A Few Words on Jail in America, Part 2: The Mentally Ill in Jail

A jail’s goals are simple: prevent escape and ensure the security of all inmates and staff. The mandate is to maintain order. In my last essay I mentioned that jails and prisons have become the largest psychiatric treatment facilities in the country, and I briefly discussed the challenges people with mental illnesses can face in jail. In this segment, I’m going to focus entirely on this population, which per federal statistics comprises 64 percent of all inmates. I’m going to discuss the difficulties they face more thoroughly and explain why jail is fundamentally the wrong place for someone with a mental illness.

Let’s begin with the booking process. It’s a standard component of the booking process to ask if the inmate is considering hurting themselves, or has done so in the past. If they answer in the affirmative, any jail operating properly will document this fact and immediately page psychiatric staff. In a large jail, such staff should be available at all times.

The psychiatric staff will assess the suicide risk of the inmate. If the inmate is deemed a suicide risk, they’re likely to experience the precautions discussed in Part 1 of this series. But even if an inmate suffering from a mental illness is not deemed at risk for suicide, it is vital that staff begin their care.

What would solid clinical practice look like if this were a hospital instead of a jail? Normally, a social worker, psychologist or psychiatrist interviews a client to create a thorough assessment. They seek the client’s permission to retrieve medical records from all places where the person has received treatment in the last several years at least. Finally, they, with the client’s permission, obtain independent portraits of the client from family and/or friends.

In this way, the clinician learns how the client sees themselves, how other professionals have seen them, and how their family and friends have seen them. This is possible when the clinician, or ideally a treatment team, has some hours to invest per client, and when the caseload is no more than a few dozen at most. Large jails, however, operate at a scale far greater than hospitals or smaller private agencies.

Herein lies the rub. Quality mental health treatment requires a rapid response to immediate need, and it is difficult to do this when a facility has thousands of inmates. Indeed, the Cook County Jail, largest in the nation, had an average daily population of 8,870 inmates in 2014. By contrast, the largest hospital in the United States by bed count has a capacity of 2,259 beds, not all of which are used at once. Of course, these are both extremes, but there are many large urban jails with well over a thousand inmates on a daily basis. In this era of cash-strapped municipalities, it can be very difficult to procure the funds to pay sufficient staff to handle so many inmates.

In jail, the assessing staff member might have ten to thirty minutes to interview the inmate before writing a diagnosis and moving on to the next inmate. The problem is that some diagnoses are very difficult to arrive at quickly. For example, if an inmate is psychotic, is it because they suffer from a mental illness, or is the psychosis drug-induced? If both, which mental illness and which drugs? Is there some other cause entirely? Or, less commonly, are the symptoms being faked? Sometimes only the passage of time can help the clinician answer these questions.

However, if the clinician must also ensure scores of new intakes are handled in a timely fashion, it may take weeks for them to be able to check back with that inmate to obtain greater accuracy. If the clinician is fortunate, they’ll be able to obtain records from an inmate’s previous treatments at other places.

The clinician may deem medication appropriate once a diagnosis has been made. In order to save money, a jail’s pharmacy won’t be stocked with as many psychiatric medications as a pharmacy outside jail might have. Most likely it will have no more than two to three of each category — categories such as mood stabilizers, antidepressants and antipsychotics.

Outside jail, a clinician and client might experiment with different dosages, different medications, or different combinations of medications in order to find one that works best for the client. In jail, it can take much longer to arrive at the right combination, or the right combination may not be available. It’s also possible the inmate was on a successful medication before they were arrested, only to find it’s not available in the jail. They must do their best with what’s available in addition to dealing with everything mentioned in Part 1 of this series.

What about therapy? All of the same challenges of scale apply, particularly for individual therapy. It’s difficult for inmates to engage in group therapy. Even in the outside world, after all, it can take weeks for a group therapy cohort to form the sort of bond that allows the group to be therapeutic for its members. In jail, the boundaries of mistrust are much greater. This doesn’t mean group therapy is impossible in jail, but it does mean that the facilitator must be very skillful. In addition, people leave jail every day, so the group will likely lose members without warning, changing the group dynamic from session to session.

Outside of jail, a person with a serious mental illness may have a support system comprised of their family, friends and possibly a mental health agency. At a mental health agency, the client would have a case manager to ensure that they were going to appointments, had housing and were taking their medication. It’s also possible that the client is receiving government benefits, such as food stamps and Social Security. What happens to such support systems if the client goes to jail?

An inmate may or may not be able to contact their family, as I mentioned in my previous essay; either way, a crucial part of their support system is now missing. As for case managers, some jails are forward-thinking and have built relationships with local mental health agencies; they might even have a worker dedicated to the jail who is able, for example, to use the jail’s database software to see if any of their agency’s clients are in jail and follow up as needed. This is especially important for the agency’s ability to advocate for the inmate in court, so that the judge can see that if they give the client probation, that agency will work hard to make sure the client is getting what they need. They can also present their agency’s more comprehensive records on the client to the jail.

But what if that infrastructure isn’t there? If an agency doesn’t have a relationship with the authority running the jail, then when their client becomes incarcerated, all the agency knows is that the client has stopped showing up. They might find out months later that the client is in jail, if they find out at all. They may have meanwhile ended their relationship with the client due to the absenteeism. In addition to this problem, government benefits — often the inmate’s only income — halt when a person is in jail for thirty days or more. They can be reinstated as long as the person isn’t locked up for a year; otherwise they’ll need to re-apply. But even if the person is released in less than a year, it can take up to fifteen days for Social Security to be reinstated, potentially causing basic quality-of-life problems; all of this happening to somebody whom the system presumes innocent until proven guilty.

Families and friends become, in my experience, very accustomed to a mentally ill inmate’s repeated incarcerations. They are often passionate advocates, though badly hindered by their ignorance as to the workings of the system and an often unhelpful bureaucracy. They are frightened for the inmate; they want questions answered that often aren’t easily answered: What’s going to be the outcome of the case? What can be done to get treatment for the inmate’s mental illness?

The answers can take weeks or months to come, years at worst, in terms of the outcome of the case. Unfortunately, it can take much longer to navigate the path to recovery from mental illness inside the American penal machine.