Proposed mental health wing at Harris jail raises question of treatment priorities

Thanks to Alan Bernstein at the Harris County Sheriff's Office for arranging a tour of the Harris jail last week, which I visited to receive a first-hand pitch regarding why Sheriff Adrian Garcia wants to expand facilities. Lt. Ronny Taylor and medical director Dr. Mike Seale joined us on an extensive tour that included all the medical wings, the mental health ward, detention units and the booking center.

The day I visited there were 8,820 inmates in the Harris County Jail, which is really four buildings in downtown Houston connected by underground tunnels. Another 1,037 Harris County inmates were in other Texas jails and 525 were housed in Louisiana, according to a datasheet Bernstein provided. In addition, 600+ beds sat empty on an unused floor that's presently undergoing infrastructure upgrades, though even if the beds were available they could only be staffed using overtime. Around 5,600 inmates that day were pretrial detainees who'd not been convicted of anything yet.

I didn't visit the jail expecting to find a den of squalor, and indeed for the most part things seemed clean and well run for such a high-volume facility (though certainly I wasn't going through a checklist point by point like state or federal inspectors might do). Employees I met universally seemed professional and took pride in their work - perhaps a bit too much pride, which of course goeth before a fall, when I consider several unsolicited, defensive reactions offered to criticisms from the Department of Justice. That's clearly still a touchy subject!

I wasn't there to assess conditions, however, nor employee morale, but the need for expanded capacity - in particular the need to expand facilities for booking and a proposed 1,200 bed mental health ward. The Harris County Commissioners Court recently declined to ask voters permission to issue a quarter-billion in bonds for the project, but Sheriff Adrian Garcia plans to go back to the well next year to try again, just as his Republican predecessor did before him.

I've given this a lot of thought since then, and I still think the Sheriff's most recent jail proposals take the wrong approach. Let me articulate why.

The booking center on a Tuesday afternoon was jammed to the brim - I'm sure it's true that on Saturday night the line runs well out the door. And there's no question that 250 or so secure beds for inmates with serious mental health problems is at best barely adequate. There are about 2,500 inmates receiving psychotropic medications at any given time, said Dr. Seale, most of whom are in the general population. (All told, he said, the Harris County Jail issues about 12,000 medication doses per day.)

The area designated for secure behavioral health treatment consists of solitary-confinement type cells with the main visible difference being some structural anti-suicide measures and the fact that the guards wear more casual clothing instead of a uniform. They've had to put in place policies to limit length of stay in the secure area because treatment volume is so high. Dr. Seale said he'd like to have about twice the number of secure beds and space more amendable to therapeutic treatment.

Those are legitimate complaints. I understand the booking center is inadequate for the volume it endures, and jails historically aren't designed to facilitate mental health treatment. This one certainly isn't. But there was another recurring theme on the tour that seems to me key to resolving the whole dilemma: Both in booking and the mental health ward, I was told by several folks that the jail sees the same "repeaters" or "frequent flyers" over and over. The problem isn't necessarily that the number of people sent to jail is increasing, in other words, but the same people are going to jail more often, too often.

At root, failures in community supervision are driving Harris County Jail overcrowding. Frequent flyers are almost all subject to the jurisdiction of the probation department, but intensive supervision and services clearly aren't being applied, or at least applied effectively, to the most high-risk folks. There are just a few thousand people cycling in and out of the jail - many of them mentally ill, homeless, addicted, or with other major barriers to successful rehabilitation - who are primarily responsible for the demand for increased capacity. These folks generate high per-person costs over time but as a matter of policy (a de facto if not an intentional one), Harris County is spending money on them at the jail instead of seeking community-based alternatives.

How much cheaper would it be to focus on reducing the number of visits and lengths of stay by frequent flyers than to simply build more capacity to accommodate a dysfunctional system? Quite a bit, I suspect. That's why IMO Harris County can't build it's way out of this problem: The same number of people can soak up a seemingly infinite amount of resources unless officials find smarter, more cost-effective ways to supervise them. Many folks, I was told (I've asked for an exact number), are processed through booking three or more times per year, and for a few of them the number is much higher.

There is no one silver bullet to address the problem but many possible evidence-based tactics to consider. Probation officers doing home visits and checking curfews for high-risk probationers on weekends, for example, might make more sense than waiting till they show up at the jail. Diversion courts, day-reporting centers and other strong-probation tactics that provide supervision in between jail stints can reduce intensity of jail use among frequent flyers. For the mentally ill, particularly the homeless among them, there's a need for supportive housing and extra community-based supervision beyond whatever happens to them in the jailhouse, or they're going to keep coming back. Consultants for years have been telling Harris County that pretrial detention could be reduced if judges would follow the risk assessments performed by the Pretrial Services division. And DA Pat Lykos recently suggested the county might create a "detox center" where people who are intoxicated could be taken instead of jail.

In light of who's in the jail, and how often, efforts at reducing the jail population should focus on ramping up community-based supervision for that finite, high-risk population who enter the jail repeatedly. Building more capacity is a short-sighted band-aid covering much more profound systemic ailments.

One of my criticisms of building 1,200 "mental health beds" is that jail beds are fungible, that moving 1,200 mentally ill inmates from the general population would simply free up 1,200 beds overall. I expressed this to my tour guides, who replied what the beds designated for mental health couldn't be easily transformed. Indeed, the specialized mental health unit is basically an isolation wing organized in more or less the same layout (with a few added anti-suicide upgrades) as the cacophonous solitary confinement wing filled.

It's true those 250 or so secure mental health beds could be used for little else but solitary confinement. But they could still be used for that, and many if not all the 1,200 proposed new beds in a mental health ward likely wouldn't diverge from that solitary confinement model with the exception, possibly, of allowing for additional therapy or creating a separate space for assessments. There's not much counseling going on, though, that I could tell; psych treatment in jail is mostly pharmaceutical in nature. So I still think it's accurate that the net effect of building "mental health" beds would be to expand overall capacity.

I asked Dr. Seale whether, assuming the government is going to build 1,200 mental health beds, it was preferable given limited resources to spend the money at the jail or on community-based infrastructure like supportive housing? His politic answer was "both are needed," but in practice expanding jail infrstructure is being aggressively pushed by the Sheriff while advocates for community-based resources are fewer, farther between, less well positioned to suggest infrastructure improvements and less aggressive in their approach. Even if you think "both" are needed, there's not equal momentum for "both" and that's not what the Sheriff is advocating.

What's more, from what I saw, Harris County could solve the jail's biggest short-term problems with much less ambitious construction plans than were recently turned down by the Commissioners Court. Dr. Seale told me he needed about twice as many secure MH beds as he has now, but the Sheriff's proposal called for about four times as many. Similarly, the Sheriff had called for quadrupling the size of the booking center to accommodate up to 1,000 people at a time, but from what I saw just doubling the size would resolve the short-term problem - particularly if going forward the Sheriff and other systemic actors use all the tools at their disposal to manage jail populations. Garcia's idea, clearly, is to "build for the future" on the assumption that incarceration rates will continue to rise, as they have in recent years, much more rapidly than overall population numbers. But I think instead new resources should focus on jail diversion and ways to alter those assumptions.

Bottom line: 1,200 beds is a good-sized mental hospital. The question confronting Harris County when processing this request is whether it chooses to deliver mental health services primarily through the jail or in less expensive, more therapeutic community-based settings? And if the answer is "both," let's make sure "both" are proposed for funding simultaneously. It's not good enough in this writer's view to pay lip service to community-based treatment then propose bonds only to support jail expansion.

UPDATE: Alan Bernstein, the Harris County Sheriff's Director of Public Affairs, responds thusly via email:

Scott:

Thanks for putting your jail tour to good use in the form of your blog post today. You make several interesting points that dovetail with the concerns and attitudes of the sheriff and his agency -- especially on the topic of recidivists.

In your important next to last paragraph, though, you forget that the proposed facility would combine county and city jailing functions (with revenue from the city). We would get all of the city's Class C misdemeanor cases that the city currently keeps in its jail and its court system. Our bookings from HPD would double. Perhaps you can clear this up with a blog update; in the end you already seem to agree now that we have a need for a new facility on some scale.

Though Dr. Seale's response seemed politic to you, I think he nailed it. It would be highly irresponsible of the sheriff to not plan for future needs and not also seek policies to lower jail population. And please remember that part of the planning for the future involves replacing aging facilities rather than just adding capacity.

The difference between advocating for a facility and advocating for programs is that the sheriff runs the jail and does not run the outside treatment programs. He does, however, take to heart his place as an important stakeholder in the expansion of such programs. Soon after taking office he formed a mental health advisory committee (chaired by defense lawyer George Parnham, who represented Andrea Yates) that still gives him valuable feedback. I am sure MHMRA, the Mental Health Association, the Harris County Healthcare Alliance and similar groups consider him a valuable partner.

I appreciate Alan's response and his welcome focus on our areas of agreement. But he and I must continue to agree to disagree on a couple of points. Not only do I not think it's a good idea to waste Houston PD's time nor fill up the county jail by arresting class C misdemeanants (let the City pay for that, if they think it's worth the bang for the buck), indeed, I'd like to see the Harris Jail go in the opposite direction: IMO there are B misdemeanors that Houston PD and Harris County Sheriff's Deputies could usefully divert from the jail by exercising their authority to issue citations instead of arresting them. Bernstein is absolutely right that the Sheriff controls just a small sliver of the system, which I sometimes think may give HCSO an especially narrow perspective: There's a myopia associated with focusing on only one cog in a vast, complex machine when more serious, causal problems may lie elsewhere in the system.

I sympathize with Sheriff Garcia's position on this: If he's told overcrowding is his problem to fix, jail expansion is really the only option he's got because he can't control the other players - particularly judges, Houston PD and the DA's office. His is an institutional stance, not a partisan one - a function of his role as Sheriff and essentially similar to the policy of the Republican he replaced. But expanding capacity without focusing on the underlying frequent-flyer problem via programming outside the jail invites repeating past patterns of failure.

I think it's perfectly reasonable if Harris County wants to open a 1,200 bed mental hospital, IMO it just shouldn't be run by the jail.