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Jails and Emergency Rooms Are Our De Facto Mental Health Clinics

So now what?
Irren-Anstalt Band-Hain by Adolf Wölfli, an Art Brut artist who suffered from psychosis. (Photo: Public Domain)

Irren-Anstalt Band-Hain by Adolf Wölfli, an Art Brut artist who suffered from psychosis. (Photo: Public Domain)

The last time Virginia state senator Creigh Deeds made national headlines, the occasion was a shocking family tragedy. In November, Deeds’ son Gus, who had been on and off medication for bipolar disorder and crippling paranoia, repeatedly stabbed Deeds, before ending his own life. Now, a recovered but visibly scarred Deeds is back in the news, publicly urging his colleagues in Richmond to help him reform the state’s mental health laws.

On the night before his son attacked him, Deeds told Scott Pelley in a 60 Minutes interview, the family had taken Gus to an emergency room and tried to place him in a psychiatric facility, because they worried that he might hurt himself or someone else. Under Virginia state law, Gus could only be hospitalized against his will for six hours, or until an available bed in a psychiatric facility could be located. But no bed was free, and so Gus went home. Deeds is now working to get Virginia to extend the length of those emergency stays, and to build a state-wide computer database that would make finding open psychiatric beds easier.

Deeds’ story was just one part of the 60 Minutes segment, called “Nowhere to Go: Mentally Ill Youth in Crisis.” Scott Pelley interviewed a number of parents who have had to repeatedly bring their children and teens to the hospital for short-term stays and unsatisfying, piecemeal mental healthcare, for things like bipolar disorder, schizophrenia, and major depression disorder. Long-term psychiatric care is just so much harder to come by. Pelley explains that their experiences today illustrate the result of a half-century-long systemic deinstitutionalization of mental health care in America:

In the decades after the 1960s most large mental institutions were closed. It was thought that patients would get better treatment back in their communities. But adequate local facilities were never built. The number of beds available to psychiatric patients in America dropped from more than half a million to fewer than 100,000. That leaves many kids in crisis today with one option: the emergency room.

But what if those people suffering from mental illness aren’t minors, and they don’t have parents or support systems to bring them in to emergency rooms? If those people are adults, and they’re out in the world, disturbing people with antisocial behavior, then chances are that at some point, they’re going to have a brush with the law.

In a recent NPR report from the nation’s largest jail, Cook County in Illinois, Laura Sullivan described the spare, padded cells that many of the inmates are housed in. At least a third of the 10,000 inmates in Cook County are mentally ill, and the jail’s staff sounded absolutely overwhelmed. Staff members called the situation they’re facing “staggering” and the policies that caused it “ridiculously stupid.” Sullivan reported that in the past three years, budget shortfalls caused Chicago to cut funding to six of the area’s 12 mental health clinics, and three nearby state hospitals. Those clinics and hospitals had provided mentally ill patients in the community with counseling and medication; without them, many of those patients tend to end up in jail.

Cook County is doing what it can to process the flow, and provide medicine and help to the people who need it—and this help, in turn, attracts more people who need it. Sullivan interviewed one inmate/patient who told her that after his local mental health clinic closed, he started relying on the jail to get regular access to the medication he has been taking for decades to manage his illness. In fact, he regularly commits small crimes just to get sent to jail, where he’ll then stay, until he goes before a judge to receive his sentence. This situation is not only incredibly ineffective in serving the community’s needs, it’s also incredibly expensive, as Sullivan describes:

It costs almost 200 dollars a night to house a mentally ill person here. Health clinics cost a fraction of that. Plus, the cases clog the courts with largely minor offenses. That lengthens jail time for everyone. The average stay is now eight days longer than it was a few years ago. And that is costing county taxpayers $10 million more every year.

This is not just a Cook County problem, nor just a Virginia, Oklahoma, or Nebraska problem. Research shows that jails across the country are crowded with the mental health patients who aren’t getting treatment elsewhere. And this has been true for decades. Dr. E. Fuller Torrey, a research psychiatrist who founded the Treatment Advocacy Center to push for better access to mental health care, has estimated that are three times more mentally ill people in jail and prisons than there are in hospitals in America (PDF). Some studies estimate that as many as 50 percent of all inmates of jails and prisons suffer from some kind of mental illness.

It would be easy to argue that there should be more funding on every level of government for public mental health care, and that as many community mental health clinics have been shut down—and more—should be re-opened. But what happens in the mean time? If jails are our de facto mental health facilities for so many adult Americans in need, what kind of care should they give?

Those are questions that researcher Amy Wilson is trying to answer with her work at Case Western Reserve University’s social work school. Wilson’s latest article, published in Qualitative Health Research, describes her ethnographic study of a newly developed re-entry program that helps evaluate the needs of mentally ill inmates as they are released from jail.

Wilson does not disclose the jail’s location, but she does explain why she chose to study a re-entry program that works with people released from jail, rather than one that works with a prison. As opposed to large and often distant prisons, jails are typically located right in the same community where the offending took place, and where the inmates live. Jails process and evaluate an incredible volume of people, many of whom need help of some kind. According to one calculation, “Jails in the United States admit more than 12 million people each year and release almost 9 million,” she writes. For these reasons, “jails to me become a possible point of intervention,” she says. (Other researchers and health care providers have also previously used the term "community public health outpost" when discussing the potential for jails to do good.)

In her study, Wilson found that the re-entry program actually did have meaningful mental health resources to offer, like counseling and medication, but that the inmates often weren’t necessarily taking advantage of them. Too often, their immediate needs of food, warm clothes, and housing took priority over long-term plans for mental health care. Of one client of the program, Wilson wrote, “despite having significant mental health problems that brought her into regular contact with emergency psychiatric services, she could not see past her need for some form of stable housing to think about getting treatment for her mental health problems.”

That type of prioritizing, which Wilson notes follows Maslow’s hierarchy of needs, was common. When asked what type of help they would need after leaving jail, 70 percent of the inmates in Wilson’s study said “housing,” and 59 percent said “money.” Only 24 percent answered “mental health treatment.” Many people had been in jail long enough (often weeks or months) to have lost whatever precarious living situation they had had prior to being arrested.

“When you go to jail, I equate it to a catastrophic event,” Wilson says. “Unless you have a pretty significant support system, you're going to lose most of what you had when you went in, so, in my opinion, you'll need a pretty significant support system to maintain those resources until you get out—or else you've got to rebuild them.”

Getting on (or getting back on) public assistance was often vital in a successful re-entry, Wilson says. Public assistance registration is a long and onerous process, for anyone: it can include long waits in crowded offices, criminal checks, substance abuse evaluations, and medical appointments. For people suffering from serious mental illness, who have just gotten out of jail, perhaps having lost any forms of government identification that they may have had, this is especially daunting.

So people with mental illness don’t just need help with treatment for their conditions, Wilson found. They need much more practical help, first, in handling the basics. Wilson suggests, for instance, offering temporary cash and food-coupon assistance, right on the day of release, to fill what she calls the “resource gap” between jail and public assistance.

Jail re-entry programs like the one Wilson looked at can be incredibly useful “points of intervention” in the lives of people who need help most, and, given the shrinking options elsewhere, that need is greater than ever. But they can’t do that important work without facilitating, and accelerating, the financial piece of the puzzle.

“For many people who were able to engage in work with their case manager, they eventually did get public assistance, but it wasn't when they needed it,” Wilson says. “They're hungry and cold, and worried about where they're going to stay, right when they get out of jail, and having these things two or three weeks later ... the reality is, how many of us could last out there for that long, living under that kind of uncertainty?”