved shootings. In Miami, for example, fatal shootings have gone down since 2010 and the number of mental health-related calls resulted in far fewer arrests, also saving millions of dollars for taxpayers.


Solitary Used More Often for Inmates with Mental Illness: Study

The odds that mentally troubled prisoners will be sent to solitary confinement for misconduct are 36 percent higher than for those without mental illness, according to a University of Massachusetts study of data from a 2004 national survey.

Inmates with mental illness are more likely to be placed in solitary confinement than other inmates, and are more likely to be punished with administrative segregation compared with other less disciplinary actions, according to a study published in the Criminal Justice and Behavior.

Kyleigh Clark, a researcher at the University of Massachusetts, analyzed data from the U.S. Census Bureau’s 2004 Survey of Inmates in State and Federal Facilities, which questioned inmates on a wide range of topics including their behavior, criminal histories, personal backgrounds, and experiences within and outside of prison.

The survey also specifically asked inmates whether they have been diagnosed by a medical professional prior to incarceration with various mental disorders: depressive, psychotic, personality, manic/bipolar, posttraumatic stress disorder, anxiety, or any other disorders.

The researcher compared the experiences of those with mental illness to those without them and found that even though both groups most often lose privileges for misconduct, the odds of those with a mental illness being put in solitary confinement for misconduct are 36 percent higher than those without mental illness.

Furthermore, those with mental illnesses are 40 percent less likely to be given other, less severe disciplinary action, 27 percent less likely to lose privileges or be confined to their own cell, 23 percent less likely to be given extra work, and 19 percent less likely to be given bad time.

It is not clear why inmates with mental illnesses are disproportionately placed in solitary confinement, but one possible explanation the author suggests is that prison management may be paying more attention to those with mental illnesses, or more attention to the actions of those with mental illnesses, and this in turn results in more infractions and harsher punishments.

Relatedly, people with mental illness are viewed as dangerous to themselves and to others, the author explained.

“[And] because many institutions suffer from a lack of resources, space, and staffing, isolation of mentally ill prisoners can be seen as the only viable option in dealing with these inmates,” Clark added.

About 37 percent of inmates have mental illness, according to U.S. Department of Justice.

The researcher excluded inmates in federal facilities due to possible unmeasured factors in those prisons that may affect their use of segregation, such as intuitional structures. The sample was further restricted to those who committed at least on misconduct during their incarceration and were not missing data for mental illness and disciplinary action

The author argued that despite news stories outlining the problematic use of isolation for mentally ill inmates, the issues had not been extensively researched until now.

He said future research should investigate whether imposing solitary confinement on mentally ill inmates, even ostensibly for their own protection, is ultimately “counterproductive.”

“Multiple studies have shown that those with mental health problems may be more susceptible to the negative effects of solitary confinement, thereby creating a cycle in which mentally ill offenders are put in solitary confinement due to their mental illness, which is made worse by isolation, leading to further or worsening symptomatic behavior,” he wrote.

“Although solitary confinement may be considered a more economical or practical choice for containing these inmates, better mental health care can be more cost effective in treating their behavior.”

A copy of the study can be downloaded here.

J. Gabriel Ware is a TCR News Intern. He welcomes comments from readers.


A Suicide in Solitary: ‘They Gave Him the Tools to Kill Himself’

Texas’ Harris County jail is considered a progressive example of being attentive to mental health needs, with a suicide rate below the national average. But the recent suicides of two inmates point to systemic gaps in how the jail system handles prisoners in solitary confinement.

Sue and Eldon Jackson were childhood sweethearts. Growing up, they held hands at the roller rink and ditched school dances together. They almost got married at 17, but instead drifted apart after high school.

Then, 34 years later, he found her again on Facebook—and they thought they would start their happily-ever-after.

But then there was the meth addiction. The hurricane. The fight. The fire. The arrest.

And by April, Eldon Jackson wound up in the Harris County jail facing a 30-year sentence for arson. He’d lit their house on fire, then slit his own throat.

He came into jail with burns on his body and bloody lacerations on his neck, a visible reminder of his internal crisis. But, apparently, he didn’t get the help he needed.

He came into jail with burns on his body and bloody lacerations on his neck, a visible reminder of his internal crisis. But, apparently, he didn’t get the help he needed.

“I don’t want to die, but being in jail is too much for me,” the 61-year-old wrote in a letter to the Chronicle.

His mental state vacillated over the three months he penned the jailhouse missive, sometimes professing his love for Sue, sometimes lashing out at her.

But then early one morning in July—a day after jailers put him in solitary confinement to prevent repeated calls to his wife—he killed himself, fashioning a hand-made noose from the gauze used to treat his burns. His death was the first of two jail suicides in barely three weeks, at a facility that’s struggled to treat the influx of mentally ill patients coming through its doors.

The suicide of Jackson, a Navy veteran who’d long battled addiction, highlights cracks in the system—cracks that prison reform advocates hoped to fill with the 2017 passage of the Sandra Bland Act.

Named for the Illinois woman who died by suicide in the Waller County jail three years ago, the legislation did much to draw attention to the needs of mentally ill populations in the days immediately after their arrest, and to diverting them from jail in the first place.

But it did less to highlight the ongoing suicide risk weeks or months into a jail stay and failed to spark discussion about the problems of putting inmates having a mental health crisis in solitary confinement.

“We didn’t consider in a real way what happened here,” said state Rep. Garnet Coleman, D-Houston. “It’s just the truth of the matter—but we will. We will work to amend the law on this because we have to.”

‘You Don’t Turn Your Back’

At first, life together was great for Sue and Eldon. But a couple of years after they reconnected, he started keeping odd hours, making Walmart runs at midnight and foregoing sleep. She knew he’d been addicted to drugs once before, but only in retrospect did it seem indicative of a larger problem.

“It’s not that he was acting crazy,” she said, “it was just the hours.”

Together, they bought a house in 2013, in the same neighborhood where they’d grown up. Yet, around that time, Sue started suspecting he’d started using drugs again. At first, it was pills. But then, he switched to speed.


Happier times: Eldon and Sue Jackson in a family photo, 2011. Photo courtesy Houston Chronicle

“The next thing I know, I’m preferring the meth daily and everything is a giant train wreck just waiting happen,” he wrote.

But to Sue that wasn’t clear until Eldon got arrested on a minor possession charge, one that ultimately got tossed for lack of evidence. Just a few months later, his son —not a biological son, but one he’d raised nearly from birth—died of an opioid overdose in Florida.

Eldon fell apart. He stayed out for days, hung with shady characters, and started selling drugs. The following year, he got arrested again—and this time he went to drug treatment.

At first, Sue said, it seemed like he’d be OK when he got out. But afterwards, familiar faces started showing up at the door, and Eldon started disappearing again. He suspected she was cheating; she suspected he was cheating. At one point, she ended up filing for divorce.

“It just didn’t seem like things were going to change, and I was trying to get his attention,” the 60-year-old said. “But you don’t turn your back on somebody like that. You just don’t do it. If he was willing to get himself right I was willing to walk him through that.”

So they hung in there. Things didn’t get better—but they didn’t get worse.

Then Harvey hit.

A ‘Crisis’ in the Jail

The Harris County jail is often considered a progressive example of an urban jail attentive to mental health needs. Their suicide rate over the past decade— just over 16 per 100,000 inmates— is well below the national 15-year rate of around 42 per 100,000, according to Bureau of Justice Statistics data.

“More than 120,000 inmates are booked into Texas’ largest jail each year,” the sheriff’s office said in a statement. “While our inmate suicide rate is below the national average, our goal is a suicide rate of zero.”

To that end, Sheriff Ed Gonzalez created the Bureau of Mental Health and Jail Diversion. The jail launched two programs to help mentally ill inmates stay out of isolation and cut in half their use of solitary confinement over the past five years.

Still, the jail is ill-prepared to be the state’s largest mental health care provider.

A quarter of county inmates are on psychiatric medication, according to Harris County Sheriff’s Office spokesman Jason Spencer. There have been 15 suicides at the county lock-up since 2009, and staff members intervene in an average of about 10 suicide attempts per month, according to jail data.

“It’s no secret that we have an abundance of inmates who are in serious need of mental health care that we’re not equipped to give as a jail,” Spencer said. “We’ve been very transparent about that.”

Sometimes people still fall through the cracks. In 2014, the jail saw a string of three suicides.

That same year, news broke of a mentally ill inmate who’d been left wallowing in a solitary cell full of bugs and feces, a supervision failure that sparked outrage and dealt a harsh blow to then-Sheriff Adrian Garcia’s campaign to become Houston’s mayor.

In 2015, a mentally ill death row inmate back in county for court killed himself in solitary confinement, using shoelaces to form a noose. Then in 2017, the jail announced procedural changes after the highly publicized suicide of a 32-year-old whose family alleged he did not kill himself.

And, just three weeks after Eldon’s death, another Harris County inmate died by suicide. On Tuesday, Debora Lyons—who’d been jailed on $1,500 bail for a felony theft charge—hanged herself in a common area of the 1200 Baker Street jail just before 7 p.m. It’s not clear whether there were other inmates or guards in the area or why no one stopped her. The jail hasn’t offered clarification, citing an ongoing investigation.

Once officers found her, the 58-year-old was taken to the hospital, where she died Wednesday—the same day she was granted a personal release bond to get out of jail.

“We have a mental health crisis in the county jail,” Spencer said, “one that the state’s aware of but has not addressed.”

‘Not the Person I Fell in Love With’

When Hurricane Harvey hit in 2017, it flooded the Jacksons’ home with five inches of water, leaving them with a daunting task familiar to countless Houstonians: rebuilding their lives without flood insurance.

“It was just overwhelming,” Sue said.

Eldon, always a fix-it man, decided to do the repairs himself. But with all the work in front of him, the drug problem just got worse. He stayed up for days at time, sawing and hammering at all hours of the night.

And Sue’s chronic lung illness got worse while living in the half-finished, flooded-out single-story home. So she and her granddaughter moved out.

“It gave him free reign to do whatever he wanted to do,” she said.

By the time things were ready for Sue to move back in last December, Eldon was a changed man.

“That was not the person I fell in love with,” she said. “Drugs took over his body and his mind completely.”

Eldon Jackson

Eldon Jackson prison photo. Courtesy Harris County Sheriff’s Office

After a fight with Sue, he was arrested on a misdemeanor family assault charge in March, then released with a protective order in place barring contact.

Despite that, they kept talking, and stayed in touch. Eventually, he asked her to drop the charge.

“I told him I’m not doing that, I’ve done it too many times,” she said. “You need to figure it out that what you do is not OK.”

Then, he showed up at the house one day in April, “completely crazed” and threatening to burn the place down.

When police arrived, Eldon ran to the back of the house and holed up in the still-unfinished master bathroom, shouting suicide threats. He slit his throat during the stand-off, but later claimed the fire that erupted was an accident, sparked when he dropped a cigarette. As the back part of their house went up in flames, Eldon slipped outside, leaving behind a trail of blood.

He passed out nearby and was arrested later, when—hoping to have him taken into custody before he bled to death—Sue lured him back home with a texted promise of a pack of smokes.

Gaps in the Sandra Bland Act

The Sandra Bland Act reformed the way jails handle mental health, but only at certain points of the process. In July 2015, the 28-year-old Bland’s death sparked national outrage, leading to a $1.9 million lawsuit settlement, a broader conversation about mental health in county jails, and state legislation. The measures passed—watered down considerably from what was initially filed—were guided closely by the specifics of her death.

Sandra Bland

Sandra Bland (via Twitter)

“We focused on diversion, we focused on people not being in jail if the reason they were there was because of their mental illness,” said Coleman, who authored the House version of the bill.

The measures also focused on suicide prevention at the front end, making sure inmates were screened better and courts were notified more promptly of mental health crises. But while it drew attention to the initial intake, the bill didn’t address ongoing treatment during incarceration, and did little to make sure jails are still attentive to burgeoning mental health needs in the weeks and months after initial intake.

“It didn’t deal with treatment or aftercare, and that’s a huge problem,” said state Sen. John Whitmire, D-Houston, who authored the senate version of the legislation. The act also didn’t address the use of solitary confinement with mentally ill populations or those having a mental health crisis.

“I’m really kicking myself,” Coleman said. “Had we been solving all of these problems when I did that bill, we would have covered this.”

No Help, No Phone

After his arrest, Eldon was taken to the hospital and later released to the jail, where staff did a risk assessment and decided to keep him in the infirmary on suicide watch, officials said. But because he denied being suicidal he was released to general population two days later.

That was in April. He did not get additional mental health help until July 18, when he saw a nurse for medication monitoring, officials said. Again, he denied having suicidal intentions.

All the while, he called his wife repeatedly, harassing her sometimes up to 20 times a day. So prosecutors went to court and asked that he be barred from using the phone. Judge Marc Carter agreed.

None of them had any idea the jail would enforce that order by placing Eldon in solitary confinement where, one day later, he would kill himself.

“I loved my husband and I still love my husband,” Sue said. “They put him into solitary confinement in the state of mind that he was in, and gave him the tools to kill himself.”

 Advocates flagged a number of possible problems in the events leading up to Eldon’s death. For one, some questioned the decision to deem him no longer a suicide risk so soon after his last attempt.

“If someone presents at the jail as suicidal or having suicidal tendencies, that person should be considered as an individual with mental health needs throughout their time at the jail,” said Annalee Gulley, policy director for Mental Health America of Greater Houston.

“You cannot say someone is suicidal three days ago and received treatment and is no longer at risk.”

Experts also questioned putting him in isolation, a potentially triggering event for those already in mental crisis.

“It exacerbates people’s existing mental health conditions,” said Greg Hansch, public policy director for the National Alliance on Mental Illness. “If a person is experiencing delusions, or hallucinations, being alone in a room by themselves is proven to often result in an exacerbation of those symptoms.

“And for a person who is depressed, it may increase hopelessness and despair.”

Like the first days behind bars, the first days in solitary confinement can be particularly high-risk moments, experts said. And, even though Eldon died at the Harris County jail, some saw his suicide as a reminder of larger systemic problems.

“I know how deeply committed the leadership at the Harris County jail is to mental health,” Gulley said. “If a breakdown can happen at a facility that is taking such measures to protect the mental health of its inmates, then I worry about other institutions.”

Keri Blakinger, a staff writer for The Houston Chronicle is a 2018 John Jay Langeloth Justice Reporting Fellow. This story was written as part of  her Fellowship project. The full version is available here.