Worlds apart in their treatment of mental illness, the Hampton Roads Regional Jail in Portsmouth and Eastern State Hospital in James City County have overlapping populations. Some even go back and forth between the two institutions.
Both house men and women diagnosed with schizophrenia, bipolar disorder, and delusional and depressive disorders. Both serve those awaiting trial on misdemeanor and felony charges and both conduct "restoration to competency" for court.
Beyond that, some go on to serve their sentences at the jail, where they receive minimal mental health treatment in harsh conditions, while others found Not Guilty by Reason of Insanity, NGRIs, receive intensive long-term psychiatric treatment at the hospital before being released to the community.
Everyone agrees — from the jail superintendent to community service boards personnel to mental health advocates — that jail is not the place for mental health treatment, yet as many with serious mental illnesses are incarcerated as receive treatment at the state hospital.
Costs versus care
"It's a hard environment. It's not therapeutic," said David L. Simons, jail superintendent. "It's a huge strain on our resources to deal with this population. The resources to take over mental health care ought to come through the state. We really are a medical mental health facility."
The relative costs are a major factor, according to Meghan McGuire, spokeswoman for the Virginia Department of Behavioral Health. The per diem cost for ESH inpatient care is $660, compared to $65 for a jail inmate. "Even by assuming the additional cost of medication and treatment for a person with mental illness … the comparative cost of hospitalization is prohibitive for all but those with the most intensive clinical needs," she wrote in an email.
Simons, however, estimates those inmate costs balloon to $500 per day for those with a mental illness, a cost that falls to localities.
At the jail
Local jails filter their most problematic inmates to the regional jail for both medical and mental health needs. "There's some resentment. They know they don't belong in jail. There's nothing we can do, but give them the care we can with the resources we have," said Eugene Taylor III, assistant jail superintendent.
Those resources primarily involve security and medications. "We're not qualified mental health professionals," said Major Taunya Hatchett, chief of security, noting that the jail's become a safety net from the street for some.
Unlike at a hospital, the U.S. Department of Justice does not establish psychiatric staffing levels for the incarcerated. HRRJ employs a part-time psychiatrist, a couple of full-time counselors and a psychiatric nurse practitioner. And, while almost half of close to 400 inmates diagnosed with mental illness at HRRJ are prescribed psychotropic drugs, which cost the jail — and local taxpayers — more than $100,000 annually, they cannot be forced to take them. Last year, 97 at the jail refused their medications, according to the annual Virginia Compensation Board report. By contrast, at Eastern State Hospital, court orders to force compliance are routine. Non-compliance creates additional problems for the jail staff and a cycle of destructive behavior for patient inmates.
Mental health treatment
There are three mental health units within the concrete walls of the HRRJ, a maze of highly polished stone floors and scrubbed-clean, bare walls interrupted by a series of remotely controlled locked doors. Jail uniforms are color-coded — green for the general population, red for segregation, and pale blue for the mentally ill. The initial intake screening by a registered nurse and a social worker determines where an inmate is housed.
Those with mental illnesses are less likely to be granted bond and their need for pre-trial mental health evaluations results in longer delays in jail, according to the Department of Behavioral Health. For those already sentenced, the average length of stay is 18 months.
There's a lot of teasing of the mentally ill by other inmates, and staff tries to protect them as much as possible from taunts and contact.
Apart from substance abuse groups conducted by community service board counselors, there's no regularly scheduled individual or group therapy, though inmates and jail staff can request a mental health sick call, according to Giovanni Montague-Sneed, health services administrator. Medications are dispensed nine times a day at "pill passes," delivered in a mobile cart to each housing "pod."
While some share cells and mingle in a common area, others are confined to small, concrete windowless enclosures, alone, with no activity or distractions for 23 out of 24 hours. There's no natural light, a metal pass-through tray in the door is used for meal delivery, and the square metal "window" to the common area is closed, except when an inmate is on suicide watch.
There are up to a dozen at any given time who are under constant observation or 15-minute checks, their clothes removed and replaced by a "suicide" blanket that they can use to cover up, or a "suicide smock," quilted fabric fastened with Velcro that functions as a soft restraint. Many have had all their personal possessions removed. They have a mat on the floor, a metal sink and a toilet. In some, the water's been turned off to prevent them flooding the cells.
'Special Management Unit'
At the entrance to the "Special Management Unit," where 49 of the most demanding inmates — a mix of disciplinary, segregation, and those with a mental illness — are housed in two tiers of cells, there's a wall of shackles and two "restraint" chairs, where inmates can spend up to eight hours at a stretch. They're shiny from regular use. There's clanging and shouting and banging and catcalls that staff say can go round the clock. Several inmates complain that they can't sleep. "It's a very stressful environment, it's not a place for the mentally ill," said Baltej Gill, senior medical director for the HNNCSB. "They don't get enough sleep. It puts patients at risk."
A seasoned supervisor, Sgt. Tony Nash talked through the side of the inches-thick metal door via intercom to Wayne McKinsey. The 29-year-old Newport News resident has been in and out of the jail for a decade on nuisance charges. During his bad spells, he smears feces all over his living quarters, at other times, he has worked as Nash's helper. In the past, he's cut himself with a chicken bone and threatened further self-injury. Nash doesn't know his diagnosis, but says he's become better at recognizing when inmates are off their meds. McKinsey has refused his before. "They made me very drowsy and lazy, they made me eat a whole lot," he said through the chink between the door and the wall. Now he's on twice-daily Depacote, which is used for seizures and to control manic episodes associated with bipolar disorder.
Drawing from a seemingly endless well of patience, the sergeant calms McKinsey from the other side of the door. He encourages him to stop being disruptive and to work to get his TV back, its spot currently occupied by a blue bin. Wayne is scheduled for release at the end of the month and the CSB is working to find him somewhere to live.
At the hospital
At Eastern State Hospital, the "forensic" population — about one-third of the total — is admitted at the same entrance as all others. Once screened for admission, they become patients, lose the shackles and jail uniform, and pick out an outfit from the hospital's "store," a boutique filled with donated clothing. They go through a 2-to 3-hour evaluation and are given a temporary treatment plan that is reevaluated within a week, said Rebecca Vauter, clinical director. For long-term patients, treatment plans are reviewed monthly.
The average length of stay for crisis care is 10 days and for jail transfers and restoration to competency it is 68. After that, they return to jail. When approved, the NGRIs receiving long-term treatment — usually over several years — are released to the community.
Light-filled hallways, decorated with art work, connect residential areas where patients live in private rooms in clusters of four groups of five with common sitting rooms and a communal dining area. In the NGRI area, each sparsely furnished room has a window, a door without a lock, and a shared bathroom. Each "neighborhood" has its own nursing stations and medication dispensary with twice-a-day service. "We try to get it so they don't need meds during the day," said Vauter, in order to accommodate schedules that largely keep them active, engaged and out of their living quarters.
There are therapy rooms and music rooms, an art room, library with computers, woodworking, horticulture, and a full gym. Workout rooms have mirror-covered walls; there are wood floors and attractive colors to create a soothing environment. There's a game room staffed by an activity director who arranges competitions and tournaments. Patients can work minimum-wage jobs in a workshop, a café, and a shop that sells Fair Trade goods to the public. There are other job opportunities in the cafeteria, housekeeping and landscaping.
Each wing has access to outdoor courtyards. While the jail transfer population is confined to two wards, the NGRIs mingle with the civil population for activities.
"There's such a big stigma. We always treat them with dignity and respect," said nurse manager Brenda Dixon. "You live for those little moments when you see a little progress."
The difference in the mental health treatment provided by Eastern State and the jail extends to the discharge of those who've been in custody. The jail has no responsibility beyond "dropping them off," though many community service boards pitch in to find housing and to ease transition.
Meanwhile, at Eastern State, the NGRIs practice independent living skills daily in a "clubhouse" that mirrors those offered in the community. Peer specialists Joe Brown and Annie Howard teach a wellness recovery action plan, WRAC, an 8- to 12-week course to prepare patients for life outside and to help them recognize and manage symptoms. "Everything is geared to getting them ready to leave," said Howard. The hospital is also required by law to have a discharge plan, though that can include releasing patients to homeless shelters if it is the individual's "preference," according to the Virginia Department of Behavioral Health's guidelines. To reduce hospital readmissions, CSBs are charged with developing a "Safety and Support Plan" for discharged patients.
For those released from jail, the lack of sufficient community support stacks the odds against a successful transition. On observing McKinsey, who has spent the better part of a decade cycling in and out of HRRJ, one mental health professional said, with resignation, "He'll last a day or two on the outside."
Jail or hospital?
After an arrest, those found to have a mental illness are usually held at the local jail for no more than 14 days before being transferred to the regional jail to await trial. In more severe cases of illness, a magistrate can issue a temporary detention order, TDO, good for 48 hours, which will send them to Eastern State Hospital for evaluation and stabilization. A judge may also order in-patient treatment at the hospital for "restoration to competency." Eastern State provides short-term crisis care and long-term care for NGRIs, those found not guilty by reason of insanity. The census of mentally ill inmates at Hampton Roads Regional Jail divides evenly between pre-trial and post-conviction status.
'Restoration to competency'
If a person charged is found not competent to stand trial, then the judge can order "restoration to competency." At one time, this process always took place at Eastern State Hospital; now it's also done by community service boards in jails or on an outpatient basis. Once "restored," they are returned to jail. "Restoration" consists largely of covering the roles of courtroom personnel and legal rights in several educational sessions, after which patients are either deemed "restored" or "unrestorably incompetent." It may also involve therapy and the use of psychotropic medications to stabilize psychiatric symptoms.
Day One: "Jails are no place to treat someone with a mental illness'
Day Two: Hampton Roads Regional Jail and Eastern State Hospital: Same population, different treatment
Day Three: Meet some mentally ill inmates in Hampton Roads Regional Jail
Day Four: A Navy veteran with PTSD deals with jail after a vandalism charge