How Texas Jails Have Become De Facto Mental Health Facilities — And Why They're Failing

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The 139 who came before Sandra Bland did not become household names.

Collectively, though, they've prompted a swarm of questions about what more jails could have done to prevent the 140 suicides that have occurred in Texas jails since 2009.

Among those 140 was Danarian Hawkins, whose mother, Jacqueline Smith, filed a wrongful death lawsuit Wednesday against the Harris County Sheriff's Office, as the Houston Chronicle first reported. Having attempted suicide months earlier, her 27-year-old son hung himself in his cell last year; he had suffered from schizophrenia and bipolar disorder. Smith told the Chronicle she believes the jail did not adequately consider his illnesses, and therefore failed to prevent his death.

Suicide is the second-leading cause of death in county jails, claiming almost a third of lives lost in custody each year. Suicide in lockup is only surpassed by death by natural causes, according to a 2013 report on Texas jail suicides by University of Texas researcher Daniel Dillon. While many found it surprising that Bland took her life after just three days, Dillon's research shows that 42 percent of suicides happened within a week. Eighteen percent of jail suicides happened within a day. Dillon also found that inmate suicides are significantly more likely to happen in single cells and by hanging, as in the cases of Bland and Hawkins, and that they happen at a rate three times higher in county jails than in prisons.

But behind the numbers is a more pressing problem facing the jails. It's why Dillon himself is hesitant to spend too much time focusing on statistics: “We shouldn't ignore the bigger-picture issue here,” he says, “which is that, in many places in the country, jails are our default mental health providers. And most jails simply aren't equipped to handle this reality.”

A report last year by the Treatment Advocacy Center found that mentally ill people in Texas were 10 times more likely to be behind bars than in a hospital. About 30 percent of county jail inmates are receiving mental health services, according to a report last month by the Texas Public Policy Foundation. But whether those services are adequate is the question.

The problem begins at the mental health screening stage, at intake.

When an inmate arrives, the Texas Commission on Jail Standards requires trained jailers to review an inmate's physical and mental health. They're asked if they've recently attempted suicide, if they've been depressed, if they've experienced a recent loss. If they answer yes to any of these, or exhibit any signs of self-harm, the jail is required to contact a magistrate so that someone with mental health expertise can further evaluate the inmate. All of which failed in the case of Sandra Bland. She had told a jailer she had attempted suicide months earlier after the loss of her baby, that she had been depressed and experienced post-traumatic stress disorder. She had cuts on her arms. Jailers took no further action and did not put Bland on suicide watch. TCJS officials confirmed Wednesday that they should have.

“The intake process is an absolutely critical phase of the process,” says Michele Deitch, a senior lecturer at the University of Texas who has spent decades researching mental health in jails. “There's so much trauma associated with coming into a jail. You've got people coming down on drugs or detoxifying, and suddenly they are aware of the enormity of their situation. It's quite a traumatic time frame when it's very important for staff to be aware that inmates are at high risk.”

While the TCJS only found five of 234 county jails to be non-compliant with the intake screening standards, a survey by the Texas Public Policy Foundation shows that only 77 percent of jails are using the screening forms to identify inmates with mental illness in the first place, only 41 percent are checking inmates' mental health history with a database of other medical records, and just 34 percent are notifying magistrates when inmates answer “yes” to any of the red-flag questions on the screening forms (definitely required).

“These smaller jails tend to be under-resourced, certainly as far as mental health resources go,” Deitch says. “They don't tend to have the same level of training. The chances that they are accredited or going off to conferences to learn about best practices tend to be less likely in those settings. And so as a result, they tend to do the minimum that is required of them under the statutory requirements of the Commission on Jail Standards.”  Texas is notorious for it's low mental healthcare budget: According to data compiled by the Kaiser Family Foundation, Texas ranks 48 in state mental health care services expenditures per capita.

Brandon Wood, executive director of TCJS, explained that limited resources have remained a problem.

The funding for mental health comes from the state level for both local mental health authorities and county jails, but that creates problems when all of those 234 relationships across the state require different needs. Wood said that, given these limited resources, the jailers are “really focused on the individuals who come in that are actually in crisis, rather than those who appear to be able to function but still need preventative maintenance.”

It's something he also expressed to the House Committee on County Affairs Thursday, in a hearing that aimed to search for solutions when it comes to treating the mentally ill in jail. (Read more about that hearing here.) Concerning the inmates who aren't overtly mentally ill, Wood said he feared that these inmates were falling through the cracks. One of the first points the committee discussed was bolstering the intake stage with trained medical professionals instead of jailers (Wood said that the “overwhelming majority” of screeners are jailers). Deitch, who also spoke at the hearing, noted earlier that this would be important because an “incoming inmate is much more likely to divulge that information to someone apart of the medical field as opposed to law enforcement.”

If jails could implement all best practices—completing the intake stage with utmost thoroughness, minimizing any environmental factors that could exacerbate suicide risk—Deitch believes suicide rates would be slashed in half. “Jails should not be having suicides in all but the rarest of circumstances if they are actually taking these precautions,” she added.

To Deitch, the first step is not putting people who have committed lower-level offenses in jail in the first place, like Sandra Bland. Especially if the person exhibits clear signs of mental illness. She stressed more staff training, continuity of the inmate's previous medication rather than simply administering generics, not isolating individuals who may be suicidal so the risk doesn't worsen. She paused halfway through her long list of recommendations. “I'm sorry,” she said, “I just have so many things... If any one of those things could happen, we'd be in so much better shape.”

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