Behavioral health behind bars and beyond

Dirk Scheribel's body was shaking from alcohol withdrawal last November when he walked into a grocery store on Chicago's North Side. He made a beeline to the liquor department, opened a bottle and took a deep pull before tucking the bottle in his belt and heading for the exit.

“I needed it real bad and didn't care,” said the 54-year-old ex-Marine, who lives with anxiety, depression and alcoholism. He was stopped at the door, arrested, and taken to Cook County Jail—a place he has been taken to several times after similar arrests.

This time, however, he was assigned to a mental health dormitory, where he was given the medications he needed. Later, the military veteran joined counseling sessions with other inmates who had substance abuse and addiction disorders.

When he left the jail in March, Scheribel entered a 21-day treatment program. Upon discharge, Scheribel was sent to a recovery house in Chicago's North Center neighborhood, where he lives with nine other men who have similar histories. Scheribel is in charge of signing men in and out, handling the chore list and enforcing curfew.

“A lot of good things are happening for me,” Scheribel said. This includes getting a driver's license, working to re-establish his credit, opening a Facebook account and renewing ties with his family in Indiana—including a 27-year-old daughter he has never met.

Guard towers and high fences topped with razor wire are not conducive to producing the healing environment most healthcare facilities seek to create. But Cook County Jail is trying to change its reputation as the “nation's largest mental health institution,” where from 30% to nearly half of its 9,000 inmates on any given day have a diagnosed mental illness.

“I talk to the detainees on a regular basis and they say it's the best treatment they've ever gotten,” said Cook County Sheriff Tom Dart. “Is that not a horrific indictment of our society that people go to jails for the best treatment?”

Dart's innovative program is leading a nationwide movement to reverse a long-running scandal: Thousands of people with behavioral health issues are being held in jails and prisons instead of getting help in hospitals and community facilities. After decades of treating this troubled population as petty criminals, the political forces seeking change are beginning to align. There is now bipartisan recognition that the get-tough-on-crime agenda, when applied to the mentally ill, has been a tremendous waste of money.

In every U.S. county that has both a psychiatric facility and a jail, there are more people with a serious mental illness in the jail, according to a 2010 report by the Arlington, Va.-based Treatment Advocacy Center. “What most people don't understand is just how much healthcare is delivered inside our jails and prisons,” said Maureen McConnell, director for business and healthcare strategy development for the Chicago-based social services agency Treatment Alternatives for Safe Communities. “Making a difference in someone's behavioral health can make a difference in terms of not returning to the criminal justice system.”

The American Psychiatric Foundation reports that 2 million people with mental illness cycle through the nation's jails each year. The APF, National Association of Counties and the Council of State Governments Justice Center launched in May the Stepping Up Initiative to convene leaders committed to reducing that number. The initiative seeks to develop an action plan using research-based approaches and to create systems to track and report measurable outcomes.

As a testament to the growing bipartisan mood for change, Republican Florida Gov. Rick Scott, who has wrangled with the CMS over Medicaid expansion, recently began a prototype program at the state's Lake Correctional Institution in Clermont to “explore the impact” of special housing, treatment and rehabilitation efforts for the mentally ill inmate population.

Dart estimates that there are typically 2,000 inmates at the Cook County Jail being held on “crimes of survival” such as theft of basic necessities or trespassing in an attempt to find someplace to sleep. It costs $69,350 to hold these people in jail for a year. But it would cost only $10,243 to provide them community-based treatment plus $9,200 to subsidize their rent—an annual savings of almost $50,000, according to an analysis by the Chicago-based Thresholds social service organization, which helped find housing for Scheribel.

Despite these benefits, “there's a complete lack of will” to significantly expand the program, Dart said. The idealistic movement to deinstitutionalize the mentally ill eliminated much of the nation's behavioral health hospital capacity, which was never replaced with community-based treatment. The existing community services have been cut back because of budget constraints.

Congress has so far not done much to address the issue. It allocated only $13 million of the $51.4 billion commerce, justice and science appropriations bill for measures contained in the Mentally Ill Offender Treatment and Crime Reduction Act.

More comprehensive mental healthcare reform could be on the agenda this fall, however. The Helping Families in Mental Health Crisis Act, sponsored by Reps. Tim Murphy (R-Pa.) and Eddie Bernice Johnson (D-Texas), calls for reforming how existing federal mental health programs operate, including promotion of tele-psychiatry for rural and underserved areas, increasing bed capacity and beefing up the mental health workforce.

“There is an interesting alignment of different political stripes” between politicians who see providing more accessible mental healthcare as a means to reduce crime and those who are discovering that a get-tough-on-criminals approach is not very effective when it comes to addressing mental illness, said Dr. Jay Shannon, CEO of the Cook County Health and Hospitals System.

The insurance expansion under the Affordable Care Act has also played a role by providing financing for alternative approaches to treating people with behavioral health issues who are caught up in the criminal justice system. Illinois has expanded Medicaid eligibility to many of the previously uninsured, and more than 12,300 people have been enrolled while in custody.

Jennie Sutcliffe, director of the Sargent Shriver National Center on Poverty Law's juvenile justice initiative, said this has made it easier for people to continue the treatment and medication they started in jail after they're released. “It's one of the best things that's happened for both the public health system and the criminal justice system,” she said.

Scheribel has been enrolled in a Medicaid managed-care plan since before his last arrest. He chose the plan because it didn't require copays. But it was a major shift in his court handling that made the biggest change in his life.

For most of the previous decade, he had bounced in and out of the regular court system. But after his latest run-in with the law, the ex-Marine's case was handled by the Veterans Treatment Court division of Cook County's specialty court system. “I've never experienced anything like this before,” Scheribel said. “The judge talks to me like a friend.”

Dart's strategy for overhauling the county corrections department began with bringing in professionals skilled at handling people with behavioral health issues. Dr. Nneka Jones Tapia, who now heads the jail, was the former chief psychologist at Cermak Health Services, a branch of the Cook County Health and Hospitals System that serves as the jail's medical provider.

Jail employees begin screening pre-bond detainees at the jail immediately after they are brought through an underground labyrinth to a basement holding area. Elli Petacque Montgomery or one of her staff members will ask each of the detainees whether they have been diagnosed with anxiety, bipolar disorder, post-traumatic stress disorder or schizophrenia, and whether they used alcohol or drugs.

Petacque Montgomery, the facility's director of mental health advocacy, said most inmates are astonishingly frank about their conditions. “When we say, 'We're here to help,' they open up,” she said. “Most people want to get help—you'd be surprised.”

Stephvon “Bo” Cook is doing his part to reduce recidivism among behavioral health patients at Cook County Jail. A counselor with the WestCare Foundation, Cook runs group sessions in a 48-man dormitory in the jail where inmates are serving 120-day sentences and participating in a court-ordered substance-abuse treatment program.

Cook leads talks on anger management, drug issues, forgiveness, grief, relationship skills and self-control. While these topics may not be topics hardened inmates typically discuss, Cook's animated and charismatic delivery plus his football lineman's build help make it work.

Last month, his clients gave him a homemade birthday card expressing gratitude for helping them turn their lives around. Former inmates are also invited to keep the conversations going free of charge at Cook's One More Chance Clinic, which he operates on the University of Illinois at Chicago campus.

Cook said he's “helping men get free of bondage. They don't think they're redeemable, but I teach from a spiritual philosophy that all are redeemable.”

There's still room for improving the program, Scheribel said. Though ex-inmates upon discharge are eligible for two 30-day prescriptions for medications taken in jail, they must travel to distant hospitals to get them. They should be given at least a two-week supply at discharge upon release, he said.

A recent study in the American Psychiatric Association journal, Psychiatric Services, found quick access to medications can be critical to avoiding a return to prison. Using Florida Medicaid records, North Carolina researchers found quick access to outpatient services and medications were “associated with a reduced risk of arrests.”

Cook County health system CEO Shannon said the refill program is an important bridging strategy that can be used while the former detainees look for a medical home to manage their complex conditions. He is working on integrating the county's primary-care and mental health services. “We've reached a societal and political tipping point,” Shannon said. “There is an energy and an urgency to address these things, which gives me hope.”