Local jails are increasingly the biggest mental health treatment centers in many communities
By Adam Geller
AP National Writer
Day or night, the lights inside cell 135C of central New Mexico's Valencia County Detention Center were always on.
Locked inside, alone, for a total of eight months, Jan Green says she heard the constant drip of water from a broken showerhead, pitting the concrete floor where she curled up on a sleeping pad. When she was awake, Green - a 52-year-old computer technician diagnosed with schizophrenia and bipolar disorder - rocked back and forth on a three-foot bench, hour after hour, confiding in an imaginary companion.
"I didn't have a calendar or a pencil. I didn't have anything. So ... I pretended I had a friend in there with me," says Green. "I would talk and hold conversations just in my little crazy world, I guess you would say, just to keep me company."
Though locked in solitary, Green was, in a sense, far from alone. In jails around the country, inmates with serious mental illnesses are kept isolated in small cells - some no wider than a man's arm span - for 23 hours a day or more, often with little or no treatment or human interaction.
Lawmakers and activists in some states have worked to curb the widespread use of long-term "solitary confinement" in prisons, where research shows it can drive those with mental illnesses further over the edge. But there has been little attention to the use of isolation in the country's 3,300 local jails, increasingly the biggest mental health treatment centers in many communities.
Partly, that is because so many independent jurisdictions run jails. In June, Colorado banned its state prisons from long-term solitary confinement of inmates with serious mental illnesses. But the new law left out county jails despite reports spotlighting isolation of inmates with mental illness. Texas legislators voted last year to form a task force to study inmate segregation, but dropped a provision including jails for scrutiny when county officials objected - and then did not fund the study at all.
Unlike prisons, jails hold those awaiting trial or serving shorter sentences, limiting the time inmates spend in lockdown. But inmates with serious mental illnesses are much more likely than others to break jail rules and to stay jailed longer than other inmates, increasing the chances of weeks or months in isolation that risks inflicting additional psychological damage.
The Associated Press obtained a report last fall showing that mentally ill inmates at New York City's jails were disproportionately put in lockdown, some for thousands of days, a practice that coincides with increased violence inside the jail. Inmates who spent time in isolation were far more likely to harm themselves - and for those with serious mental illnesses, the odds of inflicting potentially fatal self-harm are particularly high, according to a second report by staff of the city's health department.
"At many jails and prisons around the country, solitary confinement has become kind of the default placement for the mentally ill," says Dr. James Gilligan, a New York University psychiatrist and lead author of the first study, who has worked in the Massachusetts prison system and San Francisco's jail and has consulted in cases involving detention centers around the U.S.
Jails use isolation to punish inmates, but it also is frequently used to separate those with serious mental illnesses because officials worry they may be victimized by fellow inmates or because they are considered dangerous. Many inmates in lockdown end up there because of behavior linked to mental illnesses that experts say can be highly disruptive to jail routines.
Small jails often lack specialized housing units or care for inmates with mental illness. Large ones often manage populations that include hundreds of mentally ill prisoners. It can take months to secure an opening for the most seriously ill inmates in the few remaining state psychiatric hospitals, so some jailers decide that isolation is the only suitable place to put them.
"If they can't follow the rules outside the facility, how in the world do you expect a mentally ill person to be able to function as an inmate?" says Mitch Lucas, assistant sheriff of Charleston County, South Carolina, and president-elect of the American Jail Association. "So you end up having to deal with whatever tools you have at hand and, in many jails, the tool is restrictive housing and that's it."
Jail operators say critics mischaracterize their treatment of inmates in isolation. While activists routinely target "solitary confinement," jails use a number of terms for the isolation of inmates, including administrative or punitive segregation, restrictive housing, or special housing. Privileges granted to inmates and the conditions in which they're held in different types of isolation cells can vary significantly.
But jail operators acknowledge that lockdown is the subject of growing debate in the corrections industry, in particular its use for inmates with serious mental illnesses at jails not built to house them.
Experts have pointed to rising numbers of inmates with mental illnesses at both jails and prisons since the 1970s, when states began closing psychiatric hospitals - without following through on promises to create and sustain comprehensive community treatment programs.
But as the number of those with mental illnesses has climbed or surpassed 20 percent in some jails, many have struggled to keep up, sometimes putting inmates in jeopardy. The task is complicated by the churn of inmates through jails. U.S. jails hold less than half the number of inmates as prisons - about 731,000 - but each year process more than 19 times as many new inmates as prisons do.
The rising number of inmates with mental illnesses has been spotlighted by the debate over lockdown.
-In New Mexico, three counties have been sued since 2008 for holding inmates with serious mental illnesses in lockdown for between eight months and two years.
Green won a $1.5 million settlement in January after suing Valencia County for inhumane confinement in a cell that was roughly 7½ feet wide and long. Since her release, she has been treated for post-traumatic stress disorder, with panic attacks triggered by the sounds of doors locking or the sight of people in uniform.
Last year, Dona Ana County agreed to pay $15.5 million to Stephen Slevin, who was jailed for 22 months after a 2005 arrest for driving while intoxicated and isolated after being deemed suicidal. The county argued that Slevin, who came into jail with depression, was offered the chance to move into the jail's general population, but he declined. Matthew Coyte, the attorney who brought the suits, calls that an abdication of the jail's responsibility to protect and care for Slevin. In his cell for months, Slevin's toenails grew so long that they curled under his feet.
-In Tennessee, a 2011 investigation by federal officials of the Robertson County Jail, about 30 miles north of Nashville, found that officials denied treatment to seriously mentally ill inmates, including one man left untreated for more than a year despite his history of suicide attempts. Instead, officials at the jail relied on long-term "therapeutic lockdown," isolating mentally ill inmates in cells where they were denied any interaction with staff, including health providers.
-In Ventura County, California, an inmate, Daniel Hernandez, committed suicide in a segregation cell where he was held for months before he was transferred to a state psychiatric hospital and then after he was returned to the jail. When Hernandez died in 2009, it had been more than three months since he'd been seen by a jail psychologist; he was locked in a cell where the opening in the door was covered with a piece of paper, a lawsuit by his family alleged.
The decision to isolate Hernandez "was made without input from the mental health staff at the jail, and persisted despite indications that segregation housing was adverse to his mental health condition," a judge wrote. The county settled the suit by agreeing to pay the family $775,000.
-In Dane County, Wisconsin, jail inmates with serious mental illnesses are routinely kept in isolation cells measuring about 6 feet wide, behind steel doors with a portal a few inches wide and a feed slot. Deputies attempt to get inmates out daily to shower, but the most mentally unstable inmates often refuse to leave their cells, Sheriff David Mahoney said.
"They haven't violated any rules. They can't be housed in general population because they could be victims themselves, so we're forced to house them in solitary confinement because it's the only housing we have," Mahoney said. On an average day the jail holds between 20 and 50 inmates in lockdown solely because of a mental illness or a medical condition.
Mahoney has lobbied county officials to build a new jail with a unit designed for mentally ill inmates, and has taken Madison area residents through the lockdown cells to make his case.
"People say, 'I can't believe that this exists in our community,'" he says.
Mahoney said he is concerned that time in isolation makes mental illness worse. Research bears that out.
In prison, healthy inmates who are confined in isolation for a few months routinely show increased anxiety, disordered thinking which becomes paranoia, despair that can lead to suicidal thinking and depression, said Dr. Terry Kupers, a psychiatrist who, as an expert witness, has investigated correctional facilities around the country. It's worse, though, for inmates who are already mentally ill.
"You put them in solitary and they break down," Kupers says.
For many people with serious mental illnesses, symptoms typically wax and wane, with acute psychosis often followed by extended periods of remission when they appear nearly normal, he said. But many of the prison inmates he has observed in lockdown are in a continuous state of breakdown, hallucinating all the time, he said.
There's been little research about the impact of lockdown on inmates in jails, where time in isolation is typically more limited than in prisons.
One of the only studies, examining 244,000 incarcerations in New York City's jails from 2010 to early 2013, found that inmates who harmed themselves were seven times as likely to have spent time in lockdown. Inmates who inflicted the most serious, life-threatening injuries were 10 times as likely to be both seriously mentally ill and have spent time in isolation. Many of those incidents occurred among inmates who harmed themselves in the days just before being put in isolation, in what appeared to be attempts to avoid it.
The report found that the time inmates - particularly those with mental illnesses - spent in lockdown stretched on because of additional violations of rules committed once they got there. Last year, one mentally ill adolescent inmate accrued 1,002 extra days of punishment beyond the 374 days of time owed, according to an investigation by the Justice Department, released in August.
In recent months, New York officials have moved to reduce the use of lockdown for inmates with mental illness. The city has closed a punitive segregation unit with many mentally ill inmates and shifted those with the most serious psychoses to a new 60-bed therapeutic housing unit. The city council passed a bill in August requiring the Department of Correction to report details of how lockdown is used. But that comes after city jails expanded punitive segregation units from a capacity of 614 in 2007 to 998 in June 2013, many of them occupied by inmates with mental illnesses, according to the report co-authored by Gilligan. Among the jails' adolescent population, 102 of the 140 inmates in lockdown last June were diagnosed as either seriously or moderately mentally ill.
Many small jails provide little special housing or treatment for mentally ill inmates. And for inmates who are not released soon after admission to big-city jails, the length of their stays may be stretched by court system backups and the lack of connection with family who might bail them out.
That increases the likelihood that jail inmates with mental illnesses wind up in isolation cells for weeks or months at a time, said University of Colorado psychiatrist Dr. Jeffrey Metzner.
"That's very problematic," says Metzner, a specialist on mental health in correctional institutions. Metzner said he pushes jail administrators to limit the negative impact on inmates with mental illnesses by ensuring that regular mental health care is provided to those in lockdown, that time out of cells is increased and that inmates are allowed to have radios and other items that make it easier to pass the time and interact with the outside world.
Green, the former New Mexico inmate, says her months in lockdown left her with deep psychological scars. She was arrested twice in 2009, charged with assaulting her husband. For much of 2010 and 2011 - the county's and Green's lawyers disagree on how long and records are missing - she was held alone in a small segregation cell used for female inmates, off a corridor near the jail's booking area. Both sides agree that the symptoms of her mental illnesses were obvious to jail administrators and inmates.
"The reason she was moved into administrative segregation was for her own safety and the safety of others," says Brandon Huss, an attorney who represented Valencia County in the case. "Other detainees would approach staff and report incidents. They'd wake up and find her face in their face."
As Green's case dragged on for two years - until the charges were dismissed - her mental health continued to deteriorate. She went for extended times without showering; Huss said she resisted. She ate and slept on a mat on the floor. Deputies brought food, but while people in the corridor often peered through the window in the cell door, there was almost no conversation. When she was transferred in late 2011 to a state psychiatric hospital, she was described as "thin" and "disheveled," and told staff she was Ana Marie Ford of the Ford Motor Co. and that she'd been kidnapped, court papers say.
Nearly three years later, Green, who now lives in Minnesota, says her mental health is stabilized by treatment. She speaks clearly, if haltingly, about her experience. But she says she has been diagnosed with post-traumatic stress disorder that "causes me to fear things that I really shouldn't fear in everyday life."
The PTSD causes flashbacks and dreams about the jail, triggered by the sight of people in uniforms or the sound of locking doors, Green says.
"She's definitely not the same woman she was going in," says her daughter Jessalyn Middendorf. "She's my mom, but she's not my mom. She's not the mother that I knew, that I grew up with, that I was raised by."
Published: Tue, Sep 23, 2014
