Mental Health Template
A note from Sheriff Thomas J. Dart:
Dear Sheriff or Jail Director,
As I’ve traveled the country in recent years raising awareness of the root causes and potential solutions to the criminalization of mental illness, I’ve had the good fortune of meeting many of my counterparts within sheriff’s offices big and small. We all come to these positions from a diverse array of backgrounds – many are police officers; some are lifelong corrections officials; others (like me) are former prosecutors. One quality unites us all – absolutely none of us signed up to run the largest mental health institutions in our respective communities.
Yet that is where we find ourselves. As we know all too well, jails and prisons now serve as the largest mental health providers in 44 of the 50 states. Through benign neglect and disastrous public policies, state and local governments have apparently decided over the past few decades that it is perfectly acceptable for our jails to serve as warehouses for the mentally ill.
Most national media attention has focused on jails that house incredibly large mentally ill populations like Rikers, L.A. County Jail and Cook County Jail (which I oversee), yet studies have shown that individuals with mental illness are responsible for the explosive incarceration rates occurring in smaller counties and jails. Every one of us is on the front lines of this crisis.
And while we as sheriffs have firsthand experience of the shameful and fiscally irresponsible consequences of the criminalization of mental illness, we’ve traditionally had no say or discretion in the matter. We must take all of the defendants remanded to our custody by other stakeholders in the criminal justice system, even if everyone would be better served by diverting some of those defendants to treatment instead of jail.
I came to my breaking point on this issue several years ago. I grew tired of the runaround and empty promises from elected officials who continued to senselessly slash mental health budgets with no regard to the long-term effects on our criminal justice systems.
So I decided to do something about it, in my capacity as a sheriff and advocate. I began inviting outside-the-box ideas from my staff and experts throughout the country, tweaking and implementing as I saw fit. Quite frankly, we improvised as we went along. Some ideas didn’t work as planned – so we scrapped them, with no harm done. But most of these concepts resulted in immediate and demonstrable success. Since 2013, my overall jail population has dropped about 20%, and the mentally ill individuals in custody participating in our progressive programs are recidivating far less often into the jail. I’m saving millions of dollars in reduced overtime and operational costs, including the shutdown of several large and (now) empty buildings of Cook County Jail.
I’ve created this template in an effort to share what we have learned, because I know that if we can achieve such measureable progress in the largest jail in the country – with all the red tape and bureaucracy that comes with it – similar success is attainable in all American jails. The ideas outlined in the template are scalable, from small lock-ups to sprawling multi-divisional compounds. Several of these proposals do require budget on the front end, but if my experience is any indication, they will save you significantly on the back end as recidivism rates among the mentally ill population begin to decline.
Regardless of how many of these concepts are appropriate for implementation at your jail, my staff and I would be happy to help you and your corrections team with any questions or challenges you face.
Please feel free to contact my staff at CCSO.MentalHealth@ccsheriff.org at any time with questions, ideas or feedback.
Simply put, I understand the mental health calamity that has been dropped in your lap, and I want to help as best I can. Together, we can achieve significant reform and send a strong message to our legislative counterparts that we will no longer allow our institutions to devolve into repositories for the poorest, sickest and most vulnerable among us.
Tom Dart, Sheriff of Cook County
The over-incarceration of people with serious mental illness is nothing new. In the late 1700s, John Howard – in his book The State of Prisons – noted of the many mentally ill people he observed in English prisons: “No care is taken of them, although it is probable that by medicines, and proper regimen, some of them might be restored to their senses, and to usefulness in life.”
Howard’s words ring as true now as they did 250 years ago. Yet, the criminalization of mental illness has taken a seemingly irreparable hold on American communities in the past 40 years. American jail populations have more than quadrupled to 646,000 since the 1970s, directly coinciding with the deinstitutionalization of the old psychiatric asylums. The recent recession ushered in a fresh wave of cuts to mental health services at both the federal and state levels, flooding jails even more swiftly with unmedicated mentally ill individuals in custody. There are now ten times more mentally ill people housed in American jails and prisons than in mental health hospitals.
Sheriffs and jail directors have traditionally been powerless to stop or control these types of insidious trends. Police have discretion to arrest or divert to hospital; prosecutors have discretion to charge or not charge; judges have discretion on setting bond. But jail administrators could only stand idly by as their institutions morphed into mental health hospitals. And unlike prisons – where they know exactly how long mentally ill individuals will remain in their custody – the transient nature of jail populations makes it exponentially more challenging to execute thoughtful plans to reduce recidivism among the mentally ill.
This document offers sheriff and jail directors a template to change that paradigm. It provides an overview of scalable reforms and strategies to better cope with the modern day realities of running a jail, while simultaneously advocating for a more efficient and just system.
This template does not presume to instruct doctors how to diagnose illnesses or administer psychiatric medications. Rather, it provides a menu of innovative yet practical solutions – which have been proven to work in Chicago’s Cook County Jail – that sheriff’s offices can apply to reduce recidivism and operational costs.
These concepts are introduced in the chronological order in which they would apply to an individual’s time in custody at a county jail.
- Public Advocacy (with video)
- Advanced Mental Health Training (with video)
- Pre-Bond Diversion (with video)
- Insurance Enrollment (with video)
- Know Your Population
- Treatment: Going Above & Beyond
- Discharge Planning
- Family Support
- Post-Incarceration Engagement (with video)
- Legislation (with video)
For most Americans, jails are out of site, out of mind. Most do not understand the difference between jails and prisons, nor are they aware that individuals in custody at jails have not been convicted of a crime. Members of the public unconscious to the basic tenants of running a jail are equally unlikely to know the extent to which jails have become de facto mental health asylums.
It is incumbent on sheriffs and jail directors to expose the unfortunate reality to their constituents. Only jail administrators have the power to open the door and compel our society to come to terms with this crisis.
This begins with humanizing the individuals in custody. Some mentally ill individuals are incarcerated for heinous, violent crimes – which the criminal justice system will eventually address. However, most are in on run-of-the-mill, non-violent charges such as drug possession, retail theft and criminal trespassing. Allowing the local media in to meet these men and women will dissuade the public of the notion that jails are entirely full of dangerously violent criminals, instead educating them that jails have in effect been asked to serve as community mental health hospitals.
The media attention will highlight the jail administration’s work to make efficient use of taxpayer dollars by lowering the costs of incarceration. However, it will also put pressure on local stakeholders – the municipal police, prosecutors, public defenders and judges – to consider more thoughtful ways to address mentally ill offenders rather than reverting to the default option of pre-trial incarceration.
Cook County Jail – Proof of Concept
Sheriff Dart has opened Cook County Jail to local reporters as well as the national media, including 60 Minutes, Associated Press, The Atlantic, The New York Times and The Wall Street Journal. The media exposure has spurred public outrage that the nation’s largest single-site jail is now its largest mental health provider as well. But, most importantly, it has spurred other public officials and stakeholders to get serious about addressing the issue. After decades of precipitous cuts to mental health services in Illinois, in 2013 state legislators finally re-invested in the State’s mental health budget following persistent advocacy from the media and community at large.
- Educate the public
- Engage the local media
- Open doors to the jail, humanize the mentally ill individuals in custody
ADVANCED MENTAL HEALTH TRAINING
Advanced mental health training for law enforcement – formally known as Crisis Intervention Team (CIT) training – is gaining significant prominence as uses of force by the police come under a microscope. The benefits of CIT training on the streets – where the presence of firearms make any encounter potentially deadly – are clear. However, correctional facilities also stand to benefit from the increased safety and reduced liability brought to bear by CIT trained officers.
With jails bursting at the seams with mentally ill individuals, the capacity for tension and unpredictable behavior increases in turn. And the transient nature of jail populations means a disproportionate number of individuals in custody are fresh off the streets, where they may not have been taking the medication they desperately need. All jails are forced to manage individuals in custody who demonstrate actively psychotic behavior, which requires officers who are well trained in how to diffuse situations through words in lieu of force. Numerous counties have had to make multi-million dollar payouts as a result of officers utilizing excessive force on mentally ill individuals in custody, which potentially could have been avoided through an investment in CIT training.
Of course, not all jails – particular smaller county jails – have enough manpower to be able to dispatch large groups of officers for a week’s worth of CIT training. For that reason, it’s best to initiate the CIT investment with new recruits, who can undergo the training before stepping foot into the jail. Meanwhile, jail administrators can strategically cycle through active duty officers at a rate that does not disrupt the jail’s staffing structure. As the media and mental health advocates increasingly focus on the power of CIT training, jail administrators should also pursue grant money to account for the costs of certified CIT instructors.
Cook County Jail – Proof of Concept
Cook County Jail employs approximately 3,500 correctional officers. In addition to the Sheriff’s Police officers, all new correctional recruits are required to undergo no less than a week’s worth of CIT training. Veteran staff members are provided with the training in cycles, with an emphasis on supervisors and staff who work in divisions heavily populated by mentally ill individuals in custody. The emphasis on this valuable training has resulted in a noticeable decline in uses of force in mental health housing tiers. As of the publishing of this template, over 65% of Cook County Jail officers are CIT trained.
- Require a full weeklong course of CIT training for new correctional officer recruits
- Gradually cycle through veteran officers for advanced mental health training
- Engage the federal government and civic non-profits for grant money to support additional mental health training for sworn staff
“Mental health diversion” is typically analyzed in a community policing context, with first responders routing low-level mentally ill offenders to treatment settings rather than incarceration. However, diversion is still attainable even by the time an arrestee arrives in jail.
The stretch between an arrest/charging and bond court is perhaps the best window to truly gauge a defendant’s mental health disposition. At this point, enough time has passed from the arrest that they are likely calmer and more aware of their surroundings, but it will still be noticeable whether they are off their medication and in a state of psychosis.
With the exception of the actual trial, bond court is the most important occurrence within a defendant’s case. Bond court judges should ideally have as much relevant information as possible – particularly mental health status – as they determine whether defendants should be incarcerated or fight their cases from home, within the community. As public defenders often lack both the time and clinical expertise to decipher a defendant’s mental health status prior to bond court, only jails have the power to get this information to the judiciary. Pre-bond screenings have the capacity to reduce individual in custody populations by compelling judges to consider house arrest on the condition of mental health treatment, in lieu of incarceration.
Additionally, since the mentally ill disproportionally commit low-level crimes, they are more likely than the average offender to receive pre-trial house arrest (separate from pre-bond diversion). Because these offenders are only passing through the jail on their way to court and do not get admitted as official individuals in custody, they often fall through the cracks and head back into the community without treatment or medication, where the risk of a more serious incident or crime only heightens. This scenario is particularly problematic for homeless offenders. Pre-bond diversion can head this off at the pass, allowing jails to facilitate community treatment for low-level offenders and prevent them from becoming future individuals in custody.
Cook County Jail – Proof of Concept
Since 2012, Cook County Jail has required two stages of mental health assessments – pre-bond and post-admission. The post-admission assessment is standard in all jails, establishing the housing location, level of treatment, and medication schedule of the individual in custody. But the pre-bond assessment is unique, allowing Cook County Jail staff to alert judges and public defenders to arrestees’ mental health status. The pre-bond assessments allow Cook County Jail staff to organize housing and treatment plans in the event of a successful diversion or standard recognizance releases. This strategy has secured stability and long-term health in the lives of hundreds of would-be individuals in custody, keeping them out of the criminal justice system.
- Install mental health screenings for individuals in custody in the post-arrest but pre-bond stage
- Work with public defenders to make bond court judges aware of the defendants’ likely mental health disposition at the time of the arrests, with an emphasis on non-violent charges
- Partner with mental health service providers to secure treatment for mentally ill offenders who get house arrest or are released on their own recognizance
The Affordable Care Act is an unquestionably controversial piece of legislation, invoking strong opinions across the political spectrum. That said, the Supreme Court has ruled, and ACA is here to stay.
As of the publishing of this template, 32 states have expanded Medicaid through provisions of ACA. This provides a unique opportunity for jail administrators tired of seeing the same mentally ill people passing through year after year.
For many mentally ill offenders, the cycle is clear: lack of insurance leads to lack of access to mental healthcare, often bringing about low-level criminal behavior and cycles of incarceration. Many individuals in custody are simply not aware of the insurance options available to them. Educating them on the new law and helping to facilitate their access to badly needed healthcare can break this cycle and effectively address the “frequent flyers” who can be so expensive to house and treat.
Cook County Jail – Proof of Concept
Beginning in 2012, Cook County Jail partnered with its healthcare provider and a community service provider to offer uninsured individuals in custody an opportunity to open applications for Medicaid enrollment. The process occurs at post-admission intake. Over 15,000 people – many of whom suffer from mental illness – are now insured as a result of beginning an application in Cook County Jail. Their newfound insurance has provided them access to quality mental health treatment within the community, likely playing a role in Cook County Jail’s population drop.
Recommended Strategies (ONLY for jails in states that expanded Medicaid)
- Offer Medicaid applications for new individuals in custody at post-admission intake
- Partner with a local service provider who can do the heavy lifting and facilitate the applications
KNOW YOUR POPULATION
Numerous county agencies maintain a stake in the criminal justice system, but only one has access to every bit of data pertaining to a given defendant’s personal identifiers, current case and criminal history: the sheriff’s office. Jail administrators maintain nearly everything there is to know about their individuals in custody – age, race, height, weight, charge, bond, past cases, past jail admissions, past custodial behavior, mental health status, medications….even dietary restrictions. As a result, sheriff’s offices are uniquely suited to identify, expose and effect change with regards to cases and defendants that have clearly fallen through the cracks.
Particularly at medium to large jails, it is common for low-level and inconsequential charges like retail theft and criminal trespassing to take 6-9 months to get through the system. This is the natural result of disparate criminal justice stakeholders with unworkably high caseloads and too little time to think critically about how quickly individual cases progress through the system. Even in smaller counties with significantly smaller individual in custody populations, unusually long lengths of stay for pre-trial individuals in custody are becoming all too common.
County jails – and only county jails – have the data at their disposal to paint a three-dimensional picture of the individuals in their custody and motivate criminal justice stakeholders to expedite cases when warranted.
Cook County Jail – Proof of Concept
In 2014, Cook County Jail proposed and initiated weekly “staffing” calls with the Cook County State’s Attorney’s Office and the Cook County Public Defender’s Office. The purpose was and remains to discuss low-level cases worthy of senior-level attention, taking into account mental health status, excessively high bonds and senselessly long stays in pre-trial custody. To ensure the success of these meetings, Sheriff Dart enhanced his research team and founded a Sheriff’s Justice Institute, with a mission of improving the distribution of justice in Cook County by finding and addressing individuals in custody whose pre-trial incarceration simply served no purpose for anyone.
This strategy has been met with acclaim from the other criminal justice stakeholders, resulting in dozens of cases getting expedited or otherwise disposed of rather than continuing to drag on for months on end.
- Assign staff to thoroughly parse through individual in custody populations, with an emphasis on length of stay and bond amount
- Organize regular meetings with the chief prosecutor and public defender to bring to their attention cases that have fallen through the cracks
TREATMENT: GOING ABOVE & BEYOND
Jails are constitutionally required to provide individuals in custody with prescribed medications and access to psychological treatment when warranted. However, simply adhering to this minimum standard is a modern recipe for sky-high recidivism. Jails must think boldly and creatively to address the mental health crisis through thoughtful treatment programs.
Mental health stigma plagues many aspects of American society, but the most damaging form of stigma occurs within those that personally suffer from mental illness. Many – particularly those caught within the criminal justice system – feel shame and the sense that they’re all alone. Jails must invest in therapeutic measures to build their self-worth and help them manage their emotions.
Jail administrations that put good-faith efforts into treating both the mind and body will find their individual in custody population demonstrating genuine desires to address their mental illnesses and turn their lives around.
Cook County Jail – Proof of Concept
The Sheriff’s Mental Health Transition Center has emerged as a hub for a diverse array of innovative treatment strategies. Individuals in custody participate in both comprehensive one-on-one and group counseling to freely discuss their shared experiences and fears. Mental health counselors work with individuals in custody in a therapeutic setting isolated from the rest of the jail. The individuals in custody are all housed together, allowing them to continue working together at night on the skills taught to them during the day.
The Transition Center treatment programs have evolved beyond verbal remedies. Art therapy programs allow individuals in custody to visually express themselves and see the world in a new light. In recent months, the Transition Center has instituted programs pertaining to photography and urban farming.
Individuals in custody come out of Transition Center programming with enhanced self-esteems and renewed vigor to maintain happy, healthy lives outside of the criminal justice system.
- Employ comprehensive group counseling
- House individuals in custody in group counseling together, allowing them to continue the therapeutic conversations even after the professional facilitators have exited for the day
- Utilize forms of therapy that tap into diverse facets of the human psyche
As a result of the widespread slashes of social safety net slashes, it can be very challenging for ex-offenders to navigate their options upon re-entry into the community. Treatment and social service programs available in low-income communities are as fluid as ever, coming and going without warning.
The first few days upon community re-entry are critical for mentally ill ex-offenders in particular. Without access to immediate housing and treatment, they can quickly fall into the same traps and bad habits that brought them to jail in the first place. They must be able to transition seamlessly from jail to long-term out-patient treatment, yet that is a tall task considering individuals in custody can discharge from a jail abruptly, without advanced warning.
Jails can eliminate this gap and exponentially increase ex-offenders’ chances at long-term stability by working with them to develop scalable discharge plans, ready for execution at a moment’s notice. These plans can be developed in partnership with local service providers or non-profits. In particular, the National Alliance on Mental Illness (NAMI) maintains chapters throughout the nation that may be keen to support jails with this type of initiative.
Cook County Jail – Proof of Concept
Sheriff Dart’s mental health counselors work one-on-one with individuals in custody on personalized plans for their re-entry to society. For individuals in custody in need of housing, counselors negotiate directly with service providers to secure temporary homes with which to pursue out-patient treatment. For individuals in custody in need of employment, counselors work with them to craft resumes and establish connections with employers willing consider hiring non-violent ex-offenders. For individuals in custody in need of continuing education, counselors sign them up for adult literacy, GED, and/or college courses as necessary. The Transition Center has even hosted job fairs, bringing in local employers who are open to considering non-violent ex-offenders for job openings.
Most importantly, counselors craft long-term treatment plans aimed at keeping the individuals in custody on proper medication and in treatment upon discharge. For those with dual diagnoses, counselors connect them to support groups such as Alcoholics Anonymous and Narcotics Anonymous. This thoughtful strategy has yielded a nearly 100% success rate among Mental Health Transition Center alumni who have re-entered the community.
Additionally, Cook County Jail has instituted a “Discharge Lounge” for outgoing individuals in custody who suffer from mental illness but who do not fit the criteria for admittance to the Mental Health Transition Center. At this lounge, they meet with counselors who educate them on the closest mental health resources to their homes as they go out the door.
- Establish strict and realistic treatment plans for mentally ill individuals in custody to adhere to upon discharge
- Forge working relationships with local non-profits and low-income housing providers to support outgoing individuals in custody with no place to stay
- Engage local employers, encouraging them to open their hearts and minds to considering non-violent ex-offenders; welcome the employers into the jail by staging job fairs for them to meet individuals in custody
- Institute a discharge center solely for outgoing mentally ill individuals so they are aware of the most up to date community mental health resources
As mentally ill individuals in custody prepare to re-enter society and pursue sober and stable lives, buy-in from their community support structures are essential. These are the same people who have likely been burned on several occasions by the unmedicated behavior of their family member.
Simply put, people living with serious mental illnesses and embarking on their recoveries are bound to hit a couple speed bumps and will need to be able to lean on their families along the way. In particular, these family members may represent the ex-offenders’ only chances at maintaining stable housing. Jails that facilitate these therapeutic and constructive dialogues will yield structures where families are prepared to welcome the ex-offenders into a culture of positive support rather than tense skepticism.
Cook County Jail – Proof of Concept
The Sheriff’s Mental Health Transition Center administers family counseling sessions, providing a safe place for families of mentally ill individuals in custody to discuss their frustrations and fears prior to discharge. These sessions allow families to establish ground rules within the home and enhance the person in custody’s commitment to adhering to their treatment schedule.
- Engage family members of mentally ill individuals in custody, encouraging them to have honest dialogue about the effects of their loved one’s unmedicated behavior
- Help the family members avoid the triggers likely to cause their loved ones to revert to their previous unhealthy conduct
A jail administration’s constitutional responsibilities are simple – detain individuals remanded to their custody by the courts, providing housing, food, medication and transportation to court hearings.
However, the states and municipalities have failed in their duty to take the baton upon community re-entry and connect ex-offenders to the long-term treatment they need. All too often, this gap proves impossible for them to overcome, with recidivism emerging as the inevitable end result. Jails that step up to fill that gap will surely incur costs on the front end, but the investment will pay off on the back-end through reduced recidivism and operational costs.
Cook County Jail – Proof of Concept
Cook County Jail staff maintains close contact with high-functioning, mentally ill individuals in custody upon their discharges back into the community. After working with individuals in custody on discharge plans, counselors from the Sheriff’s Mental Health Transition Center regularly follow up to ensure that the men and women are attending their meetings and remaining on their treatment regimen. Cook County Jail staff also administer a mental health hotline for former individuals in custody in crisis and in need of intervention to avoid recidivating.
Additionally, Sheriff Dart recently appropriated for a mobile unit that drives former individuals in custody in need of transportation to their regular counseling meetings as well as Mental Health Transition Center alumni sessions. This small investment has paid for itself several times over by keeping repeat offenders from re-entering the jail.
- Encourage former individuals in custody with mental illness to remain in contact and follow up on treatment plans
- As necessary, invest resources to physically transport former individuals in custody to necessary treatment if they lack vehicles
Sheriffs and jail directors have long been forced to clean up messes initiated by short-sighted state legislators. It does not need to be this way. Jail administrators may lack a vote in the legislative process, but they still deserve influence in any debate pertaining to criminal justice.
The “tough on crime” philosophies of the past are increasingly evolving into “smart on crime” legislation. Sheriffs have been presented with unique opportunities to present state lawmakers with outside-the-box proposals aimed at lowering jail populations and doing right by the mentally ill.
Cook County Jail – Proof of Concept
In 2014, Sheriff Dart authored state legislation to launch a “Rocket Docket” in Cook County. The legislation decreed that defendants charged with either retail theft or criminal trespassing without a background of violence were to be discharged from jail – either on their own recognizance or on house arrest – if their cases weren’t disposed of within 30 days of assignment to a judge. The Rocket Docket bill passed the legislature overwhelmingly and was signed into law by the Governor. In 2016, Sheriff Dart introduced legislation that expanded the Rocket Docket to include minor traffic offenses and petty drug possession. As of the publishing of this template, it has passed the state legislature and is pending the Illinois Governor’s signature.
These types of low-level crimes disproportionally affect mentally ill offenders. The Rocket Docket takes the broken bond court system largely out of the equation, placing the mentally ill back in the community to pursue the treatment they need.
- Work directly with legislators to prevent further cuts to local mental health services
- Submit “Rocket Docket” type legislation for consideration and debate (please reach out to CCSO.MentalHealth@ccsheriff.org for a model ordinance you can apply in your jurisdiction)
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