Cellblock Door Visits: They Are Not ‘House Calls’
If you have worked inside a local jail for any length of time, you are well aware of the problem of the mentally ill coming into the jail. You are called to booking for backup as fellow jail correctional officers (JCOs) or deputies struggle to maintain control of a psychotic offender who is clearly out of touch with reality. Managing the mentally ill offender is one of the most difficult tasks for correctional officers. In local jails, some inmates with mental health issues are transferred in from other facilities-they may have court, etc. Some may return from the prison system for reconsideration of sentences, and so on. They usually have been seen and managed by mental health professionals, usually by medication. Managing means checking with them frequently-but cell door visits are not ‘treatment’; they are not like old time doctor ‘house calls’. There will be more about that later.
However, most mentally ill offenders are coming into local jails fresh off the street and from the arrest. The scenes of arrest can be a public park, a store, a movie theater or inside a home where families have dealt with the person for long periods. Mental illness is tragic, and unfortunately deadly in the cases of injuries or death to family members, people on the street, and law enforcement personnel. Sadly, we read too often news stories of a mentally ill person brandishing a weapon, or hurting people.
The seriously mentally ill in (SMI) in our nation’s jails are a problem. Some we can talk to, and will follow our instructions. They will not ‘bang their heads’ against cell walls, not yell and scream for hours, or will not smear themselves with feces and excrement. They will keep their jail uniforms on and not exhibit nudity. Some may be so manageable that they can be placed with other inmates, thus saving segregation cells for violent, dangerous and out of control inmates. This compliance may be due to medications, therapy sessions, counseling and other methods from the hard working, professionally trained and experienced jail mental health staffs.
As a classification jail deputy, my staff had to devise ways to safely manage mentally ill inmates. Some we placed in general population-housing units after screening by the medical staff and mental health personnel. Other we had to place in segregation-for the safety of other inmates and staff. Mentally ill inmates in segregation must be observed every 15 minutes-or as I recommend-sooner. Medical staff generally have had some mental health training. Managing the mentally ill inmate safely requires teamwork. The front line are the police officers and jail correctional officers-some JCOs are in booking and some are assigned to general population. Many articles talk about mentally ill inmates being booked into the jail. Many are brought in by arresting police officers, who pick up the signs of mental illness and relay this information to the jail. However, an inmate may get through booking, is classified and moved into the jail general population. The signs of mental illness may appear and be seen by the JCO working the unit. The JCO notifies his or her squad supervisor, the medical and mental health staff are advised, as is the classification staff. A team approach requires several things. First, a concern about staff and inmate safety has to exist. Second, open, clear and two-way communications and actions between line officers, supervisors, medical, mental health and classification is crucial, especially written communications. Third, ongoing training has to address the problems of housing and managing SMI inmates. Included in that training is dispelling the view that a mental health staff member seeing the inmate in a hallway through a cell door window or food slot is treatment. It is not.
So-let us explore in more detail the aforementioned ‘team approach’ within a jail setting, when dealing with mentally ill offenders.
Concern: Mentally ill inmates can be frustrating, as many refuse medications and exist in their ‘own world’. However, they are still people, with limited protections under the U.S. Constitution, as put forth by statute, case law and correctional standards. Mental illness is a sickness-it cannot be cured, just managed. Mentally ill inmates, especially in restraints must not be ignored, even in segregation, on restraints and/or on high observation.
Open and clear communications: Per the Bureau of Justice Statistics, an estimated 64% of jail inmates have some type of mental health issue or problem [1]. I have asked jail veterans in my in-service classes if this is accurate, and often they answer-at least and significantly higher than that percentage. Large jails, small jails-it does not matter. Everyone has to communicate with each other-from the line JCO being relieved to classification discussing the housing and conditions of confinement of mentally ill inmates. While oral communications are easy and fast, written communications-your logs, incident reports, classification files, mental health evaluations and medical records-are the best in both planning on how to deal with this inmate and answering questions in a civil lawsuit. Included in these communications are staff precautions, suicidal behavior, medications, etc. But these communications must be clear and accurate.
Training of staff is critical: Recently, the development and use of Crisis intervention Team training (CIT) for law enforcement officers, including jail staff has markedly improved the understanding of the mentally ill offender. A good example of a CIT program can be found at the DuPage County, Illinois Sheriff’s Office. With assistance from the DuPage Health Department and the DuPage Northern Alliance on Mental Illness (NAMU DuPage), a 40-hour training program was developed and approved by the Illinois Law Enforcement Training and Standards Board. The topics are wide ranging, including the signs and symptoms of mental illness, community resources, verbal de-escalation and tactical responses, risk assessment and crisis intervention skills, medical conditions and psychotropic medications. Other topics include older adults, intellectual and developmental disabilities, autism and self-care for law enforcement [2].
However, two areas need further discussion. First, I mentioned that the mentally ill inmate cannot be ignored while in restraints. An example can be found in the case of Andrew Holland, a 36-year-old mentally ill inmate that died in the San Luis Obispo (CA) County Jail in January of 2017. He had been diagnosed as schizophrenic when in his 20’s, and had been transferred back and forth from the jail to a county treatment facility since he entered the jail in September of 2015. A judge had ordered psychiatric treatment for him 12 days prior to his death. He had been booked in on resisting arrest and public disturbance charges. Although beds were available in a mental health facility, he was not transferred. He was observed, while in solitary confinement, punching himself in the face. He was placed, naked in an observation cell, in view of the central control center, and restrained in a seven-point restraint chair. According to the coroner, he refused, on several occasions, food and water. However, he was in the chair for 46 hours and no reason was reported for why he was in the chair for so long. County policy says that the facility manager must approve the restraining of inmates for long periods of time. State law stipulates that if the inmate cannot have restraints ‘safely’ removed within 8 hours, further evaluation from medical staff is necessary. Although the sheriff’s office said that he was under observation in a glass observation cell, the cause of death was reported to be a pulmonary embolism, related to deep vein thrombosis. The coroner found a five-centimeter clot in the inmate’s lung, possible from blood clots in the legs because of immobility from being restrained for a long period. He died 20 minutes after being released from the chair. The sheriff’s office settled with the inmate’s family for $5 million [3].
I am not passing judgment on the jail staff in the Holland case. They are tasked with managing the SMI inmate. No one wants inmates to die. However, our local jails are not mental health facilities, but are tasked with the care and custody of seriously mentally ill offenders, keeping them safe, other inmates safe and the staff safe. The last thing a jail department or sheriff needs is a news story like the Holland case, where staff mistakes are scrutinized. That is why more training and developing proactive attitudes among staff are so badly needed-to prevent such tragedies.
Second, it is important not to view ‘cell door visits’ from mental health staff as a form of treatment. An Indiana inmate filed motions in court to obtain a preliminary injunction to receive adequate mental health care. He claimed that his treatment needs were ignored by the staff. In the case of Robertson v. Deputy Commissioner, 2019 (N.D. Ind), the federal judge noted that records indicated that the inmate refused out of cell treatment. Also recorded were weekly checks with mental health staff at the inmate’s cell front, which were considered as treatment by the judge. In my experience working inside a large county jail, mental health staff talking to mentally ill inmates through a cell door window or food slot is not really treatment-but an information gathering tool and assessment observation for staff. The obtained information lets classification, custody, courts, attorneys, medical and mental health staffs know how the inmate is acting, if precautions are necessary and if he or she can be moved from segregation to general population. In addition, the mental health professional can recommend medication, commitment to a mental health facility or other assistance. Often, these visits take place in the noisy environment of a jail corridor, and may last for only a few minutes or a little longer. These visits must be recorded, and recommendations and information gained from them be placed in the inmate’s classification file. By doing so, informed decisions can be made. However, the mental disorders that we encounter among inmates in jail cannot be treated in just a few minutes in a cell door encounter. That is not treatment-and jail training staff and supervisors must advise officers-especially new ones-that treatment takes a long time, in a much more structured setting. Cell door visits cannot be compared to the ‘house calls’ of the past-where the family doctor drops by, checks the vitals, gives the patient medicine and tells the family to ‘call me in the morning’ [4].
Jails are different-very much different.