Untreated: Steep Costs for Mentally ill Inmates

In unit 4C of the Pueblo County jail, any human presence draws inmates to the narrow windows of their solitary cells.

They bark requests and complaints, or just grin and make small talk. One man’s ceiling is leaking; another wants to know how many more days he has left in segregation.

“Ma’am, do you work here?” asks a tall African-American man with a steady, serious gaze, who wants to know when his glasses will be delivered.

“I’m the warden, Darlene Alcala,” she replies. Alcala is small and elegant in black, and sports a friendly smile at odds with the cinderblock bleakness of the jail. “You can call me chief.”

Though they live on opposite sides of the jail’s heavy doors, these two have come to see eye-to-eye on a crucial point: Inmates like him don’t belong here.

A sheriff's deputy checks on prisoners in Unit 4C of the Pueblo County, Colo., jail on April 4, 2014. Inmates with mental illnesses are often placed under administrative segregation in 4C and other parts of the jail where they are kept isolated in their cells for 23 hours a day and their only human contact is with the guards. (Joe Mahoney/Rocky Mountain PBS I-News)

Joe Mahoney / Rocky Mountain PBS I-News

A sheriff's deputy checks on prisoners in Unit 4C of the Pueblo County, Colo., jail on April 4, 2014. Inmates with mental illnesses are often placed under administrative segregation in 4C and other parts of the jail where they are kept isolated in their cells for 23 hours a day and their only human contact is with the guards. (Joe Mahoney/Rocky Mountain PBS I-News)

The man has been in 23-hour-a-day lockdown for a year and a half now. Like most of his fellow residents in what’s known as administrative segregation, he is mentally ill. Brief interactions with the staff are nearly the only contact he has with the world outside his cramped cell.

As a shortage of funding has depleted options for those in need of treatment for mental illnesses, there’s still one place that can’t say no: Jail. Inpatient psychiatric beds have dwindled to 1,093 for the state’s entire population, according to state human services data, a decrease of 20 percent from five years ago. People with mental illnesses are more than five times as likely to wind up in jail or prison.

“Years ago we deinstitutionalized mental health treatment,” says Boulder County Sheriff Joe Pelle. “People felt it was shameful that we had people in custody or locked up in mental health facilities. Now, instead, we lock them up in jail.”

The burden on jails is growing. A 1992 jail survey found that 11 percent of Colorado inmates had a serious mental illness, according to research by Public Citizen’s Health Research Group and National Alliance for the Mentally Ill. This year, 10 county jails surveyed by I-News reported that, on average in 2013, 18 percent of their inmates were mentally ill.

Sheriffs say that the trend is noticeable from year to year. At the Douglas County jail, for example, the number of mentally ill inmates has grown 10 percent in the past three years, even as the general daily population has dropped 25 percent.

Once they’re in, inmates with behavioral health problems have more trouble getting out. The seven metro Denver counties in 2008 found that mentally ill inmates stayed an average of five times longer than other inmates. In Pueblo, an inmate detained for a misdemeanor stays an average of 28 days; mentally ill inmates jailed for similar offenses stay between 171 and 180 days.

“Jails and prisons have become the warehouses for people who aren’t getting treated elsewhere,” says Attila Denes, a captain at the Douglas County jail. “It’s among the most expensive and least humane” ways to provide care.

Solitary confinement is routine. Even as Colorado’s new state prison chief, Rick Raemisch, has pledged to remove mentally ill prisoners from isolation because of concerns that it is counter-productive and inhumane, jailers say they still use 23-hour lockdown to keep staff and other inmates safe.

Denes, a student of history, sees patterns in American society’s treatment of people with mental illnesses. As early as the 1650s, the plight of so-called “lunatics” in prisons attracted a call to the colonial legislature to find alternative housing.

“We’ve gone full circle,” says Denes. “We’re back today to where we were in the 1650s.”

Becoming a last resort

The confinement of thousands of mentally ill Coloradans in jails and prisons can make a striking contrast with the sensibilities of the people whose job it is to confine them.

Alcala first took a job as a receptionist at the Pueblo jail 30 years ago to get health insurance for her newborn son. Her ambition to become a deputy was stoked by a supervisor who told her she was hired “to look pretty and answer the phone.”

It was in the ‘90s that she became aware of the prevalence of mental illness in the jail; there was a woman who s smeared feces on the wall, and an inmate who licked the floor. Alcala recalls that the detention officers had no real tools for handling what they simply saw as strange behavior.
Alcala and other staff have worked to acquire the skills to communicate with inmates in the throes of a crisis. When she enrolled in crisis intervention training eight years ago, says Alcala, “I wish I’d had it 15 years earlier.”

Sheriffs are increasingly enlisting mental health professionals to improve care for the mentally ill in jail, by training detention officers to communicate through a crisis and by offering therapy to inmates.

John Parsons, who was released from the Pueblo jail in March, says he got help from a jail-based program called Moral Reconation Therapy—a type of cognitive behavioral therapy—to handle his depression, anxiety and alcoholism.

“MRT told me how to handle the stresses and pressures of life in the way normal people do,” Parsons said in April.

Jagruti Shah runs the state’s offender mental health programs, overseeing a budget of about $2.7 million to help connect inmates with treatment for substance abuse and co-occurring mental health disorders. The programs run in 33 counties, reaching about 90 percent of the state’s jail population.

Shah says that the programs have had some success in treating inmates while they’re jailed.

But the short-term stay of most inmates means they walk out with only a few days’ worth of medication. Outside, care can be hard to come by—both before and after incarceration.

“Quite often people don’t have the opportunity to engage in these treatment programs until they hit the front door of the jails,” says Denes.

Pueblo inmate Erin Hedden says she tried.

Erin Hedden, during an interview at Pueblo County, Colo., jail on April 4, 2014. Hedden said she has bipolar disorder and used crystal methamphetamine to self-medicate after she lost her insurance and couldnÕt afford medication to treat her illness. SheÕs serving a four-year jail sentence after she crashed her car while driving on drugs, killing a 69-year-old woman. (Joe Mahoney/Rocky Mountain PBS I-News)

Joe Mahoney / Rocky Mountain PBS I-News

Erin Hedden, during an interview at Pueblo County, Colo., jail on April 4, 2014. Hedden said she has bipolar disorder and used crystal methamphetamine to self-medicate after she lost her insurance and couldnÕt afford medication to treat her illness. SheÕs serving a four-year jail sentence after she crashed her car while driving on drugs, killing a 69-year-old woman. (Joe Mahoney/Rocky Mountain PBS I-News)

After symptoms of bipolar disorder emerged when she was 28 years old, Hedden was prescribed a laundry list of drugs. Each one failed until she found a combination that worked: Prozac and Zyprexa.

But when she left a job as a nursing assistant to work on her mother’s ranch, Hedden lost her insurance. At $1,000 a month, the medication was out of reach. It took three months for the symptoms of mania to resurface, and Hedden says she sought refuge in crystal methamphetamine.
Three years later, Hedden is in jail on a four-year sentence for drugged driving. She was behind the wheel in a crash that killed Linda Sue Sublett, a 69-year-old woman she never met.

The county now pays for her Prozac and Zyprexa.

Paying for confinement

Two miles northwest of the jail, on a road spiked with wind-driven tumbleweed, is the campus of the Colorado Mental Health Institute at Pueblo, one of only two state psychiatric hospitals.

Beds at the state hospitals have disappeared steadily even as Colorado’s population has boomed, the victim of federal and state budget cuts and a change in philosophy that emphasized removing people from institutions. In 1980, there were 1,103 public psychiatric beds in Colorado; in 2014, there are 553, many of them earmarked for those charged with or convicted of crimes.

Ryan Conely / Rocky MountaIn PBS I-News

Some of the most significant mental health expenses in Colorado are largely due to untreated mental illness. Lost wages, preventable medical expenses and jail costs dwarf the $730 million the state spends on care, an investigation by Rocky Mountain PBS I-News and 9News has found.

Pueblo Sheriff Kirk Taylor says that the state psychiatric hospital sends its patients to the jail when they lash out or act violently, including people who have previously been found not guilty by reason of insanity. At the same time, Taylor and other county jail officials complain that the state hospitals frequently turn away inmates who are put on emergency mental-health holds because they pose a danger to themselves or others.

“These people don’t need to be in jail,” says Taylor. “They need to be in a therapeutic community.”

Bill May, who heads the state hospital in Pueblo, believes it’s appropriate for some of their patients to be arrested and sent to jail if they commit a crime while stable in treatment.

Meanwhile, state psychiatric hospitals can’t receive people on mental-health holds unless they’ve been treated and cleared first for any physical problems, says Dr. Patrick Fox, a Colorado Department of Human Services official who oversees the hospitals. He suggests taking inmates to the emergency room.

At issue, in part, is the question of who bears the high costs of housing mentally ill inmates. Psychotropic medications, additional security and lengthier stays all add to the costs. A seven-county study in the metro Denver area found the cost of accommodating seriously mentally ill inmates to be around $44.7 million a year in 2010, up from $36.5 million in 2006. Costs haven’t declined since then, and are likely to have increased, says Regina Huerter, the director of Denver’s Crime Prevention and Control Commission.

The influx of ill inmates has contributed to overcrowding in Boulder, say jail officials there. Boulder is reconfiguring its cells to expand the special management unit where mentally ill inmates are housed. But that means taking space from other areas, says Division Chief Bruce Haas.
In Denver, the construction of a new jail in 2010 took into account the extra medical resources and supervision demanded by an increasingly ill population, says Sheriff Gary Wilson.

Like the homeless, mentally ill inmates often have trouble meeting judges’ standards for bail, which take into account qualifications such as stable housing, employment and family support, says state public defender Douglas Wilson. This is despite the fact that their crimes may be low-level offenses.

“The reality is, most of the time what we’re talking about is trespasses, the guy who roller skated into somebody’s garage because he thought it was a roller rink, public urination,” says Wilson.

Denver recently found that the 99 people most frequently jailed for low-level offenses had a high rate of mental illness—around 35 percent. They were also frequently homeless and addicted to alcohol or drugs, adding to the complexity of treating them.

Some get into more trouble behind bars, committing crimes that lengthen their stays, says Sheriff David Walcher in Arapahoe County.
“They commit crimes on the inside; there are assaults on staff. They tend to get more charges when they’re in jail,” says Walcher. “They’re a more challenging population overall.”

On the inside

From their stark walls to their locked doors to their narrow, light-deprived spaces, jails are meant to confine criminals, not promote recovery.

“There’s nothing soft about what we do,” says Alcala. “We’re built for offenders.”
Hedden has sharp memories of her episodes in 23-hour lockdown. The 35-year-old inmate, who is being treated for social anxiety and depression along with bipolar disorder, says her last 12-day stay there led her to a breakdown.

“All day long it’s a cacophony of voices, of screams, of shouting,” says Hedden. “There is no human interaction except for what’s between you and the guard, and who you can yell at next door through the wall. The loneliness is overwhelming. I get a sense of intense anxiety like I just want to claw at the door. I just want to get out. I would do anything to get out. I beg to get out.”

A growing understanding of what it means to isolate people who have mental illnesses is leading to changes in the state prison system.

Evan Ebel

Department of Corrections / State of Colorado

Evan Ebel

When former prisoner Evan Ebel shot dead prison chief Tom Clements last year, the incident raised questions about Ebel’s time in solitary confinement and his direct release into the community. Clements’ replacement, Raemisch, has criticized the overuse of solitary confinement nationwide, and has pledged to stop placing mentally ill inmates in administrative segregation. And the state legislature recently passed a bill – now pending Governor John Hickenlooper’s signature – banning long-term solitary confinement for seriously mentally ill prisoners.

But 23-hour lockdown is still widely used as a tool to control mentally ill inmates in jails.

Jailers in Douglas County, Arapahoe County, Boulder, Pueblo and elsewhere say they try to minimize the use of it, but none said they were considering doing away with it.

“Most jails are pretty close to full if not overflowing,” says Denes, in Douglas County. “Sometimes when you have people classified as dangerous offenders and you have people packed into a housing unit, the reason that you use (23-hour lockdown) is to prevent victimization of inmates from other inmates.”

Staying out of jail

The best hope for cutting the costs of jailing mentally ill inmates may be to keep them out of jail in the first place.
Some jurisdictions have built mental health courts—also called wellness courts—intended to divert people from jail to treatment. Some, like Denver, are pushing to enroll inmates in health insurance so that they can get the care they need once they leave jail.
The state’s flagship project for improving mental health treatment—a planned network of crisis centers, now stalled amid a lawsuit—may help direct people to more settings more appropriate than jail, says human services official Fox.

For now, Colorado’s jailers and their inmates are stuck dealing the best way they can with a broken system.


Read other stories in our project "Untreated: How Ignoring Mental Illness Costs Us All"

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