Healers In The House Of The Ill

When you walk into the reception area of the Mendocino County Jail on Low Gap Road the room is lined with photographs of county sheriffs going back through the 19th century. Looking back through time the sheriffs look more and more like the black-and-white studio portraits you’ve probably seen of your great or great-great grandfather: formal and stern-looking. The dress code and the facial hair, along with the definitions and philosophies of crime and punishment may have evolved over the centuries, but one need is always the same; there has to be a place to lock up the bad guys.

Many of today’s needs at the Mendocino County jail stem from the jail’s rising number of mentally ill inmates and the jail’s legal obligation to keep them and the people around them safe. That obligation and all that it entails is increasingly difficult for county law enforcement, and it’s one of the main reasons that the jail has slowly evolved into a default treatment center for mental illness. Its roots are multi-pronged, beginning with then-Governor Ronald Reagan’s signing of the Lanterman-Petris-Short Act, which was signed into law in 1967 and took full effect on July 1, 1972. The Act deinstitutionalized the state’s mentally ill and essentially put them in charge of their own mental-health care and meds, largely creating today’s environment where one-third of the state’s homeless population suffers from severe mental illness at the same time that the number of available hospital beds in the state’s mental hospitals has been sharply reduced. All of this has increasingly burdened county jails with treating and caring for their mentally ill arrestees and inmates.

Nowhere is this more evident than at the Mendocino County jail. “About 30% of incoming arrestees haven’t had outside care,” said RN Teresa Brassle, who has worked five years in the mental health department at the jail. “Most have chronic untreated conditions before they get here,” she said, adding that “90% also have addiction issues.” She says there’s also a good amount of self-diagnosis to wade through, all of which must be investigated. Treating these conditions puts enormous strain on the jail and law enforcement in general, which lack the training and resources to deal with psychiatric emergencies and ongoing mental health care in a jail setting. “We’re not a hospital, we’re a jail,” said Sheriff Tom Allman in a phone interview. (The Sheriff has led a ballot measure that would boost the sales tax a half-cent for five years to create Mendocino County's own psych unit.)

An additional seismic shift after the deinstitutionalizing of mental patients was California’s 2011 historic public safety realignment, which followed a federal court order ruling that the state’s prisons were overcrowded. The alignment required shifting inmates from state prisons to county jails to meet the lower prison populations mandated by the federal court, causing Mendocino County’s jail population to be pretty much maxed out almost all the time. “Realignment did a good job of reducing the state prison population,” said John Bednar, Lieutenant of Corrections, who has worked 21 years at the jail, 11 of them in his present position. But he says that realignment has had several unintended consequences. “Inmates are staying longer,” he said, “and they are more (criminally) sophisticated. Assaults on jail personnel are up.” He said that officers try not to use pepper spray and tasers, the only weapons available to them since they can’t carry guns. “Inmates have spit on us and thrown water, urine, and feces at us,” he said. More of the most serious offenders who used to be in a state prison are now housed at the jail. Bednar says that prison inmates’ greater sophistication extends to legal grievances, heaping a de facto legal role on top of the jail’s complicated mental health obligations. “It used to be a rough-and-tumble environment here,” Bednar said. “Now we have so many grievances it’s more of an ‘I’ll sue you’ environment.” But he’s quick to add that the overall effects of the state’s realignment pale beside the increase in the mental health needs of the county’s jail population. “Twenty years ago what I would have considered mental illness wouldn’t even make the charts today,” he said. “This is not the place for the mentally ill.”

The RNs who serve as the jail’s first line of defense with mentally ill arrestees and inmates couldn’t agree more. “10% to 15% of inmates here take psychiatric meds,” Brassle said, on a day last week when the jail was right up against its 300-person capacity at 273. “And at least 50% of them are Frequent Flyers,” the colloquial reference to recidivists. A nation-wide psychiatric shortage is not making the situation any easier, she says. Inmates needing to speak with a psychiatrist do so via an overhead monitor connected to the jail’s on-call psychiatrist, who lives in Monterey. This growing practice is called telepsychiatry or e-Psychiatry. When worse comes to worst and an inmate is suicidal, the legal requirement to keep him or her from self-harm requires drastic measures that should clearly happen in a hospital or mental health facility instead of in a jail. “If there are suicidal statements or suicide attempts the situation leaps to requiring a safety cell,” Brassle said. “If an inmate says ‘I’m done with this world, I want this to be over,’ we are legally responsible for keeping him or her alive.” This means that the inmate is undressed, then dressed in a safety smock with Velcro tabs. “This is because jewelry, socks, a t-shirt, pen, or even a pen can be used as a weapon to self harm. Adding insult to injury, the suicidal inmate is then locked in a safety cell with only a thin blanket and a drain. "Unfortunately, the only way to keep suicide risks safe in a jail is to put them in a concrete box with a locked door,” she said. “It’s probably one of the harshest, most inhumane places you can imagine,” she added, putting her hand on the outside steel door of a safe cell to show how cold it was, even with the outside temperature above 100 degrees. When asked if she thinks this aggressive isolation further deteriorates a suicidal inmate’s already-fragile mental state, she said it does. “I witness that every day,” she said.

RN Robert Hurley says that even if an inmate is somehow assigned to a hospital it typically takes 8 to 10 weeks to stabilize him or her on their psychiatric meds – far too long for anyone to occupy a bed in the state’s overcrowded mental health facilities and hospitals. “They can’t keep them long enough to have an effect,” he said. He tells the story of one of his pleas to keep a mentally ill inmate longer for treatment. “A doctor working for an insurance company turned down my request for five more days of treatment,” he said.

And these seemingly insurmountable problems are only while inmates are still in jail. Once released, often abandoned by the families many of them stole from, assaulted, and terrified, most return to the drugs and danger of living outdoors on the streets. “A little bit of meth keeps you awake so you’re safe to sleep,” Hurley said. “One inmate said to me, “My goal is to have a key that opens a door to a place where I will be safe.” Another inmate, facing a judge who threatened him with imprisonment because of his repeat offenses, replied quickly, “I’ll take it.” He had been homeless since he was 15 years old. Brassle recognizes that breaking the cycle when an inmate is released is tough. “When they’re released they often say ‘I don’t have money for food, I don’t have money for a pair of shoes. But there are always drugs and alcohol to share.’”

In addition to handling this wide spectrum of mental health issues, the jail’s RNs are the first to evaluate the physical problems that incoming arrestees bring with them to the jail. “We deal with severely damaged feet from walking barefoot,” Brassle said. “We also treat conditions like diabetes, high blood pressure, heart disease, and many other maladies, including communicable diseases.” A doctor visits patients in the jail twice a week. At least one of the four on-site nurses is on duty 24/7. Brassle says that all of these factors – mental illness, addiction, family isolation, homelessness, and crime also eventually add up to a kind of public fatigue. “We become more thick-skinned over time,” she said. “If the homeless prevent me from using the restroom in the park where I take my children, where is my tolerance for that?” she asked rhetorically. “If I feel threatened I have no sympathy.”

Lieutenant Bednar says he wants the public to recognize how much the jail’s 40 staff members do every day. “It’s my staff that performs CPR on inmates, that puts their lips on the lips of strangers to save their lives, that waits for those strangers in the ER,” he said. “It stays in your head.” He says it’s also important that people understand the reasons behind why so inmates become Frequent Flyers. “A lot of them have parents who were in jail,” he said, adding that it becomes a vicious lifestyle cycle. “Robberies and drugs and everything that goes with them are the root of so many crimes,” he said: being under the influence, getting drugs, getting the money for drugs, stealing that money if you don’t have it, assaulting those stealing your drugs or being assaulted yourself by those stealing your drugs.

Bednar says that inmates have broad access to educational and other specialized skills at the jail, but that by far the toughest part of breaking the Frequent Flyer cycle is bridging the ‘resume to job’ gap since so many employers won’t hire a felon. “You have no idea how rewarding it is to see it happen when inmates decide to change their lives,” he said. He tells the story of a Frequent Flyer who had been in custody dozens of times. “He said to me one day that he was sick and tired of going in and out of jail and that he’d decided to do the opposite of what he used to do,” Bednar said. Then this chronic Frequent Flyer told Bednar that, “I don’t want to disappoint you guys.” Today he’s made it, working and staying out of jail. “You get those little wins,” Bednar said.

Despite the many obstacles and the high Frequent Flyer rate, Bednar said, “We keep chipping away at it until we find the tools that work. We treat our inmates like human beings, and we work hard to recognize the window, the timing, when an inmate’s ready to change his or her life. Then we pounce on it.”