Making mental illness a crime
For more Georgians, disorders mean time in jail, not treatment centers
Telegraph Staff Writer
First of four parts
The woman with the uncertain smile has an eighth-grade education, no permanent address and a head full of schizophrenic delusions.
"Let me tell you about the Force," she says. "I call it the Force: Something that makes me do things, and I can't stop 'til I do it."
The Force has been her constant companion since she was 17, when she descended into paranoid schizophrenia. The petite woman, who wears her short hair in tiny braids, is now 40 and homeless. As best she can recall, she has been treated four or five times at Central State Hospital. Prompted by her invisible tormenter, she often says and does bizarre things. She is bad about fighting and stealing.
When she takes the antipsychotic medication Zyprexa, the Force loses its power. She is lucid, calm and friendly.
She is taking Zyprexa now - but only because she is in the Bibb County jail.
The woman, who asked that her name not be used in this article, is among thousands of Georgians with mental illness who are in jail or prison instead of under treatment in Georgia's public mental health system. She represents a growing concern for police as well as mental health authorities. Jail and prison administrators across Georgia say they are holding far more mentally ill inmates today than a decade ago - people with costly, complicated medical problems that present a financial burden and a liability to law enforcement.
At any given time, according to Bibb County Sheriff Jerry Modena, about 150 of the 585 inmates in the Bibb County Law Enforcement Center have a mental illness, a substance abuse problem or both. Of those 150, nearly 40 have a mental illness by itself. Some are chronic repeat offenders in jail on minor charges.
The situation is similar throughout the state:
-- An estimated 4,700 inmates in Georgia's county jails have a mental illness. Jail administrators say their mental illness rolls have risen sharply over the past decade.
-- Georgia Department of Corrections officials say at least 6,000 of the 46,000 state prison inmates have a serious mental illness - a fourfold increase since 1991.
-- In the past decade, the budget for mental health services in state prisons has grown nearly 1,000 percent. But spending on Georgia's system of state psychiatric hospitals and community mental health offices barely budged during that period.
Modena has coined a term for the growing number of mentally ill inmates in the state's jails and prisons: The Shadow Hospital.
It has grown, silently and out of public view, during more than three decades of change in the mental health network: Radical downsizing for the state's public psychiatric hospitals, and what most agree has been insufficient funding for community mental health services.
The clientele cycles endlessly in and out of custody, with no real resolution to their problems. In jail they become victims of other inmates. Once released, they often get no treatment, get into trouble and go back to jail.
It has come to be known as "the criminalization of mental illness." Not only is it bad for people with mental disorders, but it ties up law enforcement man-hours and jail cells that otherwise might be reserved for more serious criminals.
"They're out there committing small violations and are being put in my jail," Modena says. "If someone gets out there and urinates on the streets, I don't want them to end up here. But if the city makes a charge, we're obligated to take them into the jail and provide treatment.
"This is a statewide problem. It is not getting better."
'A jail is a poor mental hospital'
The woman with the uncertain smile was jailed on an arson charge a couple of months ago.
She says the Force told her to set a fire in the place where she lived. When she was picked up, she fought so hard that the jail staff put her in seclusion. This is not her first time behind bars.
"It's been so many I can't count," she says. "Usually I come to jail and leave, come and leave, come and leave."
She has been arrested at least five times since 1995. The charges usually are minor. Last February she was arrested for breaking a window at the Valu-Lodge on Broadway. Six months earlier, she went to jail for breaking a window at The Medical Center of Central Georgia. Three other arrests were for shoplifting. She seldom stays in jail for long.
Besides having a mental illness, she is addicted to crack cocaine. And after selling her body on the street to get drugs, she became infected with HIV.
"I have family, but we're not what I would call close," she confides.
Her myriad, perplexing problems have alienated her relatives and practically everyone else in her life.
"I'll be done did something before I know it," she says, a little sheepishly.
Like her, many of Georgia's incarcerated mentally ill have been jailed not because they set out deliberately to commit crimes, but because their untreated illnesses set them on a collision course with the legal system.
Often their offenses - born of confusion and hallucinations - are more a public nuisance like trespassing or stealing a bite of food, than a threat to society. Many of them abuse drugs or alcohol to counter the pain of their illness, setting up addictions that compound their mental and legal troubles.
There is near universal agreement among the officials in charge of detention and mental health: These people don't belong behind bars.
"A jail is a poor mental hospital," says Bibb County Probate Judge Bill Self, who presides over involuntary commitment hearings for people with mental illness.
Counties face growing burden
Many county jails offer no mental health treatment. Bibb's is one of those that do. Providing treatment isn't cheap, but failing to provide it can be expensive.
Two years ago, a federal jury in Wisconsin awarded $5.4 million to an inmate with schizophrenia after a jail administrator and sheriff failed to make treatment available.
Partly out of concern over such cases, Modena and Bibb County Commission Chairman Tommy Olmstead last year pushed successfully for $262,000 in county funds to provide mental health services in the jail through River Edge Behavioral Health Center. River Edge is Macon's public community mental health office.
In addition to the contract amount, the jail spends $75,000 a year for mental health medication and more than $100,000 a year driving inmates back and forth from Central State Hospital and other treatment centers. The county also bears other expenses, such as the cost of prosecuting each case.
Modena says it costs $67.50 per day, or nearly $25,000 a year, to house an average inmate, whether ill or not. Jailing even 40 inmates with mental illness costs the county more than $1 million a year.
The county pays the bill, even though public services for the chronically mentally ill are a state responsibility.
"We can't stay on this merry-go-round," Modena says. "It's something we don't want from the law enforcement point. The jail is not the answer. It may be convenient, but it's not the answer."
The same thing is happening in jails all over Georgia.
"I think everybody has that situation," says Undersheriff Donnie Anderson in Chatham County. "The regional hospitals don't take that many people anymore. The last few years, psychotropic drugs that our doctors prescribe have gone through the roof."
A 1998 survey of mental health services in 23 Georgia jails found that every jail reported an increase in mentally ill inmates in the previous decade.
In December, Georgia's 148 county jails held a total of 29,412 inmates. The federal Bureau of Justice Statistics estimates that nationwide, 16 percent of jail inmates and state prison inmates have a mental illness. Based on the federal estimate, more than 4,700 inmates in Georgia jails likely are mentally ill.
"This is one of the biggest problems we are facing right now in our public safety arena," says Jerry Griffin, executive director of the Association County Commissioners of Georgia. "We have become the treatment of last resort."
'Where did these people go?'
In the 1960s, Georgia housed 13,000 people at Central State Hospital in Milledgeville. Today, a statewide network of psychiatric hospitals houses only 1,100 inpatients on any given day.
"Where did those people go?" asks Putnam County Sheriff Howard Sills. "You see a lot of (them), in my opinion, in the form of homeless people, walking up and down the street in a catatonic state or screaming at the top of their lungs. It's pathetic."
They were supposed to go back home and live with the help of modern medications and treatment at community-based public centers.
On any given day, more than 58,000 people with mental illness are active clients in Georgia's community mental health system. But that system, according to mental health advocates, is incomplete.
"The original concept was never adequately funded. ... You'd have to say it wasn't completely implemented," says Mary Sloan, executive director of NAMI Georgia, the state chapter of the National Alliance for the Mentally Ill.
While many people with mental illness live successfully at home with the help of treatment from public and private sources, many others have had a more difficult transition.
Without treatment, and under the sway of visions or imaginary voices, mentally ill people may act strange and run afoul of the law. Their health problems, by default, become law enforcement problems.
"It seems to be a growing problem, from what our constituents tell us," Sloan says. "A person who has a mental illness may commit nonviolent crimes - just kind of pesky crimes like loitering or public urination or trespass. And they end up in jail."
The rapid increase in the cost of treating mentally ill people in jails and prisons stands in sharp contrast to the rate of state spending on mental health through Georgia's social services arm.
The 1990s, which brought the promise of a major restructuring of Georgia's mental health system, also brought no increase in the system's funding.
Between 1993 and 2001, when Georgia's state government budget swelled by 65 percent, Georgia's mental health spending remained almost flat. Although money was moved out of hospitals and into community treatment offices, the overall mental health budget changed little.
In the 1990s, Georgia's population grew by 26 percent. Health officials estimate that 2.8 percent of the population has a serious mental illness. So Georgia's mentally ill population grew, but funding did not.
Community treatment 'more effective'
Jim Martin, head of Georgia's Department of Human Resources, acknowledges that jailing people with mental illness represents a serious problem, and that stagnant state funding is at least partly to blame.
"We're concerned about the problem," Martin says. "(The state) has to bear responsibility for ... the lack of resources in terms of treatment."
But he says other factors play a role as well:
-- The way that law enforcement officers and courts respond to mental illness, by favoring incarceration over treatment.
-- Federal court rulings that have forced downsizing of state hospitals.
-- Laws that sharply restrict the circumstances under which a mentally ill person may be ordered to receive treatment.
-- The challenging, perplexing nature of serious mental illness itself.
Martin also acknowledges that Georgia's public mental health system is under considerable strain.
Officials throughout the system say they are struggling to cope with multiple stresses: Rising case loads, a new funding formula that has created chaos, a mountain of paperwork created by managed care systems, staff burnout and difficulty finding qualified new staff.
They say the situation leaves many caseworkers unable to find time for clients, and leaves clients without the continuity of care that they need.
"If a mentally ill person breaks the law and we can't serve them, they've got to go somewhere. It'll probably be the jail," says Ken Marsh, director of adult mental health at Phoenix Center, the community mental health services agency in Warner Robins.
"As our money dwindles and the corrections end increases, they'll see more mentally ill. We see more people getting out of prison who are on psychotropic meds every day," Marsh says.
Richard Elliott, former medical director for the state mental health system and now a psychiatrist at Mercer University School of Medicine, says many studies have shown that providing good, community-based mental health care is no more expensive than putting sick people in prisons and jails.
"Overall you can say they're cost-neutral, and a possible savings," he says.
DHR Commissioner Martin says the cost-benefit equation involves more than dollars and cents.
How, he asks, do you calculate the ultimate cost to society of minor criminal activity, repeat arrests, public nuisances and lost productivity because a mentally ill person is not in the work force and not receiving treatment?
"There is no question," he says, "that community mental health is more effective."
To contact Don Schanche Jr., call (478) 453-8308 or e-mail schanche@alltel.net.
Macon Telegraph