Mental Illness, Addiction and the Whatcom County Jail

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1 March 1, 015 Mental Illness, Addiction and the Whatcom County Jail Bill Elfo, Sheriff Whatcom County America is experiencing a disturbing and increasing trend in the number of offenders housed in its county jails that suffer from severe, persistent and often dangerous forms of mental illness and addiction disorders. The Whatcom County Jail is no exception. While most people with mental illness do not commit crime, certain types of mental illness and addictions ultimately lead to crime and incarceration. The severity of crimes varies greatly, but range from offenses against public order and property to those involving extremely serious and violent offenses. For the past 60 years, social, political and economic forces coalesced to move severely mentally ill patients out of long-term psychiatric hospitalizations. Community-based treatment models seemed like viable alternatives to. Due to this ideological shift, there has been a 95% reduction in the supply of inpatient psychiatric beds in the United States since Correspondingly, the alternative treatment models never materialized so as to fully meet needs. As a result, there is less access to long-term care options for the approximately 10 million Americans with serious mental illness. This population includes those assessed as lacking insight, chronically unable to care for themselves, and potentially dangerous to themselves and the public. 1 Over the past decade, reductions in state and federal funding for community-based mental health and substance abuse treatment in Washington State have resulted in a crisis in terms of available treatment and housing. The Associated Press reported: A report by Mental Health America that ranked states based on whether mentally ill people had access to care placed Washington 48 th. Even when treatment is available, it is often episodic and lacks the continuity needed to stabilize symptoms. Many patients become homeless, which may increases the likelihood of crime and arrest. Family members of people with mental illness who attempt to intervene and seek involuntary treatment are often frustrated by the lack of services and the high threshold criteria for involuntary commitments. Even when psychiatric in-patient care is available, health care providers frequently refuse to admit patients because they are ill; have co-occurring addiction issues; or are violently out of control. In some cases, hospitals and other health care providers refer patients for arrest because they are unmanageable and assault staff and other patients. The lack of available treatment and housing for those suffering from dangerous forms of mental illness and addictions has resulted in jails and prisons becoming the largest mental health care providers in America. The United States Department of Justice Bureau of Justice Assistance reported that over 64% of people in jails suffer from mental health problems (4% reported as serious mental illness) and 68% have a substance abuse disorder. The Whatcom County Jail population approximates these same proportions and many offenders have co-occurring mental health and addiction issues. 1

2 Compounding the problem are Washington State laws governing competency determinations and treatment to restore the competency and stability to those offenders with acute symptoms of mental illness. While the law requires that evaluations and involuntary treatment be performed at Western State Hospital, the Legislature in recent years reduced the programs that provide these services. The result is very violent offenders accused of the most dangerous of crimes remain confined in the County Jail for months while they await the treatment needed to restore competency and stability. The backlog of those awaiting competency determinations and treatment within jails exacerbates existing safety and offender management issues. The Whatcom County Jail is the de facto largest behavioral health institution in our community. However, it operates at nearly twice its designed capacity and lacks sufficient space to safely house, manage or optimally treat those with serious forms of mental illness and addiction issues. Offenders requiring close monitoring are housed in a busy booking area that operates 4-hours a day. As little space exists for mental health and chemical dependency professionals to communicate with offenders, evaluation, treatment and counseling normally occur through a hatch in the steel door that separates inmates from staff. These physical limitations and the lack of privacy hamper the effectiveness of treatment and efforts to restore stability. The lack of staffing and space also preclude frequent visitation and the maintenance of family connections that are often vital to post-release success. An absence of appropriate housing for those with dangerous forms of mental illness creates enormous safety issues for staff and other inmates. Persistently overcrowded conditions often aggravate existing mental health symptoms. Whatcom County is moving ahead to plan for the replacement of its existing jail with a safer facility that will be sufficiently sized, equipped and staffed to effectively house, monitor, evaluate and treat those suffering from mental illness and addiction issues. However, even in the best of scenario this facility will not open until at least 019. Interim steps were drastically needed to enhance existing mental health and addiction services and fill some of the voids in a broken mental health system. While there are no simple or immediate solutions to this problem, the Sheriff s Office worked within the parameters of existing limitations to ensure that the offenders with serious mental health and addiction problems are to the extent possible, evaluated and treated while in jail. However, our experience with recidivism demonstrated many offenders upon being released from jail, either lacked access to or had an unwillingness to follow through with referrals for community-based treatment and soon re-offended. Without appropriate treatment and medication, disabling symptoms often generate the same behaviors that send them back to jail as a direct result of their untreated disorders. Nationally, studies report that offenders with serious mental illness are to times more likely that those without mental illness to be re-incarcerated. 4 One major obstacle to the availability of community-based mental health services for released offenders is their inability to pay. Most mentally ill offenders are uninsured. Even when eligible for health care subsidies, most have not enrolled. While many are

3 eligible for Medicaid that would otherwise help pay costs, federal and state regulations suspend Medicaid eligibility once offenders are incarcerated in jail. Re-enrollment in Medicaid and application for other federal insurance benefits is an onerous process. Mentally ill and chronically offenders often need help to access these benefits. Without these benefits and the connection to treatment, their untreated symptoms may quickly return them to jail. In response to the prevalence of unmet mental health and addiction issues in our community, the Whatcom County Council enacted a local sales tax to create a chemical dependency and mental health fund designed to provide new and expanded treatment and therapeutic court programs. An advisory board was established and quickly agreed on a need to prioritize finding pathways to treatment rather than continue the treadmill that often returns mentally ill and addicted offenders to the criminal justice system. In 01, the Sheriff s Office partnered with the County Health Department to enhance the delivery of mental health and addiction services within the jail through the Jail Behavioral Health Program. Relying on sales tax funding, the goal of this program is to stabilize behavioral health symptoms for those incarcerated in the jail and ensure effective connections to community-based services upon their release. A local psychiatric clinic places professionals within the jail to diagnose and treat acute symptoms. This process includes screening, triage, assessment, treatment planning, medications, counseling, coordination of civil commitment and evaluations. Behavioral health staff develop release plans that include solid connections and follow up with community-based treatment; assistance with health care enrollment or re-enrollment; and if needed, assisting with co-pays and housing. Our County Jail is the only jail in Whatcom County and has wide responsibility that includes booking and detaining offenders on charges and sentences generated by: all local, state and tribal law enforcement agencies and courts; the State Department of Corrections for violations of conditions of release; and other states who seeking the return of fugitives. From February 01 through December 014, jail staff performed 15,5 bookings (many involved the same person booked multiple times). Whatcom County also experiences a unique border bounce back factor when those seeking to enter Canada exhibit symptoms of serious forms of illness; have specified criminal convictions; or are indigent are denied entry and are returned to the United States. Some leave the area but others remain in our community. From February 01 through 014, there were 854 referrals to the Jail Behavioral Health program for evaluation and/or treatment. Our Health Department staff is continuing to evaluate the program and will track improvements in behavioral health within the jail as well as the offenders who were treated in the jail and subsequently received timely community-based treatment.

4 Not all mentally ill and addicted offenders need to be incarcerated in expensive and scarce jail space while awaiting a resolution of criminal charges. The mental health and chemical dependency tax helped fund Mental Health and Drug Courts as well as community-based treatment and supervision that divert the mentally ill from the criminal justice system to treatment designed to restore stability and reduce recidivism. Not only is treatment less expensive than incarceration, but many individuals who receive adequate treatment find stable recover and can become positive contributors to our community. All too often our community seeks to find solutions after symptoms of mental illness and addiction manifest themselves in criminal behaviors. Prevention strategies can serve as an upstream means to provide access to treatment prior to those afflicted entering the criminal justice system. Intervening early to support youth challenged with behavioral health concerns can prevent an unnecessary default to incarceration. Towards this end, the sales tax has funded the placement of behavioral health professionals in every school district within Whatcom County. The Health Department also recently convened a multi-disciplinary summit to make recommendation for reducing and treating addictions, especially those relating to the soaring abuse of opiate-based drugs. As law enforcement is often the only 4/7 first responders available to address emergencies involving mental health crisis, the tax has provided the funds needed to train officers in crisis intervention and establish a specialized team of highly-trained professionals to peaceably resolve the most dangerous and challenging of cases. A mental health and addiction triage center is being remodeled to provide law enforcement with alternatives to booking minor non-violent offenders. The issues of untreated mental illness and addictions are very complex. By necessity the law and public safety will require that the jail and the criminal justice system hold some people with mental illness and addiction issues. However, jails in many instances should not be the first default and when used, provide a safe and humane environment that is conducive to treatment and recovery. Fully addressing these issues will require significant policy and funding priorities at the state and national level. While there is no quick solution, Whatcom County is finding locally tailored incremental solutions to what is a national crisis. Bill Elfo is the Sheriff of Whatcom County and currently chairs the Whatcom County Behavioral Health and Substance Abuse Revenue Advisory Committee. Bill holds a B.S. and M.S. in Criminal Justice as well as a J.D. from Nova Southeastern University. He is past president of the Washington State Sheriffs Association and holds a Governor s appointment as Vice Chair of the Washington State Criminal Justice Training Commission. 4

5 1 Dominic Sisti, Andrea Segal and Ezekiel Emanuel, Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia Opinion: Improving Long- Term Psychiatric Care Bring Back the Asylum, Journal of American Medical Association, January 0, 015 Vol. 1, Number Bernton, H. and Carter M., Families seek an easier way to detain mentally ill involuntarily, The Associated Press as reported in the Bellingham Herald, February 9 th, 015 James DJ, Glaze LE. Mental Health Problems of Prison and Jail Inmates, Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (006) 4 Baillargeon J, Binswanger IA, Penn JV,Williams BA, Murray OJ. Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatry. 009;166(1):