Boone County struggles to meet mental health care needs for inmates

Monday, December 17, 2007 | 6:01 p.m. CST; updated 12:00 p.m. CDT, Monday, July 21, 2008
Pascha Boyd makes calls from her office at the Boone County Jail where she is the psychiatric nurse. Boyd has been providing mental healthcare to the inmates since September 2001.

COLUMBIA — For five years, psychiatric nurse Pascha Boyd has cared for the men and women urgently in need of her attention. She has listened to the stories of their pasts and dealt with the rushes of emotions that are their presents. Their mental illnesses affected their ability to manage their lives on the outside. Now, Boyd treats them inside of Boone County Jail.

Missouri’s Department of Corrections estimated that in 2006, almost one in five prison inmates, or 19.7 percent, suffered from a mental illness. The number of mentally ill inmates has steadily risen and is up 10.9 percent compared to 1997.

How this story was reported

I went to Boone County Jail and observed three psychiatric evaluations performed by psychiatric nurse Pascha Boyd. The inmates were told that I was a Missourian reporter writing an article on mental health care in the jail. The three inmates gave consent for me to observe their evaluations. Three weeks later, I returned to the jail to interview two of the three inmates one-on-one. I explained during the interviews that I was a Missourian reporter writing an article on mental health care and that I wanted to know more about their experiences. One inmate agreed to observations and interviews on the condition that I not use his real name; the other inmate wanted me to use his name. The inmates gave consent and provided information about their medical conditions. I did not have access to any medical files. Before going to the jail, Lisa Viero, chief financial officer of Behavioral Health Concepts, sent me a document on privacy under the federal Health Insurance Portability and Accountability Act of 1996. I was required to read the document and sign a second document attesting that I had read about privacy issues under HIPAA.

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According to Capt. Warren Brewer of the Boone County Sheriff’s Department, the number of mentally ill inmates at the Boone County Jail is much higher ­­— at least 30 percent of the jail population, which totaled 7,652 in 2006.

Boyd, the psychiatric nurse at the Boone County Jail, said jails have become a “mental warehouse.” The mental care provided at Boone County Jail is better than what inmates get at other Missouri jails, she said, but is still not enough to meet demand.

Boyd treats as many as 60 inmates a month in 90 to 100 sessions. She usually visits with a given inmate once a month, but is available for another session if emergency situations arise. Two counselors and a psychiatrist also work at the jail, but Boyd is the primary caregiver. She is contracted to work 20 hours a week.

A 20-year-old Boone County Jail inmate, whose name has been changed for medical privacy, sits with Boyd in a small, barely furnished, white-brick room about once a month. If he is feeling really stressed, “Jack” might see her twice in a month. But Jack would like to get things off his chest more often. He wants to see Boyd or a therapist every three weeks.

“It relieves a lot of stress,” he said. “I don’t feel like everything inside of me is just tension.”

When he talks about his feelings with Boyd and takes the prescribed medication, Jack feels less likely to hurt himself or others, he said.

This prisoner regularly takes mood stabilizers to help with his anxiety and depression. He has a history of attempted suicides and mental hospitalizations. Cautious, and somewhat ashamed, he described one of his earlier suicide attempts. He was about 11 or 12 when he impulsively decided to set himself on fire; he thought it would make his problems go away.

“I think of how stupid I was,” he said. “That I was inconsiderate of my family’s feelings and only thinking of myself.”

Before he went to jail, Jack said, he worked at a gas station, had his own apartment and grew flowers and tomatoes. He was jailed for assault last year, returned to jail for another assault and received probation. He violated his probation while off his medication, he said, and has been in jail since. He said he does not know when he will get out.

The Missouri Department of Corrections estimated that in 2006, 14.2 percent of convicts released from prison for the first time returned within six months.

People with mental illness have an additional hardship. “Because of their illness and lack of access to care, they’re getting in trouble again and again,” Boyd said.

Boyd has treated inmates at the jail since the Boone County Commission contracted with Behavioral Health Concepts for services. The independent company provides health care services, including mental health care in jails. The county renewed a one-year contract in 2006 that has been extended for four more years and pays $140,532 a year to Behavioral Health Concepts for mental health care at the jail. The money also helps train officers to recognize and deal with mental illness.

The Sheriff’s Department and Boone County Mental Health Board joined forces to help convince county commissioners to approve the contract with Behavioral Health Concepts. “It was a combined effort of us crying and screaming very loudly,” Brewer said.

Before getting mental health care at the jail, officers tried to send mentally ill patients to Mid-Missouri Mental Health Center, but the hospital did not always have space, Brewer said.

The care provided at the Boone County Jail helps provide treatment for inmates who aren’t eligible for the Mental Health Court in Boone County.

The diversion court has strict guidelines for enrollment. The court gives mentally ill offenders one year to complete a program that includes regular visits with a court-appointed psychologist and/or psychiatrist, a court appearance every two weeks and, if the offender has a substance abuse problem, regular drug screenings. Offenders in the program also get assistance finding employment and housing. In exchange for following the rules, the offender does not have to serve his or her jail or prison sentence after completion of the program.

Thirty-eight offenders have successfully completed Mental Health Court since its inception in 2003. The court currently is handling 22 cases.

“We have room for more,” Christine Carpenter, presiding judge of the Mental Health Court, said. “Our goal is to have 40 people. Sometimes, we say no.”

Mentally ill offenders must meet several qualifications to get accepted into Mental Health Court. The court does not accept sex offenders and usually does not accept violent offenders. The offender cannot have committed a Class A felony, such as robbery, and persons convicted of Class B felonies, such as burglary, may also be denied.

The offender has to be a Boone County resident and must have committed the offense in Boone County. He or she must also have an “Axis 1” diagnosis, which includes anxiety disorders and mood disorders such as depression and bipolar disorder. The offender must be a voluntary participant in Mental Health Court and be recommended by their lawyer as well as their prosecutor.

Offenders that complete the program are less likely to be repeat offenders, said Andrea Hayes of the Boone County Prosecutor’s Office. “For some people, when they complete Mental Health Court, depending, their conviction may go away,” she said. “That makes them eligible for jobs.”

Jack tried to go through the program, but his violent offenses disqualified him.

John Amaty didn’t make it into Mental Health Court either.

Amaty, 44, is accused of first-degree burglary, first-degree robbery, felonious restraint and armed criminal action. He said he does not remember committing a crime but was told that he supposedly stole a van and drove it into a house in September.

Amaty said he has been in and out of jail throughout his life. He has used marijuana and cocaine and said he has suffered from depression, though he has not been formally diagnosed. Memories of abuse from his childhood sometimes give him nightmares, he said.

In his first psychiatric evaluation with Boyd, he described how bad he felt, sometimes sheepishly and other times assertively. He had lost his appetite, had trouble sleeping and felt sad.

“It’s like floating in space,” he told her. “That’s how I feel, like a loner.”

He told Boyd that sometimes, when he thinks about his future, he gets physically ill.

Boyd asked him if he had suicidal thoughts. “I’m not gonna tell you that and get thrown in the tank over there,” he replied.

She urged him to tell her how he really felt because she was there to help him. Amaty told her he had thought about suicide in the past. He said he could not see what kind of life he’d live if he were found guilty. Facing 10 to 30 years in prison, he would not get out of prison until he was 65. He has no children, no wife and thinks he’d be too old to get a job, he said.

“If you were assigned 15 years, is suicide something you would consider?” Boyd asked. “Well, yeah,” he said.

Boyd said Amaty may be struggling with depression, which is likely in a situation that is depressing and anxiety-provoking. She thinks jail inmates tend to be more depressed than prison inmates because of the back and forth and uncertainty about their case and where they will end up — in prison or at home.

Boyd prescribed Amaty a medication to curb his depression and help him sleep better. Three weeks later, the bags under his eyes were deeper and Amaty seemed to be confusing facts, including what had happened at his previous meeting with Boyd. He had not visited with her since then.

Amaty said he needs more psychiatric attention but understands that Boyd and the counselors are “doing as best they can.” He knows that if he is sentenced to prison, the transfer will force him to abruptly stop his ongoing treatment, see a new psychiatrist and start treatment anew.

He feels depressed about the entire situation and thinks the justice system is unfair, from the incarceration of the mentally ill to his feeling that his case is moving too slowly through the system.

“There are certain people that belong in jail, that’s my belief,” he said. “But there are certain people that are shafted.”

Psychiatric and counseling services outside of jail are recommended to inmates, but jail officials do not keep track of whether the released inmates pursue those services.

“I think, unfortunately, sometimes they are falling through the cracks,” Boyd said. She attributes the gap in care mostly to ex-offenders not having the financial stability to get treatment and the motivation to ask for help. Even those with motivation sometimes cannot get immediate care because of long waiting lists, she said.

Jack hopes that one day he will feel well enough to not need to take so much medication or see a psychiatrist or therapist. He’d like to go to school and become an architect.

Boyd, too, hopes that her patients can manage their illnesses enough to live normal lives.

“You always hope,” Boyd said. “Yeah, you have to believe in that; otherwise what are you doing this for?”

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