Meet the sheriff who runs the nation's largest psych facility

Tom Dart has served as sheriff of Cook County, Ill., since 2006. As head of Cook County Jail in Chicago, the nation's single largest jail site with about 8,500 inmates, he has received national attention for his work in reforming the handling of inmates with mental health and substance abuse problems. He has pushed to end what he calls the criminalization of mental illness. In 2013, he launched a 24-hour care line for mentally ill ex-inmates and families of current mentally ill inmates, while screening all pre-bond detainees for mental illness. Modern Healthcare reporter Andis Robeznieks recently spoke with Dart about why jails house so many people with mental health issues, the programs he's launched and prospects for reform around the country. This is an edited transcript.

Modern Healthcare: Cook County Jail, which you oversee, has been described as the nation's largest psychiatric facility. Is that description accurate and, if so, how did it get that way?

Tom Dart: It's unfortunately accurate, though some might quibble about whether we're No. 1 or No. 2. Some people would say this is the result of years of cuts. But as someone who was in the state Legislature for years, I say you have to hold lawmakers accountable. When you are making dramatic cuts around the country over the course of decades, you have to be aware of what the net result is going to be.

It would be one thing if there were new medications that clearly treated or cured people's schizophrenia or bipolar disorder so we did not need community clinics or hospital beds. But that's not what occurred. What has occurred is governments throughout the country have horribly cut funding for mental health treatment. As a result, the people who traditionally would go to community locations for treatment are ending up in jails and prisons in outrageous numbers.

MH: These are not violent offenders, correct?

Dart: The vast majority of the people—70%-plus folks in here who have a diagnosed serious mental illness—are in for nonviolent property or drug crimes. The unfortunate thing is detainees tell me the treatment they get at Cook County Jail is the best treatment they've ever gotten. We find some solace in that. But is that not a horrific indictment of our society that people go to jails for the best treatment? We are somewhat of the anomaly, though. Around the country, lawsuits are flying because of the conditions that people who suffer from mental illness are experiencing in jails and prisons.

MH: Why did you recently name a clinical psychologist, Nneka Jones Tapia, as executive director of the jail?

Dart: When you have a correctional facility turning into a quasi-mental health hospital, you sure as heck better have upper leadership with a background in mental health issues. Nneka understands both the mental health component and corrections.

MH: How has the Affordable Care Act expansion of Medicaid in Illinois affected your situation at the jail?

Dart: It has helped quite a bit. Before, we were bringing people to a point where they were stabilized, taking medications, were involved with therapy, and things were going pretty good. Then we were turning them loose to the community where there were less services available. With the Medicaid expansion, we've enrolled over 12,300 people in Affordable Care Act coverage. Now they have an insurance card and can have access to services. It's still a struggle to have the services available out in the community.

MH: Can you describe the jail's Mental Health Transition Center and a similar program in the south suburban Cook County Courthouse in Markham?

Dart: The jail setting was not necessarily where you would want to treat patients. We had a boot camp that is an incredibly peaceful setting, with gardens and a solar farm. So I made it the Mental Health Transition Center. We brought in the professionals. The mantra is that these are folks who are nonviolent and who are going to the community soon. Let's get them ready. We have been doing that now for a little over a year. It's been outrageously successful. We're expanding that. We partnered with Adler University to open a clinic in the courthouse in Markham. If people live in the south suburbs, they now will have a location to go to for treatment when they leave the jail. We're trying to put together a continuum-of-care model. It's the compassionate route to go. Fiscally speaking, to not do this is literally dumping money down the drain.

MH: How many jail detainees self-report as having a mental condition?

Dart: Our population that is diagnosed with serious mental illness is usually about 30%. Among those who get some type of bond and are not incarcerated but whom we interview, the rate is about 40%. The number of people with serious mental illness who are coming into the criminal justice system on any given day is about 3,000. The vast majority are absolutely no danger to society. Housing them here doesn't serve any societal purpose. The corrections system is being asked to do something that it wasn't designed to do.

MH: Is the problem all about money or is it that the mental health infrastructure was dismantled?

Dart: It's a combination. There's a complete lack of (political) will. If you were to look for the perfect group of people for whom to cut funding, the mentally ill jump to the top of the list. The normal things that would prevent that—a strong family, advocacy organizations—they're difficult to find. Many of the people I have in my custody will come right out and tell me they've burnt out their families, after the umpteenth time of going off their medications and causing problems. The mentally ill don't have the sort of structure that usually makes politicians queasy about making cuts. You combine that with the stigma around mental illness, and you have a population that's easy to shortchange.

MH: Are there other corrections departments in the country that you think are doing innovative work?

Dart: The initial analyses that we've done have shown very little programming in this area. Around the country, you will hear people talking about mental health courts, and those are fine, but they're so small. Mental health courts are putting your finger in the dike.

In San Francisco, they've been working on triage out in the community. We're working on that as well. We send a psychologist with one of our officers in a van to some of the people that are out on electronic monitoring, to keep on top of them.

I was talking to a detainee who said he got disqualified from mental health court because he also has a substance-abuse problem. Frankly, that's the majority of the people with the mental health issues in here. They have co-occurring substance abuse issues.

With some of these people, we scratch our heads and say, “This is not a criminal. Why do we feel the need to jam them into the criminal justice system?” It's not a good use of taxpayer money. The person stole something to eat or broke in some place to sleep.

MH: Do you think the situation will improve?

Dart: We are very optimistic about a lot of our programming. We are not optimistic about governments providing the funding levels these programs need throughout the state. But we hope the programs that we're working on here will multiply throughout the country.