In 2006, Sheriff Adrian Garcia led the Harris County Sheriff's Office in an innovative and comprehensive initiative to update the mental health protocols within the Harris County Jails and to implement new ?Best-Practice? strategies for the care, custody, and control of the growing mentally ill inmate population. A startling illustration of the growing mental health problem came from a recent Mental Health and Mental Retardation Authority (MHMRA) Local Plan Review, which stated:

• There are approximately 500,000 adult Harris County residents who experience a mental health condition each year;
• Approximately 140,000 of those suffer a severe mental illness, such as severe depression, bipolar disease and/or schizophrenia;
• Almost half of adult Harris County residents who suffer from a severe mental illness could not access treatment; and
• Approximately 20 percent of inmates in the Harris County Jails have a history of mental illness.

According to some experts, the Harris County Jail has become the largest mental health facility in the state and one of the largest in the nation based upon the percentage of the inmate population taking prescribed psycho-tropic medication. To meet the demands of the growing numbers of inmates with mental illnesses, the Harris County Sheriff's Office established the Mental Health Unit (MHU). The newly formed MHU, which is a collaborative effort between the Sheriff's Office, Mental Health and Mental Retardation (MHMRA), and the Harris County Psychiatric Center (HCPC), represents a new paradigm for the treatment of mental illness within the detention setting and strikes a balance between detention and treatment.

The primary components of the Mental Health Unit may be summarized as the three ?P's:? Personnel, Process, and Plant, with Plant referring to the physical structures that exist within the detention setting.

Personnel

The cornerstone of this innovative program is the development of a new Division called the ?Mental Health Unit?, or MHU, which began the new designation of Mental Health Unit Officer. The MHU is supervised by a Lieutenant, and is comprised of several Sergeants and, thus far, 71 Deputies and Detention Officers, all of whom are specially trained in Mental Health-Crisis Incident Management. All Mental Health Officers assigned to the MHU receive the following training:

• Texas Commission on Law Enforcement Officer Standards and Education (TCLEOSE) Mental Health Peace Officer course (40 hours)
• Suicide detection and prevention (8 hours)
• Use of force in the jail setting (16 hours)
• TCLEOSE Intermediate CIT plus 8 hours of role playing (24 hours)
• MANDT (building healthy workplace relationships) training (24 hours)

Upon completion of their training, they are classified as a Mental Health Officer and receive $150 per month incentive pay. A different uniform, one with a less authoritative look, is also worn by the Mental Health Unit Officers. The new uniforms are expected to minimize the intimidation effect sometimes perceived by the inmates due to the traditional law enforcement uniform, as well as help distinguish the Mental Health Officers from other personnel as they implement their specialized training. Further, these officers will receive continuing education on topics related to mental illness, use of force, and crisis intervention/de-escalation.

In addition to the extensive training and distinctive uniforms, Mental Health Officers are deployed differently within the Jails. Previously, Deputies or Detention Officers would be assigned to work in non-specific cellblocks within the Jails, which may or may not house inmates with mental illnesses. Mental Health Officers are permanently assigned to only those cellblocks that make up the Mental Health Unit. Often, the Mental Health Officers work the same cellblock each day, which allows them to become better accustomed to individual inmates and their particular needs. The Mental Health Officers are also on-call to respond as a Crisis Intervention Response Team (C.I.R.T.) to incidents of inmates experiencing mental health crises throughout the Detention Bureau. Thus far we have seen a noticeable decrease in incidents requiring use of force when verbal strategies and techniques consistent with crisis intervention training are utilized.

Process

As part of the new Mental Health initiative, the Sheriff's Office significantly reorganized the process through which inmates with mental illnesses are identified and evaluated in order to better address the growing demands of mental illness within the jails. To accomplish this, Sheriff Adrian Garcia appointed Dr. Michael Seale as the Executive Director of Health Services for the Harris County Jails and designated his position as a staff position with direct access to the office of the Sheriff and Chief Deputy. Sheriff Thomas also established a new formal agreement with MHMRA redefining their duties and responsibilities.

The second significant component of the reorganization provides greater resources earlier in the booking process with a mind towards determining the inmates' needs for medication and/or further evaluation prior to housing. While an inmate is being booked into the Harris County Jail, nurses screen the inmates to determine the inmates' medical and mental health needs. Inmates presenting with medical needs have always been diverted to the clinic for further evaluation and/or treatment. Previously, inmates presenting with mental health concerns were given a referral for additional evaluation and/or treatment subsequent to housing. Under the new structure, inmates with either medical or mental health needs are diverted to the clinic for a higher level of evaluation prior to housing. Further, the updated process includes an increased level of screening for mental health concerns during booking, as well as improved access to psychiatrists to better determine the appropriate housing location, medication, and evaluation needs of the individual inmate.

Additionally, the appropriate information regarding an inmate's mental health condition is now sent to the courts electronically to ensure that the information is available to key figures in the criminal justice system sooner.

Plant

The ?Plant? aspect of the new Mental Health Unit describes the designation of more space and more appropriate space for inmates with mental illnesses.

Within the Harris County Jail, inmates with mental illnesses have been consolidated into specialized housing to centralize mental health services, such as medicine distribution and programming, and to facilitate the most efficient and appropriate provision of care for this unique inmate population.

On the 2 nd Floor of the 1200 Baker Street Jail, four cellblocks have been designated as mental health housing.

• Cellblock 2C ? Previously the MHMRA ?Forensic Unit,' this cellblock has been renovated to increase the housing capacity by 19 beds and to improve the treatment area. This cellblock serves as an ?inpatient' unit for those patients whose needs can be met within the jail.
• Cellblock 2E ? Designated as female ?step-down' housing.
• Cellblock 2B ? Designated as male ?step-down' housing.
• Cellblock 2P ? Designated as the Diagnostic Unit, this cellblock has undergone extensive renovations to significantly increase the number of safety rooms within the Mental Health Unit and to provide for better ongoing assessment and more efficient provision of care. Inside this cellblock is a newly constructed nursing station, a first for the Harris County Jails. Half of this cellblock serves as a diagnostic unit for patients for whom psychotropic medication may be prescribed and who would benefit from mental health monitoring. The other half of the cellblock serves as a therapeutic-management unit designed for patients requiring the intervention of an evaluation by an MHMRA-supplied psychologist and individually designed behavior management protocols. Patients may be moved from one side to the other pending results of ongoing assessment and evaluation.

An additional two cellblocks have been earmarked for incorporation into the Mental Health Unit in the near future, which will include specialized housing to provide concomitant treatment protocols and programs for inmates dually-diagnosed with mental illness and substance addictions.

Also falling under the heading of ?Plant? is a groundbreaking initiative undertaken last year in conjunction with Harris County Psychiatric Center , or HCPC, where inmates within our custody partake in what is generally a seven to ten day, intensive psychiatric program at HCPC. Under this cooperative effort, MHU personnel transport selected inmates to and from the jail and HCPC and serve as in-unit security function at HCPC. At least two Mental Health Officers work on the unit at all times and interact closely with HCPC staff. Patient eligibility for treatment at HCPC is contingent upon prudent security, medical and mental health criteria and candidates are chosen on a case-by-case basis considering a variety of factors. Ultimately, all transfers to HCPC require a psychiatrist's recommendation and signature. This innovative unit has been in operation now for the better part of a year, and the treatment results have been characterized as positive and beneficial by virtually all involved.

Future Efforts

Short and long-term projections include a joint Harris County Sheriffs Office / Houston Police Department Processing Center . This facility, which is essential to the strategic plan addressing the longer term physical and mental health care responsibilities of the Sheriff's Office, will include the construction of state-of-the-art psychiatric care units and an enlarged and more capable medical infirmary. Research and discussions are further underway to determine how the Sheriff's Office can best contribute in pre- and post- incarceration interventions for those citizens who commit minor infractions of the law symptomatic of their affliction with a diagnosable mental illness. In short, the Harris County Sheriff's Office embraces its role as an integral component of the Mental Health Community and strives to be catalyst for positive change within that community.

Conclusion

The work Sheriff Adrian Garcia has initiated in detentions-mental health has thus far been an apparent, though as yet unqualified success. Nonetheless, Advocacy, Inc. has stated during a recent news conference the Harris County Sheriff's Office MHU stands as an example to the nation; and, Texas Commission on Jail Standards Director Adan Muñoz stated he recommends the Harris County Sheriffs Office system to all other jurisdictions in Texas as the example to follow for psychiatric care and control in the jail environment.

Sheriff Adrian Garcia wishes to thank the citizens of Harris County , the Commissioners Court , and all of the medical, psychiatric and security professionals for supporting the Harris County Sheriff 's Office in its commitment to creating a standard of care in detentions - mental health now being characterized as a national model for all to follow.