| Mental Health Unit News
Pioneering Jail - Mental Health Care in the 21st Century
By
Captain J.O. Coons, Ph. D, and
Lieutenant J. P. Legg, M.S, M.A.
Unfortunately, the optimistic expectations of efficient community mental health care programs that brought rise to the onset of de-institutionalization in the 1950’s were at odds with the reality of a social welfare system not fully prepared to meet the needs of hundreds of thousands of individuals afflicted with serious mental illness. As a result, a flood of people in need of mental health care were all but left to their own devices to obtain scarcely available housing, community treatment, vocational opportunities, and financial support. To make matters worse, contrary to the out-spoken good intentions of many well-wishers, a genuine heart-felt community reception for mentally ill patients upon their re-entry into society was lacking. Many discharged patients, therefore, found themselves homeless and frequently in conflict with a criminal justice system ill-quipped and unprepared to assume a de facto, mental-institutional role.
While much progress has been made, a general shortage of resources and collaborative commitment to a community-based system of mental health care continues to be a problem in the majority of American communities, and many people with serious mental illness can still be found lost among the general public without access to needed medication or treatment. When encountered by persons unfamiliar with mental illness, often symptomatic behaviors are easily perceived as troublesome, interpreted as threatening, or considered criminal in nature. When confronted with troublesome or seemingly dangerous people, citizens are understandably quick to call the only social-service agency that will respond twenty-four hours a day, seven days a week: law enforcement. And, one of the few options traditionally available to police officers and sheriff’s deputies when these individuals will not comply and/or move on is to arrest them and place them in jail.
Statistics show most severely mentally ill people in jail have been charged with misdemeanor violations such as disorderly conduct, threats, trespassing and/or harassment. Other common charges brought against the mentally ill who end up in jail are, "lewd and lascivious behavior” (such as urinating on a street corner), defrauding a business (eating a meal, then not paying for it), disorderly conduct (such as being too loud), menacing panhandling, criminal damage to property, loitering and petty theft”.
It is little wonder then, why of the estimated 2 million inmates being held in prisons and jails across the country, experts believe nearly 500,000 are mentally ill. According to the National Alliance for the Mentally Ill (NAMI), 16 percent of the prison population can be classified as severely mentally ill, meaning that they fit the psychiatric classification for illnesses such as schizophrenia, major depression, and bipolar disorder. According to a survey of staff at city and community jails, 25 percent of the jail population is severely mentally ill. However, when other mental illnesses, such as anti-social personality disorder, borderline personality disorder and depression, are included, the numbers are much higher, and NAMI puts the number of inmates suffering from both mental illness and substance abuse at well over 50 percent.
In recognition of the growing inmate population needing psychiatric treatment in Harris County, Texas, the Harris County Sheriff's Office entered into a contract with the Harris County Mental Health and Mental Retardation Authority (MHMRA) in the early 1990’s to provide evaluation and treatment to this unique population. From that point on, the Detention Operations Command Staff, worked closely with the Sheriff to ensure improving mental health care for the department’s huge inmate population remained paramount on the agenda. In 2006, Sheriff Tommy Thomas created the Health Services Bureau, which combined medical and psychiatric treatment under a unified command; he also elevated Dr. Michael Seale, MD to head the new bureau and hired long-time, nationally recognized mental health specialist Horace Stroud from MHMRA to serve as the Quality Control and Training Coordinator. While these changes were occurring internally, the HCSO became externally pressured to step-up progress of its mental health care initiatives by Advocacy, Incorporated (Advocacy, Inc.), a national, non-profit entity granted a legal right to enter the jails at any time to monitor the standard of psychiatric care, treatment and living conditions for inmates.
What could quickly have devolved into an adversarial relationship instead became one of mutual benefit. Advocacy, Inc. provided an expert to review the HCSO’s standard~of~care to psychiatric~needs inmates and his report was carefully reviewed and compared to another expert retained by the Sheriff’s Office. One of the common themes was the need for more detentions-staff training in the discipline of mental health care. If jails had in fact become de facto mental health institutions as experts were suggesting; and, it was unlikely mental health specific institutions in a quantity sufficient to accommodate the need would ever re-emerge, the Sheriff saw investing in developing a specialized mental health unit comprised of deputies and detention officers as a priority for the future. With this realization, he directed a plan of action be devised.
Conceptually, it was decided this new unit would be cross-trained in de-escalating events involving mentally-challenged persons, as well as be able to proactively manage the day-to-day activities of all inmates assigned to mental health housing areas in order to minimize mental health crises and support the mental health provider’s mission of care. Soon, Lieutenant Walter J. Bailey and Sergeant John P. Legg, who holds a masters degree in both psychology and criminal justice, were brought on board to develop and directly supervise the Mental Health Unit (abbreviated: MHU). In close conjunction with Dr. Seale, Bobby Davis and Horace Stroud, Lieutenant Bailey and Sergeant Legg went to work.
The first order of business was to determine the “standard~of~care” in the industry and then write an operational policy meeting those criteria. Next, Bailey and Legg proposed a program encompassing not only the state-required 24 hours of Crisis Intervention Training (CIT), but an additional 88 hours to include the widely recognized mental health training MANDT system. Next, the time came to interview volunteers and select the sergeants, deputies and detention officers who would staff the MHU. Concurrently, Bailey and Legg suggested the designation of multiple cellblocks in a centralized area of the jail with new mental health office space to allow for more efficient mental health care; environmental changes to include brighter, freshly painted walls; and the over one million dollar refurbishment of Cellblock 2-P for housing acutely psychotic inmates including a built-in nursing station. Lastly, a uniform change from the traditional, authoritative deputy/detention officer styles to a more subtle, less intimidating design was proposed for all MHU personnel to facilitate and enhance MHU/inmate interventions and readily differentiate the MHU members from other detentions personnel. After careful examination and consideration, the submitted proposals and the plans were authorized for implementation without delay.
Medical and psychiatric staffs were far from idle during the development of the MHU program. The Health Services Bureau hired additional psychiatric staff toward the goal of having at least one psychiatrist on duty in the jail system at all times. Dr. Seale “front-loaded” psychiatric screening of all incoming inmate who, if they exhibit symptoms or complaints indicating a possible mental challenge, are sent immediately for evaluation. Previously, mentally challenged inmates were seen after they were housed and they or staff members submitted requests to MHMRA staff. Their medications are now catalogued and contact is made with entities treating the inmate prior to their incarceration. Dr. Seale’s intention is to avoid the immediate curtailment of psychotropic medication upon being booked into custody which may lead to treatment only after the inmate experiences a mental health crisis. Under current protocol, tremendous effort is put forth to contact treatment providers, determine the inmate’s issues and medications and ensuring these medications are interrupted for as little a time as possible.
In another recently implemented operational function of the MHU, during incidents where inmates in emotional or mental crisis have been wholly unresponsive to housing personnel’s verbal orders, MHU personnel now respond in the capacity of a Crisis Intervention Response Team (C.I.R.T.), which has proven successful in calming the individual and gaining compliance through the verbal intervention techniques they’ve learned. In the past, this may have required a use~of~force to get the inmate back under control and moved to more appropriate housing. Already, the reputation of MHU employees’ skills is gaining ground, and as a result, many detention employees have begun taking notes of the protocols for their own use in similar situations; as well as volunteered for future openings in this previously somewhat under-heralded assignment.
The Harris County Sheriff's Office's ground-breaking efforts in detentions-mental health has thus far been an apparent, success. In fact, the once critical Advocacy, Inc. stated during a news conference shortly after their assessment of the MHU, that it stands as an example to the nation; and, Texas Commission on Jail Standards Director Adan Muñoz stated he recommends the HCSO system to all other jurisdictions in Texas as the example to follow for psychiatric care and control in the jail environment. Still, there is progress to be made, and now Sheriff Adrian Garcia is committed to achieving overall success in this critically important area of detention-services.
Thanks to the initiative and support of the Harris County Commissioners Court and the hard work of medical, psychiatric and security professionals, the Harris County Sheriff's Office Mental Health Unit is poised to become THE standard of care in detentions - mental health care and a national model for all to follow.
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