How One County Is Stepping Up to Keep People With Mental Illness Out of Jail

It’s become a cliché to say that the institution that houses the most individuals with mental illness is the county jail, not the local hospital. The problem is that it’s a fact, not a cliché.

Stepping Up Initiative

However, a combination of diversion away from the criminal justice system, treatment, and wraparound social services offers a chance to alleviate that problem. The Stepping Up Initiative, a national movement led by the National Association of Counties, the Council of State Governments, and the APA Foundation, is working to implement that process in America’s 3,007 counties.

Alamance County, N.C., provides a good example of how a step-by-step approach can make Stepping Up work. In North Carolina, 11,000 people with serious mental illness end up in local jails, even though most are accused of minor crimes and present a small threat to public safety. The costs for those prisoners of cycling in and out of the criminal justice system are twice those of prisoners without mental illness.

The toll on individuals is even greater, said Robin Huffman, executive director of the North Carolina Psychiatric Association (NCPA) and a volunteer with the Alamance County Stepping Up program.

“They may lose their job, their chance at future employment, their housing, their Medicaid, and often their dignity and self-respect,” said Huffman. “People are serving life sentences, 30 days at a time.”

A group from Alamance County attended the national Stepping Up kickoff conference in Washington, D.C., in April 2016. The problem was clear. When outside alternatives for care of the mentally ill shrink, there are two default options: jail or the emergency department. The question was how to put solutions into practice, said Huffman.

The most important element for success may be connecting everyone with a place in the system—police and sheriff’s departments, local elected officials, patient advocates, and social service and mental health professionals.

To get things rolling, more than 200 representatives from around the state gathered in May 2017, said Huffman. “The counties wanted help to develop tools for screening people brought into jails and then find local resources for diversion, treatment, re-entry back into the community, plus analyzing the data the system would generate.” Stepping Up provided them with the guidelines to do just that.

The county moved ahead on several fronts. The sheriff’s department recategorized two staff positions to permit hiring a coordinator for the program and a social worker for the jail (now named a “detention center”). The seven law enforcement agencies in the county committed to giving all officers 40 hours of crisis intervention training to better prepare them for encounters with people with mental illness.

“We’re creating a new case manager position for people awaiting trial to assess the likelihood of their showing up for trial and not committing a crime in the interim, even if they don’t have enough money for bond,” said Robert Byrd, a former county commissioner and a retired administrator at a local hospital.

“We’re also working on creating a 24-hour diversion center staffed by mental health professionals to eliminate taking people with misdemeanor charges to jail,” said Byrd. They have the building, but renovation and staffing are still needed. He wants to create a mental health court to shift the emphasis from the criminal justice system to one that contracts with people to get and stay in treatment.

A key element in the process is avoiding the arrest of people whose only problem is having a mental illness.

“We want to divert right from the beginning and not run the person through the booking process,” said W. James Ryan, M.D., a semi-retired psychiatrist in private practice and the former medical director of a hospital in Burlington, N.C.

Ryan saw getting involved with Stepping Up as a way to combat the detrimental effects on people who should be patients but who had ended up in jails, prisons, and emergency rooms. Diversion makes it more likely that the individual will be connected first with evaluation and treatment while minimizing the chance of a stigmatizing criminal record. Ryan has contributed his psychiatric expertise at several levels, from managing agitated patients to anticipating patient flow problems once the diversion center is up and running.

“We have also made sure that there is a mental health screening for everyone who comes into the jail and have increased treatment opportunities, including having a psychiatrist who can prescribe medications,” he said. “I was surprised by one thing, and that was the support not only by people in the community but also by the police and the sheriff’s department. The culture has changed. Every single one supports this initiative because they see that it works.”

So far, 30 of the 46 North Carolina counties that have passed resolutions committing to the Stepping Up Initiative still need help getting the program off the ground. However, counties like Alamance are taking the “Johnny Appleseed” approach, sending out newly experienced staff and volunteers to contribute their hard-won experience, said Huffman. “We [NCPA] could leverage our statewide relationships to expand the program.”

Putting her executive director hat back on, Huffman said that APA district branches can contribute to the Stepping Up Initiative by talking at the state level about the re-entry into society of inmates released from prison. “We’ve created a state coalition of elected officials, law enforcement, corrections officials, mental health professionals, consumer advocates, local public-sector mental health entities, the sentencing commission, and others who’ve pledged to find solutions to this problem.” ■