Mentally Ill in Jail, Part 2 — State and Local Efforts to Address the Issue

by Dick Hall-Sizemore(Note:  This is the second installment of a discussion on mentally ill people in Virginia’s jails. Part 1 of this series set out the scope of the problem.)

Although senior policymakers are aware of the large number of mentally ill people in jails and acknowledge the seriousness of the problem, the state has taken only tentative steps to address the issue. Furthermore, the approach has been somewhat disjointed, primarily because of the involvement of agencies from different disciplines. Mental health, local community corrections (jails), and the courts all have a role to play  And, as is typical with government agencies, each goes off in its own direction, with little coordination among them. No one at the state level has stepped up to provide coordination and sufficient funding to support a statewide policy.

Diversion. The Department of Behavioral Health and Developmental Services (DBHDS) has come the closest to providing leadership at the state level. Beginning in 2007, the agency’s Office of Forensic Services has supported programs that attempt to divert individuals diagnosed with serious mental illnesses away from the criminal justice system and connect them with treatment as soon as possible. As of 2017, the agency provided grant funds totaling approximately $2.5 million annually to 14 community services boards to support the diversion efforts. In FY 2017, these programs screened 4,505 individuals and enrolled 1,102 for services.

DBHDS also supports crisis intervention team (CIT) activities. The goal of such programs is to recognize individuals who are having an active mental health crisis and divert them from the criminal justice system to treatment. Through various funding sources, the state has funded training for local CIT members.

Additionally, DBHDS provides funding for the operation of CIT Assessment sites operated by 32 community services boards. The goal of these sites is to provide a safe place where individuals undergoing a mental health crisis can de-escalate and receive an assessment by a qualified clinician, who can determine the level of care needed. Although those sites accept individuals referred by non-law-enforcement officers, most of the assessments are as a result of “discretionary hand-offs” from the police. In 2017, the sites conducted a total of 6,691 assessments resulting from such hand-offs. Total funding for these sites in FY 2017 was $10.3 million.

The judiciary also plays a role in diverting mentally ill individuals from jail. Courts in several districts and circuits established mental health courts over the past few years. (These “courts” were actually specialized dockets in existing courts.) In 2020, the General Assembly authorized the Supreme Court of Virginia to serve as the oversight body for behavioral health dockets. The Supreme Court has approved 13 behavioral health docket programs.

As explained in the Supreme Court’s annual report to the General Assembly, behavioral health dockets “aim to divert eligible defendants with diagnosed mental health disorders into judicially supervised, community-based treatment, designed and implemented by a team of court staff and mental health professionals.” In FY 2020, there were 197 active behavioral health docket participants; 98 newly-admitted and 99 remaining active from the previous year.

Although the behavioral health docket program has been in operation for only a short time, the Supreme Court reports that “preliminary research, although still very limited, demonstrates that Behavioral Health docket participants tend to have lower rates of criminal activity and increased linkages to treatment services when compared to defendants with mental illness who go through the traditional court system.”

Treatment. Despite the attempts to divert mentally ill individuals from the criminal justice system, those efforts are limited in scope and, as shown by the data in an earlier post, many occupants of jails suffer from some form of mental illness. It has fallen to the jails to house and treat them, as best as they can.

Until recently, the determination of the number of mentally ill people in jails varied widely from jail to jail. Beginning in FY 2018, language in the Appropriation Act requires that all persons admitted to a local or regional jail be screened for mental illness “using a scientifically validated instrument” designated by the Commissioner of Behavioral Health and Developmental Services.

A screening is an initial determination of an individual’s mental health status. It can indicate whether an individual may have a mental illness, but it does not provide enough information for a diagnosis or a determination of treatment needs, if any. For that, a comprehensive assessment by a trained mental health or medical professional is needed. Although jails are not required to conduct such assessments, 51 out of a total of 59 local and regional jails reported that they do conduct such assessments.

The mental health treatment services provided to inmates differ from jail to jail, but they can be extensive. During the month of June, 2018, 7,274 inmates received a type of mental health or substance abuse treatment. During that same month, 10,675 prescriptions for psychotropic medications were dispensed in local and regional jails. In addition to in-jail treatment, 32 jails reported providing follow-up case management for mentally ill inmates after their release from jail.

Modern jails were not designed, staffed, or intended to house and treat the mentally ill. Nor have they been adequately funded by the state to conduct screenings, assessments, or treatment  In 2016, implementing a directive provided in the Appropriation Act, the Department of Criminal Justice Services (DCJS) established six pilot programs to provide services to mentally ill inmates or to provide pre-incarceration crisis intervention services to prevent mentally ill offenders from entering jails. In the first year of the program, a $1.0 million appropriation was provided; in subsequent years, there was an appropriation of $2.5 million.

This program has run into opposition in the General Assembly. In the 2018 Session, upon the recommendation of the House Appropriations Committee, funding for the second year of the biennium was eliminated. In the 2019 Session, the Governor proposed restoring the second-year funding. The House finally consented to continuing the annual $2.5 million appropriation, but prohibited the expansion of the program to additional sites.

The reason for using pilot programs is to test program ideas for their efficacy and to identify any problems in implementing them. In its 2020 evaluation of the program, DCJS emphasized that one of the lessons to emerge from the pilot programs was the challenge of integrating the provision of mental health services “into what is traditionally a custodial, control-oriented environment. Combining the two cultures has been a complex and laborious process.”

Nevertheless, the agency reported progress each year in providing services to mentally ill offenders. Following are the results for FY 2020:

  • Mental health screenings—19,708
  • Mental health assessments—2,663
  • Admissions to mental health programs—2,850
  • Treatment plans developed—2,136
  • Hours of treatment services—approximately 16,000
  • Jail climate—decrease in assaults
  • Aftercare services—Increased
  • Recidivism—18% of participants returned to jail within 90 days after release

The agency argued that the lessons learned in the pilots could be “successfully applied in a larger number of jails across Virginia” and recommended expanding the program to six additional jails. Furthermore, it recommended the establishment of stable, dedicated funding, rather than reliance on a year-to-year grant program.

Notwithstanding the recommendations of DCJS, the Governor did not propose any changes in his introduced budget. The annual appropriation remains $2.5 million and the agency is prohibited from expanding it to any other jails.

The House’s opposition to expanding state financial aid for treatment of the mentally ill in jails stems from a worry, which I share, that doing so could result in the jails becoming the de facto treatment option for those mentally ill who cannot afford private treatment programs, despite the insistence of the sheriffs that many of those offenders do not belong in jails. At this point, the state’s experiment in providing assistance for the jails in treating mentally ill offenders is in limbo.

Data sources:

Dept. of Behavioral Health and Developmental Services

Jail Diversion Initiatives: Program Annual Review FY 2017

Virginia’s CIT Assessment Sites:  Annual Report FY 2017

Supreme Court of Virginia

Virginia’s Behavorial Health Dockets:  2020 Annual Report

Department of Criminal Justice Services

Evaluation of the Jail Mental Health Pilot Programs  (December, 2020)

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13 responses to “Mentally Ill in Jail, Part 2 — State and Local Efforts to Address the Issue”

  1. I’m most impressed so far in this series by how complex the issues are and the lack of simple answers. I am encouraged to see that DOC is experimenting with solutions by means of pilot projects. Given the lack of obvious remedies, tinkering with the system through experimentation seems far preferable to enacting heroic measures that could go stupendously wrong.

    1. Dick Hall-Sizemore Avatar
      Dick Hall-Sizemore

      You are right; the issue is complex and there are no simple answers. Just a clarification: DOC is not involved with this issue; DCJS is the one overseeing the pilot projects. DOC has its own issues with the mentally ill in prison.

  2. LarrytheG Avatar

    You’re doing an excellent job and I thank you and I have a question for you or anyone else since you did say “State and Local” efforts.

    The question is this an issue where the state should set policy and standards that apply the same to all localities or is this an issue where each locality or region would decide how they would handle it in local and regional jails?

    1. Dick Hall-Sizemore Avatar
      Dick Hall-Sizemore

      The state has not explicitly grappled with the idea of whether there should be a statewide policy applicable to all localities, with the exception of the initial screening of persons brought into jails. Therefore, de facto, we have a decentralized approach in which each locality or region decides how it will handle these offenders in accordance with broad state standards.

  3. PolicyStudent Avatar

    While I love the idea of diversion, Virginia’s CSBs are not up to the task. Too often their “support” consists of referrals to other backlogged organizations. In my view, the state must invest in affordable long-term housing with on-site addiction and mental health support, regular home-based welfare checks, and routine after-hours counseling. We cannot coordinate away serious mental health problems. We need to meet people where they are and provide treatment, potentially for a long time.

    1. LarrytheG Avatar

      To play the devils advocate. What is the least expensive way to handle this to keep costs low to taxpayers?

      1. Dick Hall-Sizemore Avatar
        Dick Hall-Sizemore

        I will attempt to address the cost issue later.

      2. PolicyStudent Avatar

        I am not knowledgeable enough to suggest/price a comprehensive mental health care plan. But I’ll bet we could save overall tax payer money. Prisons cost upwards of 20k/person/ year. Weekly counseling at market rates might run $7200. I like the second number better. Thanks for responding.

        1. Dick Hall-Sizemore Avatar
          Dick Hall-Sizemore

          Offenders in jail and offenders in prison are two different populations. I have focused on those in jail. For the most part, they have been arrested and jailed for minor offenses and either are awaiting trial or are serving their sentence. Those sentenced to jail will be there for less than a year. Many of the mentally ill cycle in and out of jail.

        2. Nancy Naive Avatar
          Nancy Naive

          That would require a complete cost analyses. Something for which the penny pinchers will refuse to pay. These are the same people who then complain about the cost of any changes.

  4. James Wyatt Whitehead Avatar
    James Wyatt Whitehead

    There are many repeat offenders with mental health problems that simply reject help when it is offered. Some of these folks don’t want help from the state or a community institution. The needed reforms must address this issue.

    1. Dick Hall-Sizemore Avatar
      Dick Hall-Sizemore

      You are correct. That is one element that makes this a complex issue.

    2. Nancy Naive Avatar
      Nancy Naive

      Kinda like wearing a mask, or getting a vaccination, eh?

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