U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

DEPARTMENT OF JUSTICE

OFF ICE OF JUSTICE PROGRAMS

BJA NI J OJJDP BJS OVC

Providing Services for Jail Inmates

With Mental Disorders

by Henry J. Steadman, Ph.D., and Bonita M. Veysey, Ph.D.

R e s e a r c h i n B r i e f

National Institute of Justice

Jeremy Travis, Director January 1997

continued . . .

Research in Brief discusses the survey

strategy and findings, as well as innovative

programs and policies identified during

site visits to 10 jails selected on the basis

of survey results.

Research strategy

In the initial phase of a threefold research design, a survey was mailed to a

random sample of 600 jails with capacities of between 20 and 50 (as rated in the

1991 American Jail Association’s directory of jail administrators)3

 to gather information on the types of mental health

services available, facility-specific characteristics, and overall effectiveness of

mental health programs. Data for larger

jails (i.e., those with rated capacities of

50 or more) were obtained from a concurrent study using a similar methodology to

assess jail diversion programs for the

mentally disordered.4 Since sections of

the mail surveys describing basic components of jail health services were virtually

identical in the two studies, information

was drawn from the “diversion” data set

and combined with the new survey data

on smaller jails. Of the 1,706 jails that

received the survey, 1,053 (62 percent)

responded.

With an unprecedented number of

Americans currently in jail—either

awaiting adjudication of their cases or

serving short-term sentences—mentally

disordered offenders could be expected to

constitute a percentage of the inmate

population corresponding to their proportionate place in society. In fact, the percentage of jail detainees—both male and

female—with mental disorders is substantially higher than among the general

population.1

Increasingly, jails are perceived as alternatives to inadequate community-based

mental health services,2 but providing for

appropriate treatment for inmates with

mental disorders is a task for which most

facilities are ill equipped. Whether prepared to do so or not, however, jails are

constitutionally required to protect and at

least minimally care for such detainees.

A National Institute of Justice (NIJ) survey

sought to determine specific needs of inmates with mental health problems in U.S.

jails, the types of programs being used to

serve this population, existing policies to

ensure adequate inmate supervision, and

the allocation of resources associated with

program and policy implementation. This

Issues and Findings

Discussed in this Research in

Brief: Findings from an NIJ-sponsored survey and selected site visits

undertaken to identify innovative

policies and practices to address

the needs of mentally disordered

offenders detained in the Nation’s

jails.

Key issues: In today’s overcrowded jails, an alarmingly high

number of inmates are afflicted

with acute serious mental disorders

requiring mental health treatment

and services. Few jails are equipped

to provide a comprehensive range

of mental health services, yet they

are legally and morally bound to

meet at least a minimum standard

of care.

Key findings: Most jails have no

policies or procedures for managing and supervising mentally disordered detainees. Numerous

challenges to providing treatment

for them are indicated by the following findings:

● Approximately 84 percent of

survey respondents reported that

mental health services were received by one-tenth or fewer of

their inmates.

● Smaller jails (those with capacities of up to 99) tend to provide

screening and suicide prevention

services but little else, while jails

with capacities of more than 1,000

can offer comprehensive programs

with multiple service components.
2

cies, or procedures with regard to the

management, supervision, and treatment

of detainees with mental illnesses. The

10 jails—two small (rated capacity of

less than 99), two medium-sized (rated

capacity of 100 to 249), three large (rated

capacity of 250 to 999), and three

“mega” sized (rated capacity of 1,000

and over)—were contacted and agreed to

participate in the third phase of the

study—site visits (see exhibit 2).

Each site visit began with a comprehensive jail tour followed by interviews with

each of the key people involved with the

programs and policies being investigated.

On average, 7 interviews were conducted

at each site, and 49 program elements

were examined.

Overview of the findings

Approximately 84 percent of survey respondents indicated that 10 percent or

During the project’s second phase,

followup telephone interviews were conducted with 100 (a sample representing

jails of all sizes) of the 149 combined

mail survey respondents who had assessed their mental health services as

“very effective” (see exhibit 1). Data were

collected on services available within the

community, including any linkages, and

on special policies or practices that informed the relationship among the police,

the courts, and local mental health centers. In addition, interviewers requested

estimates of the number of persons requiring mental health services in the community, the number actually receiving such

services, and the quality of services received. Of the 100 jails contacted, 87

completed telephone interviews.

Researchers selected 10 jails from the

sample of phone respondents as having

particularly noteworthy practices, poliIssues and Findings

continued . . .

● Case management services that

link detainees, on release, to community services are seldom provided in jails of any size.

Researchers identified a number of

facilities that used limited available

resources to implement innovative

programs and policies in six core

areas: screening, evaluation, and

classification procedures; crisis intervention and short-term treatment practices; discharge planning

mechanisms; court liaison mechanisms; diversion practices; and contracting procedures. Analysis of

these innovative practices indicates

that:

● Locating the jail as one agency

in a continuum of county- and

community-based services can lift

barriers to the sharing of information, expertise, and resources that

is required to address the needs of

inmates with mental disorders.

● Jails interested in devising mental health services specific to their

institutional needs should consider

convening a work group that includes criminal justice, social services, mental health, substance

abuse, political, and religious leaders to develop a communitywide

response.

Target audience: Policymakers,

correctional officials, local government agencies, and health and

social service professionals.

R e s e a r c h i n B r i e f

Exhibit 1: Jails Rating Their Mental Health Services as ”Very Effective”

Rated Percentage Number

Capacity Frequency Selected Selected

Very Small 20–50 46 66 30

Small 51–99 23 66 15

Medium 100–249 29 66 17

Large 250–999 37 66 24

Mega 1,000+ 14 100 14

Total 149 100

Exhibit 2: Study Sites Visited

Site Rated Capacity

Shelby County (Memphis), Tennessee 2,845

Hillsborough County (Tampa), Florida 2,276

Pinellas County (Clearwater), Florida 1,979

Jefferson County (Louisville), Kentucky 823

Fairfax County (Fairfax), Virginia 614

Summit County (Akron), Ohio 402

Hampshire County (Northampton), Massachusetts 248

Henrico County (Richmond), Virginia 178

Page County (Clarinda), Iowa 29

Lee County (Leesburg), Georgia 23
3

R e s e a r c h i n B r i e f

American Psychiatric Association’s

(APA’s) Task Force on Psychiatric

Services in Jails and Prisons5

 (see exhibit 4).

Implementation of multitiered screening is expected, as a matter of course,

in large jails and therefore would not be

considered an innovative procedure.

The researchers noted, however, a particularly effective three-tiered approach

at the Summit County (Ohio) Jail that

featured an initial evaluation of mental

status by a booking officer, a cognitive

function examination administered by a

mental health worker, and an evaluation by a clinical psychologist.

Inmate classification. Although researchers found a few programs with

innovative classification systems for

mental disorders, only the Jefferson

fewer inmates were receiving mental

health services. The types of mental

health services available in American

jails varied widely by facility size. As

shown in exhibit 3, small jails tended

to offer little more than screening and

suicide prevention services, while

mega jails provided full-fledged (often

certified) inpatient psychiatric programs to accompany an array of

screening, evaluation, special housing,

and psychotropic medication service

components. Few jails, regardless of

size, offered case management services to link detainees leaving jail to

community services.

Twenty-one of the 87 respondents in

the phase 2 telephone interviews reported having instituted new programs

and policies designed to maximize

care to mentally disordered detainees

using the limited resources available.

The research team found that innovation was not correlated with jail size.

Screening, evaluation, and

classification

Of those jails responding to the mail

survey, 88 percent provided at least

some level of initial screening at booking. Of the jails participating in the

telephone interviews, 76 percent reported screening all booked detainees.

Researchers noted that the thoroughness of the process varied, however,

from cursory to extensive.

Multitiered screening and evaluation. Eight of the 10 jails visited had

implemented some form of a multitiered screening and evaluation process, as recommended by the

Exhibit 3: Jail Mental Health Services by Size of Jail

Size of Jail1

Service Very Small Medium Large Mega Total National

Small N=265 N=268 N=156 N=43 N=1,013 Weighted

N=295 Estimate

(N=3,304)

Screening 74.9 91.1 93.9 96.8 97.7 88.3 83.0

Evaluation 47.1 63.6 80.8 91.7 97.7 69.0 60.4

Suicide Prevention 62.4 78.7 88.1 93.6 95.3 79.4 72.7

Crisis Intervention 32.2 43.0 57.9 76.9 83.7 50.6 43.4

Psychiatric Medications 27.1 39.5 62.5 85.9 100.0 51.5 41.9

Inpatient Care

 In Jail 29.2 11.2 10.3 26.9 53.5 20.4 23.9

 Outside Jail 52.9 36.8 39.1 52.6 46.5 44.9 48.1

Therapy/Counseling 18.3 23.6 35.2 57.7 83.7 32.9 27.1

Special Housing Area 22.0 42.2 49.4 73.1 93.0 45.1 36.1

Discharge Planning 12.2 19.6 26.9 50.6 67.4 26.1 20.7

Average Number of

Services 3.8 4.5 5.5 7.1 8.2 4.0 4.6

1Rated Capacity (number of jails nationally):

Very Small = 20–50 (N=1,874)

Small = 51–99 (N=545)

Medium = 100–249 (N=471)

Large = 250–999 (N=338)

Mega = 1,000+ (N=76)
4

R e s e a r c h i n B r i e f

County (Kentucky) Jail stressed the

importance of ensuring appropriate

housing assignments for detainees with

mental health treatment needs. Its

“mental health manager” communicates with members of the jail’s classification team within 24 hours of arrest

to determine the most appropriate residential setting for inmates with pending psychiatric classifications.

In the Fairfax County (Virginia) Jail,

deputies in the classification department are specially trained in jail mental health issues, including making appropriate referrals to the forensics and

substance abuse staffs. A formal written policy involves mental health providers in classification decisions.

Responsibility for inmate classification is delegated to an institutional

classification committee, consisting of

one representative each from the jail’s

diagnostic and treatment, classification and programs, confinement, medical, and forensics departments. The

committee assigns and, as needed, effects changes in inmate custody levels

during confinement.

Crisis intervention and shortterm treatment

Treatment programs made up the majority of innovative policies and practices discovered during this study.

Some of the most noteworthy approaches are presented below.

Case management services. Because jail incarceration is of relatively

short duration, case management can

affect continuity of care and proper

discharge planning. Case management

was adopted 20 years ago at the

Hampshire County (Massachusetts)

Jail to coordinate services on an

inmate-specific basis. All inmates,

whether mentally disordered or not,

are assigned case managers, who have

a typical caseload of about 30 detainees. Inmate treatment needs are assessed at intake, and the case manager

then provides individual counseling,

meets with the family, and makes referrals to appropriate resources both

inside and outside the facility. Assignment of each sentenced and pretrial

inmate to a case manager facilitates

the process from intake through discharge planning (and reentry, if applicable). A high level of contact between

client and case manager ensures that

inmates have access to services and

that they do not “slip through the

cracks.”

Crisis intervention. Although the

need for crisis intervention in the jail

setting is clear, the best way to provide

this service is not. See exhibit 4 for

APA Task Force recommendations.

Most jails visited during this study

placed a high priority on providing crisis intervention services. Three facilities demonstrated innovative ways to

deliver crisis intervention: two sites

(Summit County, Ohio, and Shelby

County, Tennessee) employ crisis intervention specialists, and one site

(Jefferson County, Kentucky) has a crisis intervention team. All three facilities met or exceeded recommendations

in the APA guidelines. The primary

goals of those charged with handling

crisis intervention in these facilities,

whether a single specialist or a team,

are to assess, stabilize as quickly as

possible, house appropriately (e.g.,

into a mental health or special housing

unit), and provide direct mental health

services to inmates with mental disorders. Clients include those who are actively psychotic, those at risk of

committing suicide, and those under

the influence of drugs or alcohol.

In the Summit County Jail, the crisis

intervention specialist, a member of

the jail’s staff, receives 40 hours of

training per year from the facility’s

mental health coordinator; in the

Shelby County Jail, a technician specially trained in crisis intervention

evaluates and refers clients to the infirmary psychiatrist, administers prescribed medications, maintains contact

with involved agencies and community

resources used for referrals, and assists the infirmary psychiatrist during

patient assessment and treatment.

Exhibit 4: American Psychiatric

Association Task Force on Psychiatric

Services in Jails and Prisons

Recommendations on Screening and

Evaluation

● Initial screening performed at an

inmate’s booking into the facility to ascertain suicide potential, mental health

history, and current medications.

● Intake mental health screening performed by a member of the mental

health staff within 24 hours of booking.

● Mental health evaluation completed by

appropriately trained mental health professionals in response to referrals made

from either of the preceding screening

processes, from the custodial staff, or

from detainees themselves; evaluation

takes place, ideally, within 24 hours of

referral.

Recommendations on Crisis

Intervention

● Training to recognize crisis situations.

● Twenty-four hour availability of mental

health professionals to provide

evaluations.

● A special housing area for those requiring medical supervision.

● Round-the-clock availability of a psychiatrist to perform clinical evaluations

and prescribe emergency medications.
5

R e s e a r c h i n B r i e f

The crisis intervention team at the

Jefferson County Jail consists of a

mental health manager, a master’s

level clinical psychologist, and a certified psychiatric mental health nurse.

This jail also maintains an Inmate Suicide Watch Program, which uses twoman teams, consisting of inmates, to

accompany correctional officers on

their nightly rounds. The inmate observers receive training to recognize

signs of depression and risky behavior.

Each of the jails reported that it is better able to manage and supervise mentally disordered offenders as a result of

having specific positions responsible

for handling crisis intervention and

short-term treatment.

Discharge planning

mechanisms

Consistent with results from a 10-yearold study of 42 jail mental health programs, discharge planning was found

to be the weakest element of all programs for mentally disordered detainees.6

 Researchers observed that most

programs at the 10 facilities visited offered referrals on release, but they

were not aggressive and included little

or no followup. There were two exceptions. The Fairfax County (Virginia)

Jail program links released detainees

with mental health services and maintains incarcerated detainees’ family

ties (see “Offender Aid and Restoration Program, Fairfax County, Virginia, Jail”). In the Hillsborough

County Jail in Tampa, Florida, most

discharge planning is handled by two

social workers who set up appointments, make other arrangements (such

as transportation or housing), and—

most importantly—follow up to make

certain that mental health appointments are kept.

Discharge planning at the Fairfax

County Jail links detainees, on release,

with mental health and related services

and also maintains the inmate’s family

ties during incarceration—thus providing

the individual with an additional

postrelease support system and contributing to his or her success on the streets.

The services of this particular program are

provided by Offender Aid and Restoration

(OAR), a 21-year-old private, nonprofit

organization, located directly across the

street from the jail; OAR is 90-percent

funded by the county.

OAR’s professional staff consists of eight

members, all of whom have at least a

bachelor’s degree in criminal justice, psychology, or sociology; they work closely

with the jail to provide services that ordinarily would not be available. The

program’s essential elements include:

● Interface between the agency and the

jail’s mental health unit, including an excellent working relationship between the

two staffs and weekly meetings with the

jail’s psychiatrist.

● Good communication flow among the

judge, the booking staff, the jail’s forensic unit, and the agency.

● Transportation and housing assistance

to the mentally ill on release.

● Emergency services for those without

plans at release.

● Volunteers trained to teach, mentor,

and tutor educational classes in the facilities and serve as postrelease “guides.”

● Teachers—both professional and volunteer—to instruct in life skills, such as

parenting and preparation for release.

● Group therapy for inmates and their

families.

● Support groups for families and close

friends of inmates.

● Emergency funds for family food,

clothing, and other necessities during the

former provider’s jail stay.

Discharge planning in the Fairfax County

Jail is provided for every individual. One

special and very important feature of the

facility’s program for the mentally ill is

that detainees deal with the same professional staff person from intake through

discharge.

Offender Aid and Restoration Program

Fairfax County, Virginia, Jail

Although discharge planning and

followup should be key aspects of jail

mental health programs, most jails

seem to believe that their responsibility ends when the detainee is released.

Jails with programs addressing these

issues start planning for discharge

during the early stages of the detainee’s incarceration and have specific followup procedures in place to

ensure maintenance of any linkage

provided on release. In the long run,

making the effort to provide comprehensive discharge planning would

benefit the detainee, the jail, and the

community.

Court liaison mechanisms

Offenders typically pass through the

jails and the courts during processing

by the criminal justice system, and interactions between these institutions

can be particularly significant to the

mentally disordered detainee. In addition to holding and helping to stabilize

mentally disordered offenders for the

courts, jails provide valuable information to ensure that such individuals are
6

R e s e a r c h i n B r i e f

processed appropriately by the judicial

system. Similarly, the courts supply

jails with information that facilitates

management and retention or diversion

to more suitable placements. In general, jail personnel at all sites know

that the courts ultimately decide the

fate of mentally disordered offenders

and, thus, need to be considered in

Features of Court Liaison Programs

ampshire County

(Massachusetts)

The Forensic Clinic at Hampshire County

Jail is administered and funded by the

Department of Mental Health’s Division

of Forensic Mental Health, which contracts for staff with Behavior Management (formerly called The Child and

Guidance Clinic), a private nonprofit

agency. Current staff consists of the clinical director, a part-time psychiatrist, two

part-time clinical psychologists, three

part-time licensed social worker clinicians,

and a court clinic coordinator (who is a licensed social worker and is the liaison

between the court and the Hampshire

County Jail and House of Corrections).

Services include counseling inmates referred by the jail’s caseworkers; conducting evaluations for competency and

criminal responsibility; operating a weekly

medication clinic; and participating in

weekly meetings with jail caseworkers to

review their referrals and set up service

schedules.

This program is highly dependent on the

qualifications, skills, availability, cooperation, and effectiveness of the jail’s case

managers. It works, in part, because the

jail’s case managers screen detainees before the Forensic Clinic program is involved, thereby facilitating the triage

process to enable the clinic staff to focus

attention on those inmates who need

their services. In addition, because of the

limited time the Forensic Clinic staff

spend in the jail, case managers inevitably

inherit much of the responsibility for

implementing the day-by-day elements of

any treatment plan.

Pinellas County (Florida)

The court liaison program in Pinellas

County initially focused on mentally ill

misdemeanants. Staff did not want to

send such individuals to a psychiatric

hospital as “incompetent to stand trial”

or “not guilty by reason of insanity,”

dispositions that could result in longterm, but unnecessary, hospitalization.

This type of offender could be held in

jail for 4 or 5 months while dispositions

were processed.

Under a cooperative agreement worked

out between the District Mental Health

Board, the State’s attorney, the public

defender, and the judiciary, the court liaison goes into the jail to identify likely

candidates for civil commitment as an

alternative to the criminal justice track

and follows through with the State’s

attorney and/or the public defender’s

office to secure a civil commitment

hearing.

The civil commitment hearing is held at

Pinellas Emergency Mental Health Services (a crisis stabilization unit for

indigents), and arrangements are made

for subsequent placement. On the placement date, the criminal charges are

H dropped by the State’s attorney in the

morning, and the offender is transported

to the treatment facility in the afternoon.

To expedite matters, the court liaison walks

the papers through the process, notifies all

relevant parties, and arranges for postrelease continuity of care.

Shelby County (Tennessee)

In Shelby County, a multiagency memorandum of understanding provides that each

of the signing agencies (which include pretrial services and the public defender’s office) appoint contact persons (boundary

spanners) to act as liaisons with all other

social service agencies and service

providers.

The staff at pretrial services reports the

legal status and court dates of those with

severe mental illness to the appropriate

agencies and assists in expediting court

dates when appropriate. The public

defender’s office cooperates with pretrial

services in communicating the legal status of cases involving the severely mentally ill, assists in expediting court dates,

and enters court orders for evaluations as

needed. The mental health liaison also

meets periodically with the judges to remind them of the services available in the

program.

Judicial recognition of the program’s effectiveness is reflected in the speed with

which the liaison is able to move up court

dates for mentally disordered detainees.

planning and implementing mental

health programs.

All of the sites visited had developed,

at a minimum, relatively routine

means for ad hoc dealings with the

courts in response to special needs of

the mentally disordered offender; several sites had developed specific programs to facilitate interactions (see

“Features of Court Liaison Programs”).

The Forensic Clinic, created in 1985

at the Hampshire County Jail in

Northampton, Massachusetts, provides

detainees with the services of a psychiatrist, psychologists, and social

workers on site, in lieu of more costly
7

R e s e a r c h i n B r i e f

hospitalization. The major strengths of

this program stem from its location

within the jail: immediate treatment

responses that decrease the number of

psychiatric hospitalizations that otherwise would be required, good working

relationships (facilitated by weekly

meetings) among the court clinicians

and the jail’s case managers and correctional staff, and enhanced information sharing (e.g., patient mental

health histories or current behavioral

problems).

In the Pinellas County Jail in

Clearwater, Florida, a court liaison

goes into the jail to identify likely candidates for civil commitment, as an alternative to the criminal justice track,

and follows the case through the courts

to final disposition. This court liaison

program appears to be an effective response to the problem of diverting

mentally disordered offenders out of

the criminal justice system and into a

civil system specifically equipped to

address their mental health needs. The

court liaison maintains contact with

and gains the cooperation of a number

of players vital to ensuring that these

transfers are smooth, that individuals

are not lost in the shuffle, and that services are provided continuously and

effectively.

A multiagency memorandum of understanding was drawn up in Shelby

County, Tennessee, to the effect that

all signatories agree to appoint contact

persons to interact with other service

agencies and providers. A program

such as Shelby County’s requires commitment from the community and involved agencies, particularly the

community mental health providers,

sheriff’s department, and the jail’s

medical department. Bringing together

the involved parties to talk and acknowledge their common needs is the

Diversion practices

One frequently proposed approach for

responding to persons with mental illnesses in jails is to remove them from

jail to appropriate community-based

mental health programs. The team visiting the sites found excellent examples

of both pre- and postbooking diversion

programs.

Prebooking diversion—

Hillsborough County. Officials in

Hillsborough County, Florida, have established a Crisis Center as an alternative to jail, to which police can bring

criminal offenders suspected of also

having serious mental illnesses. The

Crisis Center was developed by the current director 3 years ago to reduce recidivism and more efficiently use

community resources. Here, assessment, crisis intervention, and treatment

are provided to all persons needing

those services. The center has the capacity to accept persons charged with

offenses up to nonviolent felonies.

The program relies on a smooth relationship between the staffs of the center

and the local police department. Prior

to its implementation, the current center director visited all police agency

roll call sessions to inform officers of

the services available and the center

staff’s willingness and ability to work

with law enforcement. The center’s bilingual staff offers services in a secured

area, and a system is in place to limit

the presence of police officers to 20

minutes or less. The most seriously ill

inmates can be sent to the center for

better treatment than is available in the

jail. Also, the Crisis Center has 24-hour

nursing capabilities and, unlike the

jail, can force medication when necessary because of its secure ward.

Prebooking diversion—Fairfax

County. Another noteworthy

first critical step. Participants in this

program have not yet developed a rapport with the public prosecutor, who

views the jail as an acute mental

health care facility. As a result the

prosecutor’s office is asked to become

involved in individual cases only when

it is absolutely necessary. Some problems have resulted from excluding

prosecutors from the program’s initial

and ongoing planning meetings.

The court liaison program in Fairfax

County, Virginia, is unique in that it is

built into the screening process and is

provided by magistrates in the jail,

who work with pretrial services staff on

a 24-hour basis to make the initial decision on whether the defendant

should be in or out of jail. Although

the program has been viable for only a

short time, it has enhanced the management and supervision of mentally

disordered offenders by diverting them

from jail to more appropriate treatment

settings. The program’s success is

credited, in part, to educating the

courts and prosecutors to make critically important pretrial decisions.

As is true of court liaison programs

in general, this program’s ability to

effectively address the needs of the

mentally disordered offender depends

on developing the necessary communication and trust among the various

players.

Key to the success of court liaison programs is open communication and cooperation among all parties. Inmates

can sense if staff are working at cross

purposes and may seek to exploit these

differences. Further, mental health

treatment particularly requires a consistent approach to be effective. The

support, contribution, and input of all

involved parties are necessary for the

proper functioning of this type of

program.
8

R e s e a r c h i n B r i e f

prebooking diversion program, the mobile crisis unit (MCU), was designed to

divert mentally disordered inmates

from jail through working with the

family, the police, and the courts.

Staffed and funded by Fairfax County,

Virginia, the MCU consists of a home

visit team for those unable or unwilling

to go to a mental health center. It is

staffed 7 days per week, from 3 p.m. to

midnight. Each afternoon, when staff

members arrive for duty, they check in

with the seven or eight area mental

health centers for referrals; reportedly,

they receive at least two each day.

MCU services include suicide assessC Community Treatment Alternatives Program

ommunity Treatment Alternatives

Program (CTAP) in the Jefferson County

(Kentucky) Jail is a formal, written program implemented, run, and staffed by

Seven Counties Mental Health Center in

Louisville, Kentucky. Its purpose is to provide community-based mental health services as an alternative to incarceration for

adjudicated offenders with chronic mental illness.

The criteria for admission into the program are chronic offender status (usually

misdemeanants) along with severe mental illness. The target population, defined

by guidelines developed by the State Department of Mental Health, includes, for

example, individuals with bipolar disorders, but not those with primary substance abuse and personality disorders.

Clients are referred to the program by

other mental health professionals,

judges, an attorney, the court liaison, or

a jail mental health worker. Caseworkers

from Seven Counties visit the jail every

morning to assess potential clients. Based

on a review of this assessment, the caseworker decides whether the detainee is

appropriate for the program.

If the decision is affirmative, correctional

services, community mental health services, and the courts work together to

develop a coordinated plan for securing

the detainee’s release from jail and assist

in meeting the detainee’s mental health

needs. CTAP detainees are released from

jail directly into the community; approximately half live in their own homes; others reside in boarding homes or in

housing provided through other programs—such as the Volunteers of

America’s Mentally Ill Men at Risk for

Homelessness Program.

The CTAP caseworker places a high priority on helping set up appropriate housing

before an inmate’s release date. At times,

judges cooperate in this effort by, for example, delaying release for a week or so

until housing is found.

Detainees in the community are supervised closely. In the first month after release, the detainee’s contact is mainly

with the CTAP caseworker. After that,

the case is turned over to Seven Counties

staff. Detainees usually come into the

center for appointments and, in addition,

Seven Counties staff do home visits to

check life management skills. Medications are monitored closely—some detainees must come to the center each day

to receive their medications, while others

are given injections.

The monthly meetings among jail mental

health staff, CTAP caseworkers, and the

court liaison provide an opportunity to

strategize and decide who in the jail

should be targeted for the program’s services. CTAP detainees must sign a contract that commits them to the program

for a 2-year period and sets out the jail

term in case of revocation for such actions as failure to participate in the treatment plan. When a contract is violated,

the detainee appears before the judge,

who can change the sentence from treatment to the contract-specified jail term or

to a new 2-year contract with additional

prospective jail time added.

ment, prevention, and intervention;

psychiatric crisis evaluation, intervention, and (when necessary) hospitalization; administration of medication in

domestic disturbances; intervention in

drug and alcohol crises that pose the

risk of danger; stress reduction for service providers; and assistance for

people coping with trauma or tragic

events. Additionally, MCU team members serve as consultants to police

SWAT teams in hostage-barricade incidents. If the incident is solely a mental health crisis, the team gathers

background information on the perpetrator and makes all necessary arrangements for care (e.g., hospital

beds). If the incident results in an arrest, the MCU notifies the jail’s forensic unit and provides it with essential

background information. Other duties

include:

• Going to police roll call sessions to

train officers and magistrates in mental health issues.

• Educating families and the community about the criminal justice system.

• Providing backup for the jail’s crisis

intervention team.

• Acting, in lieu of police officers, as

petitioners/recommenders for the mentally disordered at hearings.
9

R e s e a r c h i n B r i e f

Postbooking diversion. The comprehensive postbooking program in

Jefferson County, Kentucky (see

“Community Treatment Alternatives

Program”) is designed to provide community-based mental health services

as an alternative to incarceration for

chronically ill adjudicated offenders.

Contracting procedures

Using university resources. One of

the more commonly mentioned problems facing U.S. jails with regard to

mentally disordered detainees is the

lack of adequate resources and staff.

While interviewing a psychiatrist at

the Summit County (Ohio) Jail, researchers discovered that assignments

at the county jail are part of the local

medical college’s community psychiatry rotation. The fact that rotations

originate in the community, rather

than in the forensic training program,

is an implicit acknowledgment that

mentally ill detainees are a community

services responsibility.

The psychiatrist on a 3-month rotation

is in the jail for 6 hours per week and

primarily sees inmates already on

medication or needing to be evaluated

for medication. The jail’s “team approach” simplifies this task. Jail mental health staff screen inmates before

the psychiatrist sees them; in jails that

do not have such screening, the psychiatrist receives limited information

regarding, for example, behavioral patterns, which makes it difficult to properly prescribe medications. Psychiatrists in the jail setting interact with

jail administrators and correctional

staff as well as treat patients.

The Henrico County Jail in Richmond,

Virginia, contracts for psychiatric services with the local medical college

through a fellowship in psychiatry. The

fellow spends 3 days per week at the

State hospital, one-half day in the jail,

and the remainder of the week at the

medical college. The psychiatrist

handles medications exclusively, seeing each inmate who is on medication

every 2 weeks. Any problems between

these visits are handled by the jail’s

mental health staff. When asked if 4

hours per week of psychiatric coverage

was sufficient, the staff answered in

the affirmative since, as a rule, fewer

than 30 inmates at any given time are

on medication.

Coordination with community

mental health services. The Alcohol, Drug Addiction, and Mental

(ADM) Health Services Board is a

county administrative board that controls all funding for Summit County

(Ohio) mental health services.7

Each year Summit County and the

ADM Board enter into a written agreement that sets out the functions, responsibilities, and rights of both

parties for the following 12-month

period. In general, the jail provides

services directly, with additional responsibilities in the areas of clinical

evaluation and quality assurance, and

the board provides planning, funding,

evaluation, and monitoring of alcohol,

drug addiction, and mental health services. Funding is advanced to the jail

on a grants management basis.

Privatization of mental health

services. Three of the 10 jails visited

were contracting for mental health services through a national private care

provider, such as Correctional Medical

Services (CMS) or Prison Health Services (PHS). For example, in the

Pinellas County (Florida) Jail, the private contractor provides mental health

services, required minimum staffing,

professional liability insurance, and

medications.

A benefit of the privatization model is

that the national scope of the provider

brings resources to the jail that would

not otherwise be available to assist

with management and supervision of

mentally disordered offenders. Two

of the jails with these contracts employ

a contract monitor who ensures compliance with the contract terms, including maintenance of required

accreditation standards and staffing

patterns. In Hillsborough County,

Florida, the position of contract monitor is itself a provision of the contract.

In addition to jails that contract for

services with national health care providers, such as CMS or PHS, there are

some, such as Hampshire County,

Massachusetts, that contract with private for-profit or nonprofit community

mental health agencies to provide specific services that would not ordinarily

be available in the jail. This method

can ensure the availability of needed

services without using limited resources to create an internal program.

Taking action

Mental health litigation has established the legal right to treatment in

custodial facilities—for pretrial detainees as well as sentenced inmates.

Among its benefits, good mental health

treatment can reduce security risks by

minimizing the symptoms of mental

illness, thereby decreasing potential

disruptions to jail routines and injuries

to staff and detainees.

The problems jails experience in connection with mentally ill detainees are

associated with the absence of criminal justice policies, procedures, and

standards specifically addressed to

this group of offenders. Deficiencies in

training, communication, and resources result from viewing the jail in
10

R e s e a r c h i n B r i e f

isolation, rather than as an integral

part of a criminal justice system (that

includes the police, the courts, defense attorneys, and prosecutors) with

linkages to mental health and other

human services based in the greater

community.

Except for the largest jails in the major

metropolitan areas, it is impractical to

consider developing a comprehensive

set of inhouse mental health services.

A more prudent approach would have

the jail making effective use of community mental health centers; psychiatric units of hospitals; private

practitioners; university departments

of psychology, medicine, and social

work; and State mental hospitals. “Effective use” does not mean, necessarily, the actual transfer of inmates but,

rather, drawing on staff expertise in

these external programs and planning

services in ways that optimize program

resources.

The policies and programs implemented by jails in this study represent

promising strategies that can be

adapted to individual communities.

Ultimately, each locality must decide

what it needs and wants, how it can

pay for it, and who needs to be brought

together to make it happen. Five principles developed previously by the researchers8

 should still be considered

for possible guidance:

• The mentally disturbed jail inmate

must be viewed as a community issue.

• The jail is, and should remain, primarily a correctional facility.

• Minimum professionally acceptable

mental health services are required in

every jail and lockup.

• Jail mental health services should

focus on screening and identification

of need, crisis intervention and shortterm treatment/stabilization, and case

management/referral.

• There is no single “best” way to organize services.

Notes

1. Teplin, L.A., “Psychiatric and Substance Abuse Disorders Among Male

Urban Jail Detainees,” American Journal of Public Health 84(2):290–293,

1994.

2. Teplin, L.A., and N.S. Pruett, “Police as Streetcorner Psychiatrists:

Managing the Mentally Ill,” International Journal of Law and Psychiatry,

15:139–156, 1995; and Torrey, E.F.,

J. Stieber, J. Ezekiel, S.M. Wolf, J.

Charfstein, J. H. Noble, and L.M.

Flynn, Criminalizing the Seriously

Mentally Ill: The Abuse of Jails as

Mental Hospitals, Washington, DC:

Public Citizen’s Health Research

Group and National Alliance for the

Mentally Ill, 1992.

3. American Jail Association, Who’s

Who in Jail Management, Hagerstown,

MD: American Jail Association, 1991.

4. Steadman, H.J., S.H. Barbera, and

D.L. Dennis, “A National Survey of

Jail Mental Health Diversion Programs,” Hospital and Community Psychiatry, 45:1109–1113, 1994;

Steadman, H.J., S.M. Morris, and D.L.

Dennis, “The Diversion of Mentally Ill

Persons from Jails to CommunityBased Services: A Profile of Programs,” American Journal of Public

Health 85(12):1630–1635, 1996.

5. American Psychiatric Association,

Psychiatric Services in Jails and Prisons: Report of the Task Force on Psychiatric Services in Jails and Prisons,

Washington, DC: American Psychiatric Association, 1989.

6. Steadman, H.J., D.W. McCarty, and

J.P. Morrissey, The Mentally Ill in

Jail: Planning for Essential Services,

New York: Guilford Press, 1989.

7. The funding source for these services is the Governor’s Office of Criminal Justice Services. Approximately 50

percent of ADM money comes from

State coffers and 50 percent from a local mental health levy (a part of the

county tax base). The ADM Board consists of eight members appointed by

the county executive, five appointed

by the Ohio Department of Mental

Health, and the remainder by the Ohio

Office of Drug Addiction and Alcohol

Abuse.

8. Steadman, H.J. et al., “A National

Survey of Jail Mental Health Diversion

Programs.”

Findings and conclusions of the research reported here are those of the authors and do not

necessarily reflect the official position or policies of the U.S. Department of Justice.

NCJ 162207

The National Institute of Justice is a

component of the Office of Justice Programs,

which also includes the Bureau of Justice

Assistance, Bureau of Justice Statistics,

Office of Juvenile Justice and Delinquency

Prevention, and the Office for Victims of

Crime.

Henry J. Steadman, Ph.D., is

president of Policy Research,

Inc., and Bonita M. Veysey,

Ph.D., is women’s program director at the National GAINS Center

for People with Co-Occurring

Disorders in the Justice System.

The project was supported by

contract 92–IJ–CX–K020,

awarded by the National Institute

of Justice.
The Latest Criminal Justice

Videotape Series from NIJ:

Research in Progress

Learn about the latest developments in criminal justice

research from prominent criminal justice experts.

Each 60-minute tape presents a well-known scholar discussing his or her current studies and how they

relate to existing criminal justice research and includes the lecturer’s responses to audience questions. The

tapes in the series now available in VHS format are:

NCJ 152235—Alfred Blumstein, Ph.D.,

Professor, Carnegie Mellon University: Youth

Violence, Guns, and Illicit Drug Markets.

NCJ 152236—Peter W. Greenwood, Ph.D.,

Director, Criminal Justice Research Program,

The RAND Corporation: Three Strikes, You’re

Out: Benefits and Costs of California’s New Mandatory-Sentencing Law.

NCJ 152237—Christian Pfeiffer, Ph.D., Director, Kriminologisches Forschungsinstitut

Niedersachsen: Sentencing Policy and Crime Rates

in Reunified Germany.

NCJ 152238—Arthur L. Kellermann, M.D.,

M.P.H., Director, Center for Injury Control,

and Associate Professor, Emory University:

Understanding and Preventing Violence: A Public

Health Perspective.

NCJ 152692—James Inciardi, Ph.D., Director, Drug and Alcohol Center, University of

Delaware: A Corrections-Based Continuum of Effective Drug Abuse Treatment.

NCJ 153270—Adele Harrell, Ph.D., Director,

Program on Law and Behavior, The Urban

Institute: Intervening with High-Risk Youth: Preliminary Findings from the Children-at-Risk

Program.

NCJ 153271—Marvin Wolfgang, Ph.D., Director, Legal Studies and Criminology,

University of Pennsylvania: Crime in a Birth Cohort: A Replication in the People’s Republic of China.

NCJ 153730—Lawrence W. Sherman, Ph.D.,

Professor, University of Maryland: Reducing

Gun Violence: Community Policing Against Gun

Crime.

NCJ 153272—Cathy Spatz Widom, Ph.D.,

Professor, State University of New York–Albany: The Cycle of Violence Revisited Six Years

Later.

NCJ 153273—Wesley Skogan, Ph.D., Professor, Northwestern University: Community Policing in Chicago: Fact or Fiction?

NCJ 153850—Scott H. Decker, Ph.D., Professor, University of Missouri–St. Louis, and

Susan Pennell, San Diego Association of Governments: Monitoring the Illegal Firearms

Market.

NCJ 154277—Terrie Moffitt, Ph.D., Professor, University of Wisconsin: Partner Violence

Among Young Adults.

NCJ 156923—Orlando Rodriguez, Ph.D.,

Director, Hispanic Research Center, Fordham

University: The New Immigrant Hispanic Populations: Implications for Crime and Delinquency in

the Next Decade.

NCJ 156924—Robert Sampson, Ph.D., Professor, University of Chicago: Communities and

Crime: A Study in Chicago.

NCJ 156925—John Monahan, Ph.D., Professor, University of Virginia: Mental Illness and

Violent Crime.

NCJ 157643—Benjamin E. Saunders, Ph.D.,

and Dean G. Kilpatrick, Ph.D., Medical University of South Carolina: Prevalence and Consequences of Child Victimization: Preliminary Results

from the National Survey of Adolescents.

NCJ 159739—Joel H. Garner, Ph.D., Research Director, Joint Centers for Justice

Studies: Use of Force By and Against the Police.

NCJ 159740—Kim English, Research Director, Colorado Division of Criminal Justice:

Managing Adult Sex Offenders in Community Settings: A Containment Approach.

NCJ 160765—Michael Tonry, Ph.D., Professor, University of Minnesota: Ethnicity, Crime,

and Immigration.

NCJ 160766—David M. Kennedy, Senior

Researcher, Harvard University: Juvenile Gun

Violence and Gun Markets in Boston.

NCJ 161259—Robert Crutchfield, Ph.D.,

Professor, University of Washington: Labor

Markets, Employment, and Crime.

NCJ 161836—Geoff Alpert, Professor, University of South Carolina: Police in Pursuit:

Policy and Practice.

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Selected NIJ Publications on Issues Relating to

Health Care Services Provision in Jails and Prisons

Listed below are some recent National Institute of Justice publications related to issues surrounding the provision of health care services to inmates. These publications are free and can be obtained from the National

Criminal Justice Reference Service (NCJRS): telephone 800–851–3420, e-mail askncjrs@ncjrs.org, or write

NCJRS, Box 6000, Rockville, MD 20849–6000. Please note that when free publications are out of stock, they

are available as photocopies or through interlibrary loan.

These documents also can be downloaded through the NCJRS Bulletin Board System or at the NCJRS Anonymous FTP site in ASCII or graphic formats. They can be viewed online at the Justice Information Center

World Wide Web site. Call NCJRS for more information.

Lipton, Douglas S. The Effectiveness

of Treatment for Drug Abusers Under Criminal Justice Supervision,

NIJ Research Report, 1996, NCJ

157642.

McDonald, Douglas C., Managing

Prison Health Care and Costs, NIJ

Issues and Practices, 1995, NCJ

152768.

McDonald, Douglas C. Ph.D., and

Michele Teitelbaum, Ph.D., Managing Mentally Ill Offenders in the

Community: Milwaukee’s Community Support Program, NIJ Program

Focus, 1994, NCJ 145330.

Rubin, Paula N. and Susan W.

McCampbell, The Americans With

Disabilities Act and Criminal Justice: Mental Disabilities and Corrections, NIJ Research in Action,

1995, NCJ 155061.

Tunis, Sandra, Ph.D., James Austin,

Ph.D., Mark Morris, Ph.D., Patricia

Hardyman, Ph.D., and Melissa

Bolyard, M.A., Evaluation of Drug

Treatment in Local Corrections, NIJ

Research Report, 1996, NCJ

159313.

Widom, Rebecca and Theodore M.

Hammett, HIV/AIDS and STDs in

Juvenile Facilities, NIJ Research in

Brief, 1996, NCJ 155509.

Wilcock, Karen, Theodore M.

Hammett, Rebecca Widom, and

Joel Epstein, Tuberculosis in Correctional Facilities 1994–95, NIJ

Research in Brief, 1996, NCJ

157809.