Jail Mental Health Initiatives

The Harris Center Staff

(left to right) Sean McElroy, M.Ed., LPC-S, Mental Health Jail Administrator; Ally Frankovich, former program manager; Robert Simon, Jr., LPC-S, CCHP, Assistant Deputy Director; Dr. Nubia Lluberes-Rincon, Medical Director for Mental Health at the Harris County Sheriff's Office Jail.

(left to right) Joycelyn Horn, RN, Forensic Lead; Sean McElroy, M.Ed., LPC-S, Mental Health Jail Administrator; Dr. Nubia Lluberes-Rincon, Medical Director for Mental Health at the Harris County Sheriff's Office Jail; Maria Gutierrez, CTL, Patient Services; Kanika Anglin, Program Manager; Chelsea Ford-Freelon, CTL, Forensic Single Portal Authority; Brian Coquyt, CTL, Mental Health Jail Diversion Program.

(left to right) Dr. Kimberly Warneke, Psychiatrist; Dr. Nubia Lluberes-Rincon, Medical Director for Mental Health at the Harris County Sheriff's Office Jail; Dr. Thomas Brandon, Psychiatrist; April Dvorak, Nurse Practitoner; Ydalith Rivera-Perez, Physician Assistant.

(back row left to right) Amber Brockenbush, LPHA; Adedayo Adegbemle, LPHA intern; Tina Carr, Peer Specialist; Courtney Prudhomme, LPHA intern; Kyle Sommers, LPHA; Lisa Castillo, LPHA intern; Tamara Dalcour, COC, Case Manager; Joycelyn Horn, RN, Forensic Lead; Allison Valverde, RN; (front row left to right) Kanika Anglin, Program Manager; Maria Gutierrez, CTL.

The Largest Mental Health Facility in Texas

The Harris County Sheriff's Office (HCSO) operates the nation's fourth-largest jail, with an inmate population approaching 9,000. One-quarter of these inmates suffer from some form of mental illness. On a daily basis, the HCSO Jail houses more inmates on psychotropic medication than any single mental hospital in Texas. In order to appropriately treat these mentally ill inmates, the HCSO developed a model Jail Mental Health and Medical Security Unit.

The unit was honored as the Program of the Year for 2013 by the National Commission on Correctional Health Care. The award recognizes programs of excellence among the thousands provided by accredited prisons, jails and juvenile facilities. In the Jail Mental Health and Medical Security Unit deputies receive special training and assignments for working with inmates with mental illness. Six sergeants and 124 deputies are assigned to the medical and mental health units, which are staffed 24 hours a day, seven days a week. To be eligible to join this elite team, the officers must undergo rigorous training in skills such as crisis intervention, use of force, de-escalation techniques and suicide detection. Many of the detention personnel obtain a state certification as a mental health officer. This approach has decreased use-of-force incidents and has eliminated any need in the past two years for clinical or custody-ordered restraints. The deputies work with medical and behavioral health personnel employed by the Sheriff’s office and the Harris Center for Mental Health and IDD (formerly the Mental Health Mental Retardation Authority of Harris County).

 

The Harris County jail functions as the largest mental health institution in Texas. We are delighted to honor them for their innovation, compassion and understanding of the unique challenges of mental illness in the justice system.

Edward Harrison

President and CEO, National Commission on Correctional Health Care (2014)

Mental Health Unit

The Jail Mental Health Unit is a 108-bed unit for the most serious mentally ill. It is staffed by deputies with specialized mental health training and psychiatrists, psychiatric nurses, psychiatric technicians, and mental health professionals from The Harris Center for Mental Health and IDD (The Harris Center). Up to 77 group therapy sessions are provided each week and are open to all patients. The Mental Health Unit would not be possible without the strong collaboration between the Harris County Sheriff's Office and The Harris Center. This collaboration has existed since 1978.

 

Step-Down Unit

This is a 284-bed unit. Patients in the Mental Health Unit go to the Step-Down Unit before going to general population. Programs within the Step-Down Unit include the following:

Social Learning Unit: A 20-bed unit providing therapeutic experiences in the least restrictive environment to teach patients socially acceptable and adaptive behavior. This is an in-depth collaboration between The Harris Center for Mental Health and IDD (The Harris Center) and the Harris County Sheriff's Office.

Cognitive Behavioral Therapy Unit: A 20-bed unit for males only. It assists detainees in changing ineffective thought patterns so they can become better community members in a correctional environment and in the community at large.

Mental Health Jail Diversion Program: An integrated treatment program addressing mental health, chemical dependency, physical health and criminogenic risk factors. Services begin in the jail. Individuals resume the same services when they return to the community via The Harris Center.

 

General Population Services

Detainees in general population can be referred to mental health services by deputies, classified supervisors, mental health staff, attorneys, judges, court staff, families, etc. Mental health staff will evaluate the detainee and make the appropriate referral. Services include the following:

  • Triage
  • Brief counseling
  • Intake assessments

 

Chronic Care Clinic

Teams of registered nurses, under the supervision of a psychiatrist, provide follow-up care that includes the following:

  • On-going prescription monitoring at least every 90 days
  • Monitoring of the person's mental health status
  • Address prescription compliance issues

 

Competency/Insanity Program

Teams of psychologists provide competency/insanity evaluations. For the 2016 calendar year there were 1767 orders for evaluation. The vast majority of these orders were for competency evaluations.

 

Forensic Single Portal

The Forensic Single Portal works to provide a single point of contact for detainees in the jail with the objective of linking the detainees with mental health services in the jail and in the community once released. Specifically, the portal monitors the following:

  • Defendants returning from state mental hospitals deemed not competent to stand trial or not guilty by reason of insanity
  • Incompetent court dockets
  • Medication compliance
  • Incarcerated time limits
  • Develops discharge plans

 

Rider 73 Peer Re-entry Program

This is a peer staff program with the goal of providing in-reach services to patients in the jail at least 30 days prior to release. The programs are then continued upon release from the jail.

 

The Neurological Condition That Looked like Psych

A patient presented with an unclear past psychiatric history. He was referred to psychiatry due to appearing disorganized and unable to provide information. During the evaluation in the MHU he was initially seen as disorganized but on extended conversation it appeared that his speech disarray was related to a neurological condition. The team continued close observations without starting medications. His presentation was consistent with Brocca Aphasia. With limited information the team was able to obtain a release of information and later corroborated the diagnosis by a family member. The patient was recommended to continue treatment with neurology. A Licensed Practitioner of the Healing Arts corroborated with the family that he had a history of Traumatic Brain Injury. The treatment plan was discussed with the patient and his family. Soon after the patient was able to be released and is currently residing with his brother.

The Treatment Resistant Schizophrenic

A female patient presented with a long history of Schizophrenia. In times past she was found to be disorganized, sometimes mute, and frequently delusional. She had at least one episode of catatonia and periods of refusing to eat. She was eventually admitted at a state hospital for competency restoration. Upon return to the Harris County Jail she was being treated with Clozaril for treatment resistant schizophrenia. She was housed in the MHU for close monitoring of her treatment. After successful treatment with medications and group therapy she was able to collaborate on making treatment plans for the future.  Referrals for follow up care were provided and she now lives with her boyfriend.

2016 Statistics

Number of mental health services provided by Harris County Jail staff

Number transferred into the Step Down Unit

Number of patients in the jail receiving mental health services

Number of requests for services from detainees in general population

Number of fulltime Harris Center employees assigned to the jail

The Forensic Single Portal provided oversight to 407 patients who were pending transfer to state hospitals

Number of admissions into the Mental Health Unit

Number of patients prescribed psychotropic medications in the jail

Serious Mentally Ill in Jails and Prisons

Serious mental illness has become so prevalent in the US corrections system that jails and prisons are now commonly called “the new asylums.” In point of fact, the Los Angeles County Jail, Chicago’s Cook County Jail, or New York’s Riker’s Island Jail each hold more mentally ill inmates than any remaining psychiatric hospital in the United States. Overall, approximately 20% of inmates in jails and 15% of inmates in state prisons are now estimated to have a serious mental illness. Based on the total inmate population, this means approximately 383,000 individuals with severe psychiatric disease were behind bars in the United States in 2014 or nearly 10 times the number of patients remaining in the nation’s state hospitals.

 

Jails vs. Hospitals

In 44 states, a jail or prison holds more mentally ill individuals than the largest remaining state psychiatric hospital; in every county in the United States with both a county jail and a county psychiatric facility, more seriously mentally ill individuals are incarcerated than hospitalized. A 2004–2005 survey found there were “more than three times more seriously mentally ill persons in jails and prisons than in hospitals.”

 

Maryland and New York Jail Study

A 2009 study based on inmate interviews conducted in Maryland and New York jails found that, within the month previous to the survey, 16.7% of the inmates (14.5% of males and 31% of females) had symptoms of a serious mental illness (schizophrenia, schizoaffective disorder, bipolar disorder, major depression or brief psychotic disorder). However, 31% of the inmates who were asked to participate in the study refused, a subset that almost certainly included many individuals with paranoid schizophrenia. The interviews were conducted between 2002 and 2006. Given the continued growth of mental illness in the criminal justice system since that time and the high rate of refusers in the survey, it is reasonable to estimate that approximately 20% of jail inmates today have a serious mental illness.

Combining the estimated populations of jail and state prison inmates with serious mental illness produces an estimated population of 383,200 affected inmates. Since there are only approximately 38,000 individuals with serious mental illness remaining in state mental hospitals, this means 10 times more individuals with serious mental illness are in jails and state prisons than in the remaining state mental hospitals.

 

Length of Stay

In Florida’s Orange County Jail, the average stay for all inmates is 26 days; for mentally ill inmates, it is 51 days. In New York’s Riker’s Island, the average stay for all inmates is 42 days; for mentally ill inmates, it is 215 days.

The main reason mentally ill inmates are incarcerated longer than other prisoners is that many find it difficult to understand and follow jail and prison rules. In one study, jail inmates were twice as likely (19% versus 9%) to be charged with facility rule violations. In another study, in Washington state prisons, mentally ill inmates accounted for 41% of infractions even though they constituted only 19% of the prison population.

 

Competency to Stand Trial

Additionally, pretrial inmates with serious mental illness experience longer incarcerations than other inmates in many states if they require an evaluation or restoration of competency to stand trial. A survey of state hospital officials in 2015 found that 78% of the 40 responding states were wait-listing pretrial inmates for hospital services. The waits were “in the 30-day range” in most states, but three states reported forensic bed waits of six months to one year. Mentally ill inmates in some states are reported to spend more time waiting for competency restoration so they can be tried than they would spend behind bars convicted of the offense for which they have been charged.

 

Cost

Mentally ill inmates cost more than other prisoners for a variety of reasons, including increased staffing needs. In Broward County, Florida in 2007, it cost $80 a day to house a regular inmate but $130 a day for an inmate with mental illness. In Texas prisons in 2003, a study reports, “the average prisoner costs the state about $22,000 a year,” but “prisoners with mental illness range from $30,000 to $50,000 a year.” Psychiatric medications are a significant part of the increased costs. The cost of settling or losing lawsuits stemming from the treatment of mentally ill inmates also can add to the costs.

 

Source: Serious Mental Illness Prevalence in Jails and Prisons, Background Paper, September 2016, Treatment Advocacy Center