Jails and prisons struggle to diagnose, treat mental illness
Officials are looking at options at every stage of the criminal justice system to channel offenders toward treatment
By Sarah Volpenhein
Grand Forks Herald
Sheree Spear knows how easily a person with a serious mental disorder could cross paths with the law and end up in jail—it could have happened to her son.
But it didn't come to handcuffs one night when she asked police to find her son, whose schizophrenia was going untreated. He was suffering under the delusion he would become a god if he killed himself, and she did not know whether he had a gun.
With about one sixth of people in jails and prisons having a severe mental illness, by some estimates, and with correctional facilities ill-equipped to treat them, officials are looking at options at every stage of the criminal justice system to channel offenders toward treatment, including jail diversion programs.
Spear has been active in shaping mental health policy in North Dakota, including obtaining a $250,000 federal grant to implement a jail diversion program in Fargo to channel low-level offenders with serious mental illness out of jail and into treatment as a way to address the mental health problems at the root of their criminal behavior.
Spear said her son never ended up in jail, unlike many others with serious mental illness.
"I did this so he never will," she said, referring to her work with the jail diversion program.
The percentage of people with severe mental illness in jails and prisons across the U.S. outpaces the percentage of the seriously mentally ill in the general population, leading to public outcry from correctional officials, mental health professionals and others who say jails and prisons have become the nation's new mental hospitals after a wave of deinstitutionalization closed down the majority of the nation's mental hospitals in the 1970s and 1980s.
While figures estimating the number of jail inmates with serious mental illness vary, a 2009 journal article found that nearly 15 percent of male inmates and about 31 percent of female inmates at five jails in Maryland and New York had a serious mental illness, such as major depression, bipolar disorder or schizophrenia.
Lack of Services
It is difficult to estimate the number of inmates with serious mental illness in North Dakota jails because not all jails screen for mental illness and not all jails have staff trained to recognize—much less diagnose—mental illness in inmates.
Jails are bound by the U.S. Constitution to provide health care—including mental health care—to inmates. But county jails, where inmates are detained while awaiting trial or where they serve sentences typically less than one year, are often ill-equipped to treat inmates with serious mental illnesses.
"We are not a psych ward," said Bret Burkholder, administrator of the Grand Forks County jail. "We do not have all the capabilities of a state hospital. We don't have physicians on hand that can instantly prescribe something to somebody who is going crazy to bring them down."
Dr. Lisa Peterson, with the state Department of Corrections and Rehabilitation, said Cass County is "inching the most" toward more "robust" treatment of offenders with serious mental illnesses. The Cass County Jail may be the only jail in North Dakota with a full-time mental health professional. It also screens every inmate at booking for mental illness using a nationally recognized series of yes-or-no questions.
The Grand Forks County jail does not have any mental health professionals on staff, nor does Burleigh County Detention Center, though Burleigh County's budget will allow the jail to hire a mental health professional in 2016, according to Maj. Steve Hall, of the Sheriff's Department.
Those jails instead rely on outside providers—local hospitals, county mental health services and the North Dakota State Hospital in Jamestown—when in need of psychiatric services.
The Grand Forks County jail has three nurses on contract from the Grand Forks Health Department, none of whom are qualified to diagnose inmates with a mental illness or recommend treatment options, Burkholder said.
Contracted doctors—all of whom are in family practice and do not typically prescribe antipsychotic medication—visit the jail once every two weeks, said Korrine Olson, a registered nurse at the jail.
When nurses believe an inmate may be suffering from an untreated mental illness, but cannot find any medical paperwork pointing to a diagnosis or the inmate is not taking medication, they try to schedule an appointment at Northeast Human Service Center, Olson said.
The problem is inmates typically must wait six to eight weeks before having that appointment—if at all—by which time their condition may worsen, she said.
"If we have to wait six to eight weeks, we figure out a different plan," Olson said, saying they will treat inmates with medicine that family practice doctors can prescribe, try to check them into Altru or try committing them to the psychiatric ward at the State Hospital.
If the inmate is very ill, the nurses attempt to bump that person to the top of the list.
Nor does the Grand Forks County jail screen inmates for mental illness—aside from two questions about whether they have attempted or thought about suicide and whether they are thinking about committing suicide.
In recent decades, federal lawmakers and state and local policymakers have pushed for initiatives to treat offenders' underlying mental health issues, which may be driving their criminal behavior.
In 2004, President George W. Bush signed the Mentally Ill Offender Treatment and Crime Reduction Act, which authorized $50 million in grants for programs aimed at steering mentally ill people to treatment, rather than incarceration.
Cass County was one of about two dozen places across the U.S. to receive a grant under the program in 2007. The $250,000 grant went toward planning and starting a mental health jail diversion program at the Cass County Jail, the only such program in the state. The program screens inmates booked into the jail for serious mental illness. If they have a certain diagnosis and fit other criteria—they must be Cass County residents and typically must be charged with low-level offenses—they may be released from jail and enrolled in the program under the condition they follow through with treatment or else be sent back to jail.
State prisons generally have better mental health services than county jails, with more access to state funds.
Between 6 and 10 percent of the roughly 1,800 state prisoners have a serious mental illness, depending on which mental illnesses one includes under the "serious" heading, said Peterson, clinical director at the state Department of Corrections and Rehabilitation.
A unit in the James River Correctional Center in Jamestown houses prisoners who are seriously mentally ill, and the state DOCR employs three psychologists who are shared among the state's four prisons, said DOCR Director Leann Bertsch.
Six months before release, a case manager will work with mentally ill prisoners to find out where they are going to live and set an appointment with a nearby provider, Bertsch said. Upon release, those offenders are given a 30-day supply of their medication and a 30-day prescription.
But Peterson says case management is still lacking and the state must do a better job following up with released offenders, particularly the mentally ill.
Brush With the Law
For Spear's son, there were several run-ins with police, but he was never arrested, Spear said.
While untreated, he came into contact with law enforcement because his behavior—falling asleep in a public restroom or wearing a long, heavy coat in summer—was sometimes unusual and would attract attention.
The disorder, Spear said, took hold of her son and prevented him from realizing his problem and seeking help.
"He really believed if he went to the hospital, the doctors and nurses were going to poison him," she said.
Meanwhile, she was not having luck committing him to a psychiatric ward to have him observed and diagnosed.
It was not until Spear's son had a break with reality and a brush with the law that he was diagnosed and got treatment.
Spear called the Fargo Police Department one night after her son's grandparents found him with a gun in his mouth and then he ran away.
She didn't know whether he had a gun with him, but relayed a description of him and his car to police and asked them to find him and bring him to a hospital.
Spear said she was on the phone with her son, who was under the delusion he would become a god if he committed suicide, when police arrived on the scene, their sirens ringing through the phone. Then the line went dead, and she waited, not knowing what had happened.
"I really did not know if my son was lying in a pool of blood, dying," she said.
In the end, he was fine and was taken to a hospital.
Once he got on medication that worked, Spear said the change was "miraculous."
While testifying before legislators in 2006, Spear described what she says her son told her about living with schizophrenia: "I know now that there is a heaven and a hell. And they are here on Earth."
The purpose of the jail diversion program at Cass County Jail is to channel people out of jail that otherwise would not be there had their serious mental illness been treated.
National medical and correctional associations have been pushing for more diversionary programs, like jail diversion programs, for at least the last decade, though research is still lacking on what is necessary to have in place for the programs to be most effective.
Lynette Tastad, the mental health professional at the Cass County Jail, saw nearly 2,000 inmates in the first half of 2015, all of whom were flagged at booking as possibly having a mental illness.
She is able to diagnose inmates, recommend treatment options and tap inmates for the jail diversion program, which puts inmates on an individualized treatment plan, links them to a case manager at Southeast Human Service Center and monitors their progress in the program.
There are four inmates currently in the jail diversion program, which Tastad monitors.
The program began in 2009, and during its infancy Tastad was required to keep detailed data on its participants and their progress.
A 2010 report offers a window into the program. It notes that one person who was accepted into the program in 2009 had bipolar disorder and had initially been arrested for shoplifting. The person met regularly with a three-person review panel, which reviewed his progress and advised him to continue with his case manager. In July 2010, when the report was produced, he was on track to graduate the following month.
Another participant with a mood disorder and substance abuse problems was accepted into the program in May 2010 and had been arrested for having drugs on him. The report noted he relapsed on drugs in July, but was honest with his case manager and was doing "very well" in the program.
But Tastad does not only work with inmates released under the program. Even though inmates may have a mental health diagnosis that makes them eligible for the program, they may not get in, with one of the most common reasons being they are not Cass County residents.
Mental health professionals like Tastad have more specialized training to know what to do when an inmate is having a mental health crisis, to judge an inmate's risk for self-harm, suicide or violence, to decide when an inmate should come off of suicide watch and to monitor them after a crisis, said Peterson, clinical director at the state DOCR.
Jail officials in North Dakota and DOCR officials began meeting in late August and are working to put together a list of service gaps and identify one to three solutions to go with each gap, said Bertsch, director of the DOCR.
Among what they look at will be mental health jail diversion programs as a possibility in other counties.
Burleigh County recently was awarded a $150,000 grant through the same program through which Cass County got its $250,000 grant. The county is planning to implement a program to offer better mental health and addiction services to people who run afoul of the law.
Bret Burkholder, jail administrator at the Grand Forks jail and one of the jail officials in the discussions, is not currently looking at a jail diversion program and said the services need to be there first.
It is difficult to hire a person with a degree to work in a jail, he said, much less a person specializing in mental health.
Every county in North Dakota, except Burleigh, Cass, Grand Forks, McHenry, Morton and Ward counties, is considered to be a mental health professional shortage area.
"There is a drastic shortage of mental health professionals throughout the entire state," he said.
Copyright 2015 the Grand Forks Herald