By Dr. Corrine McIntosh Sako, Chair of Sacramento County Mental Health Board

During the California Psychological Association’s 2022 Convention held here in Sacramento during September, Thomas Insel, MD gave a presentation titled, “Healing: Our Path from Mental Illness to Mental Health.” Dr. Insel, a psychiatrist and neuroscientist that has served as the Director of the National Institute of Mental Health (NIMH) and is the current Chair of the Board of the Steinberg Institute, asked the question:  Why, with so much progress in science, have we made so little progress in outcomes for people with mental illness, especially those with serious mental illness? He reframed the current mental health crisis in which we find ourselves as more of a healthcare crisis due to lack of engagement, lack of quality, and lack of accountability. He offered immediate solutions and emphasized the importance of people, place, and sense of purpose to promote one’s recovery from mental illness. The Sacramento County Board of Supervisors must be unfamiliar with Dr. Insel’s research and expertise, given that they are scheduled on Wednesday December 7, 2022 to revisit a proposal to build a “Mental Health Jail” expansion to the Main Jail in downtown Sacramento.

People with mental illness are overrepresented in our nation’s jails and prisons. About two in five people who are incarcerated have a history of mental illness (37% in state and federal prisons and 44% held in local jails). The percentage of jail inmates who meet the threshold for serious psychological distress (26%) is five times higher than the percentage of adults who meet the threshold for serious psychological distress in the total general U.S. population (5%) or those in the general population with no criminal involvement in the past year (4%).

Given these rates, America’s jails and prisons have become de-facto mental health providers, at great cost to the well-being of people with mental health conditions. People with mental illness often face challenges to navigating life in a jail or prison. Behaviors related to their symptoms can put them at risk for consequences of violating facility rules, such as solitary confinement or being barred from participating in programming.

Sacramento County is no different. Nearly 70% of the jail on a given day is made up of people who have been booked two or more times. The mental health population enters the Sacramento County Jail more often for warrants as well as holds and violations as compared to the larger jail population. In 2021, 33% of jail bookings involved people with a Serious Mental Illness (SMI). Of those with SMI, 25% also screened as homeless. This means that there are a significant portion of bookings with complex needs in the community involving housing and mental health services.

According to data from the Sacramento County Sheriff’s Office (SCSO), people with a mental health diagnosis who receive mental health services during incarceration comprise 63% (2,147) of the population detained in its jails, making the jail one of the largest behavioral health providers in the county. Of the 2,147 patients with a mental health diagnosis, 27% (952) have a Serious Mental Illness (SMI), which includes a diagnosis of a Schizophrenia Spectrum and Other Psychotic Disorders, Borderline Personality Disorder, Post-Traumatic Stress Disorder, and/or Bipolar and Related Disorders. 

Incarceration itself can perpetuate harm by creating and worsening symptoms of mental illness.  Research shows that, while it varies from person to person, incarceration is linked to mood disorders including Major Depressive Disorder and Bipolar Disorder.  The carceral environment can be inherently damaging to mental health by removing people from society and eliminating meaning and purpose from their lives. The conditions common in jails — such as overcrowding, solitary confinement, and routine exposure to violence — can have further negative effects.  Overcrowding can often mean more time in cell, less privacy, less access to mental and physical healthcare, and fewer opportunities to participate in programming and work assignments. Being put in solitary confinement is especially harmful to mental health and can lead to permanent changes to people’s brains and personalities. Exposure to violence in prisons and jails can exacerbate existing mental health disorders or even lead to the development of post-traumatic stress symptoms like anxiety, depression, avoidance, hypersensitivity, hypervigilance, suicidality, flashbacks, and difficulty with emotional regulation.  Researchers have even theorized that incarceration can lead to “Post-Incarceration Syndrome,” a syndrome similar to Post-Traumatic Stress Disorder, meaning that even after serving their official sentences, many people continue to suffer the mental effects.

 Sacramento County is one among multiple counties throughout the state and country that have come under class action lawsuits challenging the adequacy of the mental health care and treatment inside their jails. Sacramento County was notified by advocates in 2014 about concerns regarding conditions of confinement related to medical care, mental health care, out of cell time, Americans with Disability Act (ADA) compliance, and Health Insurance Portability and Accountability Act (HIPAA) compliance in its jail facilities. Experts who inspected county jail facilities found unconstitutional conditions in custody. After years of negotiations, Class Counsel filed action in 2019. The matter was resolved and a court order, the Mays Consent Decree, was issued in January 2020.  The Consent Decree requires Sacramento County to comply with a remedial plan and provides for the Plaintiffs’ counsel and subject matter experts to issue ongoing monitoring reports about Sacramento County’s progress in compliance. According to the most recent monitoring reports by the court-appointed experts:

“There is a systemic and pervasive lack of access to medical care involving multiple processes (e.g., nurse and provider sick call, substance use withdrawal monitoring and treatment, chronic disease management, and specialty services) that has resulted in preventable harm to patients.”

●        In one case, a patient reported drinking a gallon of hard liquor daily for two years but was not started on treatment for alcohol withdrawal. Nurses did not conduct an alcohol withdrawal assessment of the patient in booking and approximately 30 hours later the patient had a seizure and died.

●        Patients with opioid substance use disorder are housed in a booking loop tank for approximately 72 hours, where they experience severe withdrawal and yet they are not monitored or treated.

●        Sacramento County Sheriff deputies that provide custody in the Jails routinely inform providers and nurses that they are not permitted to see patients due to lack of escorts, “behavioral issues,” or because unspecified activities were taking place in the housing unit. This is obstructing access to care and should not occur. While it is understood that custody is responsible for safety and security of the institution, it is the role of custody to facilitate appointments taking place, not prevent them. When behavioral issues are a factor, mental health staff need to be consulted.

Court-appointed experts have confirmed that expanding diversion programs for people with severe mental illness would be the best option for meeting the consent decree.  Despite the extensive corrective efforts set forth by all departments involved, progress toward Consent Decree compliance has been limited and a sense of urgency has arisen.

Does this sound familiar? It should. The Sacramento County Board of Supervisors almost unanimously opposed the proposal to contact a Mental Health Jail Annex in March 2021 (covered in the 3/9/21 SacWellness Blog Post). At that time, they explicitly expressed their intent to recalibrate their approach to meeting the Mays Consent Decree and explore community-based alternatives to incarceration.

Over one and a half years later and we are right back where we started – with the only examination of how to meet the Mays Consent Decree coming from the same architecture firm that oversaw the design and build of the Sacramento County Jail in 1989, at which time they folded the following provision into their plan: “flexibility in the plan provides expansion to the year 2025 through completion of ‘shelled-in’ space and of a subsequent tower.” Therefore, their recommendation is to expand the Jail with an additional tower, of course. A Jail Study was performed in 2022 to make recommendations on how to reduce the jail population and in its anemic analysis found that Sacramento County on any given day could reduce its jail population by approximately 600 people. Yet, this Jail Study was completed by someone that holds a master’s degree in International Relations and Public Policy and a bachelor’s degree in History and Political science. The Deputy Executive for the County’s Public Safety and Justice Agency took these recommendations into consideration and crafted a summary of efforts and plans to implement the recommendations, including current programs, collaboration activities, and program expansion plans. It’s also imperative to add that this County Executive is the former police chief of Stockton and has an annual salary of approximately $252,000, plus benefits. Why is this important? Because it shows just how much money this Board of Supervisors is willing to invest in ineffective, impotent strategies.

The biggest takeaway from Dr. Insel’s presentation at the CPA Convention was, “We Should Not Let Old Ways of Thinking Get In The Way of Helping People Today.”

The drive to criminalize mental illness has more to do with ideology than effectiveness. People with mental illness are seen not as victims of a failed restructuring of public health services but as dangerous sources of disorder to be controlled by containment. Over 60% of people experiencing a mental health problem lack access to mental health services. Additionally, untreated mental illness increases the risk of recidivism. A lack of stable housing and income exacerbates mental health problems, makes treatment more difficult, and contributes to the public display of disability-related behaviors – all of which make it more likely that law enforcement will be called. Reducing social services and replacing them with punitive social control mechanisms works less well and is more expensive. The cost of providing community housing for people and providing them with mental health services is actually lower than cycling them through emergency rooms, homeless shelters, and jails. The Vera Institute of Justice found that incarcerating individuals with mental illness costs two- to three times what community-based treatment does. Instead of just funneling ever-increasing amounts of money into carceral structures that purport to provide enhanced mental health services, we should be providing easy access to varied, culturally-appropriate community-based services as needed.

As mental health professionals, we have a unique and powerful position to be agents of change in our local community. Join me on Wednesday December 7, 2022 at 2pm at the Sacramento County Board of Supervisors meeting to push our local elected officials to decriminalize mental illness by opposing a mental health jail annex and instead prioritize funds for a community-based continuum of care. The California division of the National Association of Social Workers (CA-NASW), Sacramento Valley Psychological Association, and the local chapter of the American Civil Liberties Union (ACLU) have joined other organizations, businesses, and community leaders by signing on to a letter opposing a mental health jail expansion to the Main Jail in downtown Sacramento.

I hope you’ll join me in taking a stand against futility, against trauma – and championing a system of care and reform for those we serve.

Let your voice be heard!

●        Call and/or email your County Supervisor and join me in calling on the Board to end this project and commit to alternatives to incarceration that prioritize public health and community safety. Find Your County Supervisor Here: https://www.saccounty.gov/SupervisorLookUp/Pages/default.aspx

●        Join the Coalition of Health Professionals, Community Leaders, Businesses, and Concerned Residents in Opposing the Proposed “Mental Health Jail” Expansion of the Sacramento County Main Jail by adding your name to the petition at tinyurl.com/nonewsacjail

●       Attend the Board of Supervisors workshop on Wednesday December 7, 2022 at 2pm to give live public comment. You may also make public comment via telephone or email. More information on submitting your comments: https://sccob.saccounty.gov/Documents/BOS_PubicNotces/Public%20Notice%20of%20Workshop%20-%20Mays%20Consent%20Decree%2012-7-22.pdf

Dr. Corrine was born and raised in Sacramento. She is a licensed psychologist and a licensed marriage and family therapist and she has provided mental health services to Sacramento residents in her private practice since 2006. She currently serves as the President of the Sacramento Valley Psychological Association and Chair of the Sacramento County Mental Health Board.