CHICAGO – The numbers, posted daily on the Cook County sheriff's website, would be alarming at an urgent care clinic, let alone a jail: On a Wednesday, 36 percent of all new arrivals report having a mental illness. On a Friday, it's 54 percent.
But inside the razor wire framing the 96-acre compound, the faces and voices of the newly arrested confirm its accidental role as Chicago's treatment center of last resort for people with serious mental illnesses. It's a job thrust on many of the nation's 3,300 local jails, and like them, it is awash in a tide of bookings and releases that make it particularly unsuited for the task.
Peering through the chain link of an intake area holding pen, a 33-year-old man wrapped in a navy varsity jacket leans toward clinical social worker Elli Petacque Montgomery, his bulging eyes a clue that something's not right.
"They say I got bipolar, that's all," he says.
"OK, are you taking your meds?" she asks.
"When I can get them."
Two pens over, a white-haired man with a cane huddles on a bench, booked in on a narcotics charge. He tells Montgomery he is haunted by visions of people he killed in the Vietnam War, and heroin eases the post-traumatic stress.
"I'm down here every day," says Montgomery, deputy director of the sheriff's office of mental health policy. "Every morning I hear this."
The Cook County Jail, with more than 10,600 inmates, is one of the country's largest single-site jails. But it is not unique. From big cities to rural counties, jails have seen a rise in the number of inmates with serious mental illnesses, most of them arrested for non-violent crimes.
Unlike prisons — where inmates serve extended sentences — jails hold those trying to make bail while awaiting trial, or serving shorter terms. U.S. jails hold about 731,000 people, less than half the 1.57 million in state and federal prisons. But last year, jails booked in 11.7 million people — more than 19 times the number of new inmates arriving at prisons.
The revolving door greatly complicates the task of screening for mental illness, managing medications, providing care and ensuring inmate safety.
"Jails are churning people," says Henry J. Steadman, a former New York state mental health official and longtime consultant to government agencies across the country on how courts and correctional facilities deal with people with mental illnesses. "You can do things in prison, in terms of treatment and getting to know people, that is very difficult to do in a jail because of that constant movement."
Experts have pointed to rising numbers of inmates with mental illnesses since the 1970s, not long after 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 serious mental illnesses has climbed or surpassed 20 percent in some jails, many have struggled to keep up, sometimes putting inmates in jeopardy.
The Associated Press has reported that at least nine of the 11 suicides in New York City jails over the past five years came after operators failed to follow safeguards designed to prevent self-harm by inmates. In one case, a mentally ill man hanged himself from a pipe on his third attempt after orders to put him on 24-hour watch were apparently ignored.
The AP's investigation into the deaths of two mentally ill inmates at the city's Rikers Island jail complex — one who essentially baked to death in a 101-degree cell in February and the other who sexually mutilated himself last fall — have prompted oversight hearings and promises of reform.
"The incredibly high intake rate makes it very difficult (for jailers) to do their job well because they operate in environments that are so chaotic," says Amy Fettig, senior staff counsel at the American Civil Liberties Union's National Prison Project, which has sued a number of jails to demand they provide federally mandated care and improve conditions for inmates with mental illnesses.
"Frankly, local jails have become the new social safety net for individuals with mental illnesses," she says. "The only net that catches them is the criminal justice system."
By 9 a.m. the guards, public defenders and counselors who constitute the Cook County Jail's welcoming committee can see their work before them — 87 men and 19 women arrested in the city overnight, with more from the suburbs to follow. All must be processed in two hours, before they are marched through tunnels to face a judge who will hear a seconds-long synopsis of each case and set bond.
At a white laminate counter, Marianne Kelly, a substance abuse and mental health counselor, stands alongside two interns, calling up inmates one by one. Quarters are close, but the unending drone of ventilation ducts overhead and the hum of the body scanning machine drown out nearby conversation.
Kelly gently questions Jeremy, a 21-year-old wearing a black Marilyn Monroe T-shirt, arrested for simple possession. He tells her he's been taking medication for bipolar disorder since childhood. Except when he doesn't — a lapse he blames on a family member.
"I just get mad at the person who tells me to take my medicine because they tell me I'm retarded," he says. (The Associated Press agreed to a request by jail officials to use only first names in identifying inmates who have not yet been tried.)
Kelly explains that a judge will likely send Jeremy home today and urges him to reconcile with his family and resume medication. But there's no way to know what will happen or whether Jeremy, like so many here, will substitute illegal drugs for prescriptions.
"The mental health issues are causing the substance abuse. The substance abuse is causing their criminal behavior," Kelly says. "It's not about good or evil, or right or wrong. It's the complex mixing of dynamics."
On this morning, 40 percent of the people booked into Chicago's jail tell a counselor they are mentally ill. Other facilities around the country report similar rates, with nearly half of those diagnosed with a serious disorder. Cook County estimates around 30 percent of inmates have a serious mental illness.
But when Sheriff Thomas J. Dart, a former prosecutor and state legislator, took over running the jail in 2006, a DOS-based computer system (since replaced) was incapable of analyzing the inmate population. A Justice Department investigation in 2007 and 2008 found multiple problems, including a failure to provide adequate mental health care, putting the department on notice.
Federal law protects the rights of people in jails and other institutions, requiring facilities to provide mental health and other care and ensure safety. But in temporary holding facilities, dealing with serious, long-term mental illnesses has required operators to rethink what they do.
"You're given a court order by a judge to hold this person in the jail until you're told not to," Dart says. "You're not supposed to do anything other than feed him, give them a bed, make sure they don't harm anyone else or themselves. ... You're not in there trying to cure people."
Across the country, many jails are dealing with similar dynamics, with sometimes disturbing results.
—In June, federal officials cited "deplorable" conditions for mentally ill inmates in the Los Angeles County jails as partly to blame for 15 suicides in 30 months. The L.A. system, the largest in the country with 19,000 inmates, has been under federal supervision since 2002, but still fails to adequately supervise inmates with mental illnesses or provide care for "prisoners with clearly demonstrated needs," the Justice Department concluded.
—In Florida, Justice officials last year issued a scathing report about conditions at the Escambia County Jail in Pensacola, noting that it employed a single, part-time psychiatrist for 1,314 inmates. Records showed many inmates who requested care were never seen by a mental health professional. When inmates refused to take medications, the jail merely removed them from its list of those with a mental illness. The county has since taken over operation of the jail from the sheriff in an effort to address the issues.
—In Columbus, Nebraska — seat of a county of 33,000 — the Platte County Detention Center saw six inmates attempt suicide in the first few months of this year, equaling all attempts in the previous 10 years combined. Jon Zavadil, who retired June 1 after 21 years as the county sheriff, says that is a direct symptom of the influx at a jail that, early this year, had about 80 percent of all inmates medicated for some type of mental illness.
Zavadil recalled that when he was a deputy on patrol in the 1980s, he and fellow officers were rarely called to take someone with a mental illness into emergency protective custody. Now, that happens in Platte County about two to three times a week, he says. In February, one of the jail's inmates was declared mentally unfit to stand trial. But he stayed in the jail until April, waiting for one of the state's few psychiatric beds to open up, Zavadil says.
"Every county jail in the state has the same problem," says Zavadil, who blames Nebraska lawmakers for voting to close two of the state's three public psychiatric hospitals over the past decade. "I don't really know what the real answer is. Somebody's going to have to throw some money at this."
The fresh white walls and computer-equipped nursing station on the second floor of Cermak Health Services give it the appearance of a hospital. The uniformed guards watching the patients, some behind locked doors, make clear that's not the case.
Cermak is the Chicago jail's infirmary, and this floor is the landing place for inmates with the most pressing mental health needs. Many arrive knowing doctors' names, a sign not just that they've been here before, but that for many, the jail is their primary care provider, says Dr. Kenya Key, the chief psychologist.
At midday, art therapist Eric Spruth joins three patients around a small table in a room decorated with inmate drawings, encouraging them to express their thoughts in letters home while listening to the Jimi Hendrix ballad "Little Wing."
Cermak also offers individual therapy. But Dr. Jack Raba, the infirmary's interim site administrator, points out that housing an inmate here costs up to $50,000 a year, money he says would be better spent on care that would help keep people with mental illnesses out of jail. Yet in 2012, Chicago closed six of its 12 outpatient mental health clinics.
In jail, Cermak provides what amounts to urgent care in a setting that is anything but therapeutic.
"Is this the right place to be? Absolutely not," says Raba, who has visited 65 jails and prisons around the country, as an expert witness in correctional health care lawsuits. "It's simply something the jail has to do because they have the patients. They're here."
It's not like the influx of inmates with serious mental illnesses came as a surprise. Researchers have warned for decades that mental illness was being "criminalized," as police arrested and charged more people for offenses linked to untreated psychoses.
"Nothing's changed," says Linda Teplin, a Northwestern University researcher who authored a widely cited 1984 study on arrest rates among the mentally ill. "We're still talking about the same issues."
In the 1980s, researchers found about 6 percent of jail and prison inmates showed signs of serious mental illness. A survey published in 2009 found 17 percent of jail inmates with serious mental illnesses, and significantly higher rates among women. But individual jails report far greater numbers of mentally ill inmates who stay locked up longer because they often lack the money and family ties that allow others to make bail and are more likely to break jail rules.
The advent of powerful psychotropic drugs for treating mental illnesses, and exposes of conditions inside psychiatric hospitals, led to promises of a new kind of community-based care. Many of those released from the hospitals in the early years "tended to be aware of their illnesses, they had family, had a place to go. They were less severely impaired," says Dr. E. Fuller Torrey, founder of the Treatment Advocacy Center and a strident critic of the mental health care system.
But as hospital closings continued, people with more serious conditions were released. Today, many of those jailed with mental illnesses have grown up in a system full of holes.
"Even what we had when I started doing this work in 1988 was better than what we have now," says Nancy Koenigsberg, legal director for Disability Rights New Mexico, which helped bring suit against her state's Dona Ana County Detention Center in 2010 for mistreatment of inmates with mental illnesses.
The suit led to improvements inside the jail including increases in its mental health staff, she says. But New Mexico cities and counties have continued closing adult day programs, drop-in centers and transitional housing that were supposed to ensure people with serious mental illnesses maintained treatment.
Without it, many people end up on the street, some repeatedly picked up for relatively minor crimes, becoming what jail operators call "frequent flyers."
At the Volusia County Detention Center in Daytona Beach, Florida, administrators compiled a list of offenders who'd been booked into the jail at least 20 times over five years. The 19 worst had been collectively jailed 894 times, mostly for minor offenses. Nearly half had a history of mental illness.
"A lot of their behavior was low level. In fact, the majority were misdemeanor offenses," says Marilyn Chandler Ford, the county's corrections director. "So they cycle through in a fairly short period of time and they never make it to prison."
The influx has increased pressure on jails to find solutions — but not soon enough for some families.
In Wichita, Kansas, Angela Waldon starts each day by putting on a necklace threaded with a small blue glass vial sealed by a cap bearing a Celtic cross. Then she waits for people to ask about the ashen memento it holds: remains of a brother whose battle with alcoholism and delusional demons led him to the cell at the Sedgwick County Jail where he hanged himself in 2012.
"I want people to see what's become of my brother," Waldon says.
Wichita's jail, with nearly 1,400 inmates, is Kansas' biggest local lockup. On a recent afternoon, 407 of those prisoners had some kind of mental illness. One such inmate has been booked in to the jail 27 times over the last year and a half.
"These folks are going back out in to the community without medication, they re-offend and they're right back in jail," Sheriff Jeff Easter says.
But critics say jail officials long compounded the problem through negligence, allowing for abuse of inmates with mental illnesses by both guards and fellow prisoners, while limiting access to treatment.
In 2008, an inmate diagnosed with paranoid schizophrenia, Edgar Richard Jr., was severely beaten by a deputy after refusing to take medication, breaking his jaw and causing permanent brain damage. In affidavits, two former sheriff's officers alleged mistreatment of inmates and one said he saw signs of a cover-up of the beating. Richard's son, a former jail employee, filed a lawsuit, settled by the county earlier this year for $300,000.
In 2010, the previous sheriff, Robert Hinshaw, repeated a request to county commissioners for money to pay for a new housing unit for inmates with serious mental illnesses. But they again turned him down, citing the expense.
In May 2012, Waldon's brother, Jon Haehn, turned himself in at the jail for violating probation for driving under the influence. Just before, he sat for six hours while a tattoo artist inked the right side of his chest with a wing. Once he got sober, he told another sister, he'd get the other side done. But his family was wary. Months earlier, Haehn had stabbed himself with a pair of pruning shears in the belief there was a demon on his stomach. Waldon says that when he called from jail to report demons in his cell, the family warned officials he might try to harm himself.
He committed suicide days later.
In August 2012, Easter beat incumbent Hinshaw in a campaign that centered largely on treatment of jail inmates. Months later, commissioners approved Easter's request for the mental health unit. It opened in February, housing 49 inmates; it is always full.
The unit costs $740,000 a year to operate, a large part of it to pay deputies who stand guard in pairs around the clock. The county recently signed a new contract with its jail health care contractor, paying $390,000 more to bolster a psychiatrist's time at the jail from four hours a week to 12, adding a new case manager and mental health nurse, and adding hours for a physician's assistant and social worker.
Easter says he's working with the local mental health agency to have a staffer work with inmates so they can resume Medicaid and Medicare coverage after release, to maintain needed medications.
Larry Wall, the lawyer representing the family of the inmate beaten at the jail, says they settled just before trial largely because of the changes underway. But he is skeptical of the county's dedication to providing better care.
The new mental health unit was approved "shortly before the trial was to occur and it doesn't take a rocket scientist to figure out why they did it at that time," Wall says. "I would be naive to say that I believe the culture has changed, and I'm not a naive person."
The pale beige bricks of Cook County Jail's Division 2, Dorm 2 make it all but anonymous in a compound of buildings with barred windows. Upstairs, though, talk among inmates in a long chamber with 48 bunks bolted to the floor makes it clear that this is not just another cell block.
Montgomery, the clinical social worker, says she recognizes faces from jobs years ago supervising programs for children and adolescents with mental illnesses. Dorm 2 has a total of 464 bunks, most of them reserved for inmates with mental illnesses. They're always full.
In the best scenario, the jail can offer an island of stability for those inmates, Dart says. Maybe judges will consider the information about mental illnesses gathered by social workers when setting bond or at trial. In the next few months, Dart plans to convert a building that once housed a boot camp into a transition center that will help those with mental illnesses ease back into life outside the jail.
But William, a 62-year-old inmate who says he's been jailed nine or 10 times for theft to support a drug habit, doubts that will end the cycle. Too many judges dismiss mental illness as a factor in crimes, says the inmate, diagnosed with depression, anxiety and symptoms of bipolar disorder. And outside jail, treatment is increasingly hard to get.
"You come back to the streets and all the facilities are closed with maybe one or two that are still open and they have an overload. And sometimes they get you and sometimes they don't," he says. "Once we leave here, we're back on doom street."