State of Mind

Want to Fix Mental Health in Jails?

Try promoting a therapist to warden.

An incarcerated person wearing an orange jumpsuit and with his hands cuffed behind his back.
Photo illustration by Slate. Photo by Getty Images Plus.

Welcome to State of Mind, a new section from Slate and Arizona State University dedicated to exploring mental health. Follow us on Twitter. On May 11 at 1 p.m. Eastern, State of Mind and the 19th News are hosting an event titled Prioritizing Mental Health. Register here.

If you’re a mental health professional who works in a jail, there’s a sound that will always make your stomach drop. It’s the sound—multiple sounds, really—of security responding to an “inmate in distress.” It starts as the faint jingling of keys and footsteps pounding in the distance. Before long, the sound has swelled to a synchronized, thundering, Jumanji-style stampede, rounded out by the belligerent voice of a correctional officer yelling, “Take them to mental health!”

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The stampede is a regular occurrence, maybe two or three times per week, and often follows a predictable sequence of events. Security interacts with an incarcerated person in a way that causes or exacerbates an agitated response. Physical restraint ensues. Mental health professionals are called in after the fact to “treat” the patient because any time there is a behavioral problem, the assumption is that it’s because of a mental health issue.

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One day, while working as a licensed mental health clinician in a county jail, I counted 17 separate stampedes. Five out of 17 involved the same person, George: a brilliant academic with several credentials after his last name and research publications to back them up. (George is a pseudonym and identifying details have been changed to protect his privacy.) George was also diagnosed with Bipolar I disorder, and when in the throes of a manic episode, he lost any tether to reality, becoming delusional to the point of posing a danger to himself and others. On this particular day, George sat before me shirtless, handcuffed, and sweaty, his left shoulder hanging three inches below his right, rambling incoherently about how he had seen his doctoral thesis proven in the formation of the clouds outside his cell window.

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I never got the full story of what happened that day—how George ended up in handcuffs with a dislocated shoulder. The correctional officers that dumped George in front of my desk could only tell me that they were told by their superior to “take him to mental health.” Still, it wasn’t hard to picture a scenario in which George’s “unusual” behavior had been met with confrontation and coercion, further fueling the psychosis, and peaking in an act of violent restraint that dislocated his shoulder. During my five years working in jails, it felt like security was always using the same script when confronted with a problem: Get loud and posture to intimidate. When that doesn’t work, apply physical restraint. Then, “take them to mental health.” I wish George’s story was the exception, but it most certainly was the rule.

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Though I no longer work in corrections, the words “take them to mental health” still haunt me.  Implicit is the devaluing assumption that as a mental health professional, I have the magical ability to “fix” the deep-seated roots of a person’s emotional issues in five to 10 minutes. This assumption puts mental health care in a corner where band-aid solutions are the only clinical tools available, making interventions doomed to fail and encouraging both security and patients to see this essential service as ineffective. Even more problematic is that security officials have the ultimate authority in deciding how mental health care is administered in the jail. Mental health professionals, with their training, skills, and expertise, are an isolated afterthought in a process for which they are fundamentally qualified to add value.

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People with serious mental illness are booked into jails in the U.S. about 2 million times a year, according to the National Alliance on Mental Illness, effectively making jails and prisons among the nation’s largest mental health facilities. Yet health care professionals who work in corrections will tell you they are visitors in someone else’s home—keeping on their best behavior, so as to be invited back. Simply questioning the logic of a security policy from a health care perspective could get you flagged as a threat to security operations and escorted out of the building, with no invitation to return. The result is a precarious dynamic in which mental health care professionals lack authority, and security officials are making health care decisions they’re unqualified to take on. To move carceral health care from triage to treatment, mental health professionals need to occupy leadership roles at the administrative level, where top-down decision-making can translate to bottom-up change.

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Very few institutions have applied this strategy. Among them is Chicago’s Cook County Jail, where Nneka Jones Tapia, a clinical psychologist, served as warden from 2015 to 2018. Recognizing how jails have shape-shifted into holding facilities for people with mental illness, officials brought Jones Tapia on to serve in an executive role, a move that sent a compelling message: Mental health care must become the backbone around which correctional practices are developed, measured, and administered, so the infrastructure does not collapse under the weight of the system.

Under Jones Tapia’s leadership, the Cook County Jail started offering programs and services including linkage to community healthcare resources, communication with the court system, and follow-up with therapists in the community post-release. The jail also implemented a five-day-per-week mental health transition program, where individuals diagnosed with mental illness received cognitive behavioral therapy, job readiness skills, and extra recreation.

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Carceral policymakers and administrators like to say that “rehabilitation” is their goal. You might think that any genuine attempts at “rehabilitation” would embrace mental health care treatment, but that’s not the case on the ground. During my tenure in jails, I lost count of how many times someone from mental health care management told me, “We don’t provide treatment here.” But if that’s the case, then what are we doing? The answer, unfortunately, is spending a lot of money to keep someone alive while incarcerated, without any care, consideration, or planning to equip them for life outside the facility.

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This is why it is so important for qualified mental health professionals to serve in administrative leadership roles, such as warden, and not to be confined to positions like director of mental health services, which sit tangentially outside of the scope of jail operations. We need people who will not be intimidated to abandon clinical judgment and best practice to preserve the status quo. Mental health, after all, is security, because it is key for safety.

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Jones Tapia understood this well, acknowledging in the New York Times that the relationships she cultivated with correctional officers smoothed her transition into leadership. Correctional officers are key to transforming the quality of mental health care in prisons and jails. For incarcerated people, correctional officers are a 24/7 presence, assuming the role of a caregiver. And because humans are innately wired to connect to and trust caregivers, correctional officers wield a tremendous amount of power to positively influence the safety and well-being of everyone in a facility based on how they treat those in their care.

While a growing body of research and practice demonstrates the benefits of mental health intervention as a core training area for police officers, this same level of attention in correctional settings seems to be lacking. Given the inherent parallels between these groups, it is perplexing how little is known about mental health training requirements for correctional officers (not to mention what is known about program outcomes). What we do know is that there’s a high degree of variability in terms of delivery, duration, and content—reflecting the low priority this training has in correctional settings. What did mental health training for correctional officers look like in the jail where I worked, the place with the day of 17 stampedes? I could not tell you, because the mental health staff were not involved in developing or leading those trainings, nor was the correctional health care corporation that was my employer—mental health training was security’s domain.

Whenever I see a news article about a mental health crisis in a jail, I’m reminded of George and his dislocated shoulder. I also think about the hundreds of other incarcerated patients I’ve encountered for whom a different security response could have led to a different outcome, a de-escalation versus a stampede. I hear the echo of the words “take them to mental health” and how they represent a disconnect in a system that could reasonably be repaired with a willingness to listen, learn, unify, and restructure.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

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