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A system in shambles: Boone County Jail serves as mental health facility

Sunday, May 19, 2013 | 6:00 a.m. CDT; updated 9:50 p.m. CDT, Tuesday, May 21, 2013
Claudette Henderson sits in the attorney conference room Saturday in the Boone County Jail, where she is serving time for a shoplifting charge. "It hurts to know that I could be a grandma to all of these kids in here," Henderson said. "They're so young and I'm 56-years-old." Henderson said many of the times that she's stolen something, she's had the money to purchase the item. Henderson has bipolar disorder and said the condition makes her crave the rush of excitement accompanied by shoplifting.

COLUMBIA — She paid for three dresses at the checkout counter. They were for the Sunday program at church — one for the morning service, one for the evening and one backup in case something went wrong with the first two.

She had started to leave when she saw a jewelry display and stopped. She doesn't like gold, but the silver bracelets and earrings shimmered so beautifully — almost white — that she couldn't stop staring.

She could have exchanged one of the dresses for the jewelry. She could have left without them, walking past the display rack like the other customers. Physically, she could have, but mentally she couldn't. She was obsessed, possessed.

When she started to leave the J.C. Penney's, she carried a shopping bag with the three dresses inside. In her purse was a tangle of earrings and bracelets, $192 worth.

She felt the familiar rush. She started for the door, and a man grabbed her arm. The security guard for the store had seen her take the jewelry.

Panicking, 56-year-old Claudette Henderson began throwing the stolen jewelry to the floor and blurting out a confession. Maybe if she admitted what she'd done and gave back the jewelry she could avoid punishment, she remembers thinking. She'd already been convicted three times of shoplifting, in 1998, in 2009 for $12 in merchandise and in 2011 for $25.15 in merchandise.

She was issued a citation for trespassing. An ambulance took her to the emergency room to treat a sprained wrist and shoulder where the security guard had grabbed her. Then she went to jail.

Henderson is bipolar and borderline schizophrenic and has post-traumatic stress disorder, obsessive compulsive disorder and depression. She now knows that she steals for the highs that come with being bipolar and to escape the lows that cripple her. 

For eight weeks, she has been in the Boone County Jail, where she sees a counselor once a week and receives medication for her mental illness. She can't sleep, she says, or eat or even get out of her cot, sometimes. Some days, she cries — embarrassed to be a grandmother in jail and ashamed to have disappointed her family.

On those days, she can't stop questioning her actions. "I don't set out to do these things. I can't explain why I'm in here with people, I could be their grandma," she said. "What was wrong with me? Everything in my life was going so well."

Nationally, 17 percent of those incarcerated in jail have a mental illness, according to a study by the Council of State Governments Justice Center. The rate at the Boone County Jail, however, is much higher, says Chief of Custody Warren Brewer. He estimates that 30 percent to 35 percent of the inmates there, like Henderson, are mentally ill.

Outpatient clinics, hospitals, support groups — none have the resources or funds to treat everyone with a serious mental illnesses. The jail, Brewer says, has become Boone County's de facto mental health care provider.

"There's this grand notion that there is some type of community safety net that is an alternative to institutionalization, that will keep them on a structure," he said. "It's a lie, a fallacy, a myth. It doesn't exist."

Because mental health care "is low on the priority pole," Brewer said, jails have been forced into providing mental health care.

Mental health has slid further down that pole for decades. From 2009 to 2012, funding for mental health in Missouri decreased by $21.2 million, a 6.8 percent drop.

Funding and resources began to shrink in the late 1960s and early 1970s when patients were deinstitutionalized — moved out of state mental hospitals. The 512,501 resident population in mental hospitals in 1950 had dropped to 101,402 by 1989. Funding was supposed to be channeled into community-based treatment centers rather than state-run hospitals.

This community-based system, centered on privately run outpatient facilities, was to provide care for patients while allowing them to function in the community and live at home. At the same time, state governments began paring mental health budgets. Jails became the place where people with mental illnesses were more likely to end up than inpatient centers.

"The new treatments meant that some people could live and thrive in the community," said Cynthia Keele, Missouri executive director of the National Alliance on Mental Illness. But "so many just ended up on the streets. We've been trying to make up for that ever since. We were left with a system in shambles."

Funding problems

Although she has struggled with mental illness her entire life, Henderson was first diagnosed in 2008, when she spent a month in MU's Psychiatric Center after she tried to kill herself. Funding cuts to the mental health system have limited the number of beds there. Suicide attempts are one of the few remaining ways a person can be admitted.

The Psychiatric Center, the last inpatient facility in the city, has only 57 beds. They are consistently 90 percent to 95 percent full, administrative manager Richard Erwin said.

Before it became a publicly run facility in 2009, patients came from all over the state and would sometimes stay for years. Now, they stay an average of seven days. The staff checks them in, gets them on a counseling and medication regimen and releases them to other long-term care facilities, he said. A discharge plan is created for patients, but there's no follow up after they leave.

"There are not enough mental health beds in the state of Missouri," Erwin said. "If we opened another unit, we'd be full before too long. We do the best with what we've got."

After Henderson was released, she began going to Burrell Behavioral Health for outpatient care. She quit before receiving any treatment because she said she felt the staff didn't check on her enough. "I felt abandoned," she said.

In the jail, inmates' treatment is funded by the Boone County Sheriff's Department's budget; once outside, many can't afford it.

At Phoenix Programs, an outpatient care provider, staff members try to help those patients, prevention specialist Hannah Harlan said. But funding cuts often limit their ability to get treatment for patients who don't have insurance.

"We have to ration those resources," she said. "People will have to wait for months. It feels like telling them to come back when their cancer is worse."

For those who can afford it, the intricacies of treatment can be complicated. Mental health care, which involves making, remembering and keeping appointments in a complicated system, is difficult for them to do on their own, Harlan said. "It's like putting the orthopedic doctor on the fifth floor with no elevator."

The stigma attached to mental illness keeps many from trying to take the stairs.

"Stigma is the number one issue we still have to deal with," said Tim Harlan, Missouri president of the National Alliance on Mental Illness. He is also the brother of Hannah Harlan.

"There are not blood tests, X-rays to tell how sick someone is. People tend to think these behaviors can be controlled or changed. It makes it harder to get the necessary appropriations for treatment."

The community-based system isn't failing; it's being gutted by dwindling resources and lack of societal and governmental concern for it, said Pascha Boyd, a psychiatric nurse who works at the jail.

The quick fix

For people who can't afford private treatment or don't have the support to enter it, substance abuse can fill the void left open without medication and counseling. Of those with serious mental illnesses in jails, 68 percent were also abusing drugs or alcohol. Instead of waiting months for treatment after being released, many turn to them instead.

Henderson began using drugs when she was 35. Before that, she had no arrest record. She had worked as a nurse and cook while raising her two children, a boy and girl, seven years apart. She remembers being a good mom.

Her first time trying crack, she didn't feel anything. Six months later, though, she couldn't stop using.

"I was attached to the smell," she said. "Never the taste, just the smell."

The highs from the drugs helped her cope with the lows of her mental illness. She would go out at night and leave her kids with relatives, she said, who told her she was going to end up dead or in jail for the things she did.

She stopped going to work and became a drug dealer in order to make money. In 1998, after dealing for 18 months, she was arrested for distribution and delivery and sent to prison for seven years.

During her time in the Women's Eastern Reception, Diagnostic and Correctional Center in Vandalia — Henderson uses the acronym "WEIRD" to remember the name — she didn't see her family for two and a half years. She was able to call them only once a week, every Sunday after church.

But release brought no relief. "Everything just kind of went to hell. Nobody wants to hire someone with a record," she said. She started using again — crack, marijuana, alcohol. She lived in a townhouse and found a job at a call center while her mental illness and drug addiction raged, untreated.

Two years later, she attempted suicide. The year after that, she was arrested for possession of drug paraphernalia and had her first stealing arrest. She continued to do drugs and get arrested until October, when she quit everything cold turkey.

For patients with multiple issues such as substance abuse and mental illness, where to go for treatment is a crapshoot. Because the mental health system is "siloed," Hannah Harlan said, patients have to go to one place for mental health treatment, another for substance abuse treatment and yet another for psychiatric treatment. For a patient who has trouble following the schedule of one center, three is nearly impossible.

Henderson receives treatment for her mental illnesses in jail, but is not treated there for her drug addiction. For that, she reads a Narcotics Anonymous book and her Bible every morning.

The book tells her to be rigorously honest, which she knows she hasn't been in the past. The Bible helps with that, too.

"I asked the Lord for strength," she said. "It's going to take a lot of praying."

'No soft edges in jail'

In 2000, Boone County contracted Behavioral Health Concepts to provide mental health care for inmates. Four counselors and one psychiatrist provide care for the average 50 to 75 inmates who need treatment.

The presence of mental health staff has made the jail a safer place, Brewer said. Before 2000, mental health care meant shackling violent inmates with mental illnesses to the floor or hosing down a cell once a day after an inmate smeared it with feces. Often, guards and inmates were injured in the outbursts.

"We play in a concrete and steel environment," Brewer said. "There's no soft edges in a jail." Having treatment available has reduced the frequency and danger of these incidents.

As in outpatient programs, the patients can be referred for treatment but participate voluntarily; staffers cannot force anyone to attend counseling sessions or take medication. Getting approval to force medication requires a judge's decision and can take months, by which time the inmate will likely be gone, Boyd said.

An inmate off his medication is dangerous to himself and others, Brewer said. "We're the default mental health facility, but we can't force medication," he said. He wishes they could.

This is a major flaw in the community-based system, Brewer says: Health care workers can't contain the patients or make them do anything. The system of institutionalization "was more draconian," he said. "But now we're just letting them loose on society.

"I just know that what we're doing now doesn't work any more than what we were doing before."

Lack of follow up

Nationally, people with mental illnesses are 60 percent more likely to end up back in jail within one year of release than those without a mental illness. The Boone County Jail doesn't track the rate of recidivism, but Boyd sees patients return again and again. Instead of seeking treatment outside, they end up back in jail.

The staff at the jail used to do extensive follow-ups and referrals to outpatient centers, but most of the inmates never went. Now, with four counselors whose hours range from five to 10 hours a week and who treat up to 75 inmates total, they don't have the time, money or staff to follow up with each patient.

"We have a fixed population here, but once they get out we can't hold them down," Boyd said. "We just don't have the manpower or the community support. This is a population that doesn't follow through. There's no penalty for them for not showing up."

One inmate, who has schizophrenia and bipolar disorder, was arrested in October for stealing bicycles, acting on the advice of voices he heard in his head.

Since he began taking medication while in jail, the voices have grown silent. With his illness under control, he says he believes that when he leaves the jail he can function without his medication and keep them silent himself. Outside the jail, there will be no one to tell him otherwise. 

For inmates like this, better mental health care in the county is crucial not just for their own safety but for the safety of the community, Tim Harlan said.

"It's the same as any disease  — no money, you're out of luck," he said. "The difference is that it's a public safety issue. Someone with diabetes isn't a danger to others."

Mental Health Court offers alternative to jail

After her third arrest for stealing in 2011, Henderson was placed under the supervision of Mental Health Court, an alternative-sentencing program for people with mental illnesses that began operating in 2003.

People who have been arrested for misdemeanors can be referred to the court, where they are assessed and then placed in a rigid treatment program with one of several mental health facilities in Boone County that have contracts with the court.

In the Mental Health Court system, participants are punished if they fail to follow the treatment progression and are rewarded for doing well. They must show up for counseling sessions and stay drug free in order to stay in the program.

"We're trying to break the cycle (of recidivism)," said Mental Health Court Judge Michael Bradley. "For people that make it through, we've seen some turn their lives around."

Henderson did not make it through. In July 2011, she entered the program and went for treatment at New Horizons, an outpatient clinic in Columbia. She attended every class and took her medication. She made sure to show up by 9 every morning, then would go to sessions, get lunch and spoil the other patients with candy. They called her "momma."

Four months later, on Nov. 13, Henderson's mother died.

Her mom, Ruby Adams, had supported her through all the good and bad in her life. She helped Henderson raise her daughter. They made every tough decision together, such as when Henderson's daughter ought to be allowed to go on her first date. 

She also shared in the pain of Henderson's drug addiction. Ruby would lay her daughter's head in her lap and listen without anger to Henderson's sobbing confessions.

The pain of the loss, Henderson said, was unbearable. She stayed in bed for a week and gave into her depression. "I haven't been stable since she passed," she said. The depression hollowed what had been filled with treatment, and in March she stole again and was kicked out of the Mental Health Court program.

For inmates like Henderson, Mental Health Court is effective only if they can get in and stay in. Brewer views the court as a positive step in Boone County for people who have mental illnesses and were never going to be incarcerated. Because the court only accepts those with misdemeanors, detainees with felonies and violent crimes or records still end up in the jail, he said.

"Mental Health Court doesn't keep anyone out of jail. It generally only takes those with family support who won't end up in jail. There are few who have no support."

Boyd said that the court has a responsibility to keep potentially violent people off the street, but the potentially violent offenders are the ones who need treatment most.

"Their legal problems are directly because of their mental illness," she said. "It's black and white to me. People who are the sickest and would benefit most from it aren't considered because of that. I'm not badmouthing it, but they pick the people who will be more successful."

The last trial

Henderson did not set out last March to steal or do wrong. She is detached from the incident; she talks about it as if it happened to someone else whose reasoning she cannot understand.

"I can't believe someone with so much to lose would be so stupid," she said, crying. "The rush was not worth it. What was wrong with me? I want to know why I did that."

Her trial is set for Monday. She hopes to be released from the jail and allowed back into Mental Health Court.

If accepted back into the program, she says she will follow it perfectly, even if she has to start all over. She wants the stability of the treatment back. She wants the freedom to have scary movie nights with her grandkids and to go to church on Sundays. She has pledged to herself that she won't enter another store for six months after her release without bringing someone with her.

In a letter to the Mental Health Court judge, she asked for re-admission and gave the only explanation she can find for why she did what she did.

She wrote: "My mental part of me broke."


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Comments

George Lombardi May 19, 2013 | 8:44 a.m.

Custody Chief Brewer has it exactly right. Jails and Prison systems across the country are faced with an increasing clientele with serious Mental Health issues due to the lack of both outpatient and inpatient services in our communities. Because of the de-institutionalization of MH over many years now and the lack of a parachute in alternative for those with the complex panoply of MH issues, many drift into the Criminal Justice system. These people need to be interdicted while in the community instead of in the jails and prisons as presently. This takes resolve and funds. Medicaid expansion can be a significant step toward that end - with concommitant savings in jail and prison bed space.
George Lombardi
Jefferson City

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