The largest psychiatric facility in Sonoma County is not a hospital.
It’s the jail.
If not by design then by default, jail cells have essentially replaced psychiatric hospital beds for many of Sonoma County’s most severely mentally ill residents. It is a trend that began before the closure of Santa Rosa’s two secured mental health hospitals a decade ago, and has continued since.
Now, nearly 40 percent of the 1,100 inmates held at the county’s main jail and its lower-security North County Detention Facility near the Charles M. Schulz-Sonoma County Airport have some form of mental health issue, from mild depression to bipolar schizoaffective disorder.
To house them and improve the quality of their care, the county is building a $48 million wing at the jail for inmates with mental illness — drawing both praise and anger from mental health advocates who would like to see more psychiatric hospital beds and housing with supportive services that help people with mental illness live in the community.
The new wing, which is slated to open in two years, underscores the magnitude of the sweeping changes that have altered the way America cares for its mentally ill.
“I’m glad a better mental health unit is being built at the jail, but why do we not have a freestanding hospital? Why do we have to wait until people are so sick they have to go to the jail?” said Rosemary Milbrath, former executive director of the Sonoma County chapter of the National Alliance on Mental Illness, or NAMI.
With so many mentally ill inmates, the Sonoma County Jail joins facilities like the Cook County Jail in Chicago, the Twin Towers Jail in Los Angeles and Riker’s Island in New York City, where jail cells have essentially become a substitute for psychiatric hospital beds.
Milbrath, who spoke as an individual and not a representative of NAMI, calls the trend “disgusting” and a violation of the spirit of the landmark 1967 Lanterman-Petris-Short Act, a state law that, among other things, sought to end the process of indefinitely locking up those with mental illness and developmental disabilities.
“It guarantees people will be housed in the least restrictive environment for their level of illness,” she said. “But we’ve just defaulted to jails.”
A six-month review by The Press Democrat found that people with mental illness are increasingly winding up in a jail cell or a hospital emergency room — the two places where society is legally bound to provide mental health treatment.
In jail, the 8th Amendment of the U.S. Constitution, which bars cruel and unusual punishment, guarantees they be given treatment for their psychiatric condition. In a hospital, a 1986 federal mandate requires medical staff to treat everyone who enters an emergency department, regardless of their ability to pay.
Some mental health advocates argue that the wide array of outpatient and community-based mental health services in Sonoma County are not addressing the needs of those with the most severe mental illness.
But for their part, local mental health officials say their treatment model — which includes temporary crisis housing, long-term supportive housing and a relatively new 24-hour crisis stabilization center — is working and has already reduced the need for psychiatric hospitalizations.
However, no one is arguing that problems do not exist. Although the county spends about $66 million annually on a wide array of outpatient and community-based mental health services, the jail’s mental health population continues to balloon, a trend that has become all too familiar in communities across the country.
The Press Democrat review found that:
— The number of local jail inmates with some form of mental illness has nearly doubled since 2008, when the county lost its last remaining psychiatric hospital beds for low-income adults. Last year, the Sonoma County Jail held an average of 429 inmates daily with mental illness, ranging from mild depression to severe schizophrenia, up from 228 in 2008. The total jail population remained stable during the period at about 1,100 people a day.
— The number of inmates with severe mental illnesses such as bipolar disorder and schizophrenia increased 60 percent to an average of 69 inmates a day last year, up from 43 in 2008.
— Inmates with mental illness take longer to process through the criminal justice system, just as they do when they go through a hospital’s emergency department. They often end up staying behind bars longer, for the same crime, than those who do not have mental illness.
— Inmates found by the court to be “incompetent to stand trial” must be sent to a state psychiatric hospital, such as Napa State Hospital, to be treated until they are able to understand and face the charges against them. But because of the lack of bed space at the state’s mental hospitals, inmates often wait up to three months or more for an opening.
— The $48 million mental health wing at the jail will expand what is already the county’s largest psychiatric facility. It is expected to cost taxpayers $5.5 million annually to operate, according to a 2015 report.
Some mental health critics see a correlation between the decline in psychiatric beds and the rise of inmates with mental illness as evidence that jails and prisons have simply replaced the most infamous of mental health institutions: the insane asylum.
County officials are not blind to the trend and the criticism. But they say they must immediately deal with today’s realities.
“It is a lot of money on a mental health jail that could probably be spent on a hospital,” said Sonoma County Supervisor Shirlee Zane.
“Whether we like it or not, the jails have become the new psychiatric hospitals. Let’s get them (mentally ill inmates) out of isolation and provide medication management to the best of our ability and provide the wraparound service they are going to need once they out.”
Care in custody
In the spring of 2016, jail became inevitable for Barbara and Denny Bozman-Moss’s schizophrenic son when Anthem Blue Cross stopped paying for the young man’s stay at Aurora Santa Rosa Hospital — Sonoma County’s only psychiatric hospital.
Barbara Bozman-Moss said the insurance company argued that her son’s condition was “chronic” — a term used to describe a persistent, long-lasting illness — and he had no place in a hospital designed to treat acute, short-term conditions. She agreed that her son needed to be in a long-term facility that would provide the type of care needed to treat his condition.
During his final weeks at Aurora, her son, who was 27 at the time, became increasingly aggravated and desperately wanted to get out. On June 15, he assaulted two hospital staff members, one of whom he tried to strangle, she said. That landed him in jail.
Bozman-Moss asked that her son’s name not be used in this report to preserve his privacy. It’s a common request among family members whose loved ones are suffering from severe mental illness — even as they watch their son, daughter or spouse spiral deeper into their illness, there’s still a hope that one day they’ll recover.
“We knew that they wanted him out of there. We wanted him out of there,” said Bozman-Moss. “We wanted him to be moved into a facility where he can get more treatment. An acute hospital doesn’t give treatment, all it does is stabilize, supposedly, and he wasn’t stabilizing.”
The kind of treatment Bozman-Moss envisioned for her son — a residential therapeutic mental health farm or campus where psychiatric care is regarded the same way as other medical conditions, such as heart disease — doesn’t exist in Sonoma County.
One of the country’s strongest critics of the American mental health system argues that the bulk of mental health dollars are being spent on mild to moderate forms of mental illness, while those with serious mental illness are left to law enforcement and emergency room staff.
“The mental health system has an exit strategy. It’s called jail,” said J.D. Jaffe, executive director of Mental Illness Policy Org. and co-founder of the Treatment Advocacy Center in Arlington, Virginia. “When someone with serious mental illness gets arrested, that’s a success for the mental health department. One less person they have to treat.”
John Snook, executive director of the Treatment Advocacy Center, a national nonprofit that works to eliminate barriers to treatment for people with severe mental illness, said that most mentally ill inmates in local jails are serving time for minor crimes. Untreated, their illness got them there.
He and other advocates say that a lack of effective psychiatric treatment leads to decompensation, a deterioration of one’s mental health, which often leads to confrontations with law enforcement.
“This is the only illness left that we allow to be criminalized in this way,” said Snook.
“The majority of people with mental illness who are incarcerated are not bank robbers or gang members,” Snook said. “They’re in for quality-of-life crimes — trespassing, loitering, crimes that are just a result of the illness.”
Snook’s organization has for years been tracking the loss of inpatient psychiatric hospital beds and the increase of jail and prison inmates with mental illness. Between 2010 and 2016, the nation lost 20 percent of its state hospital beds for the most disabled and dangerous psychiatric patients, according to a report conducted by the Treatment Advocacy Center last year.
The number of mentally ill inmates in jail is now 10 times the number of patients in psychiatric hospitals, the center found in a 2014 study.
Counties across the country face the same dilemma. Every year in the United States, about 2 million people with serious mental illness are sent to jail. It occurs at a rate that’s nearly six times higher than that of the general public, according to estimates by the Council of State Governments’ Justice Center.
In California, the number of hospital beds at its five remaining state psychiatric hospitals and three psychiatric programs housed in state prisons has actually increased in the past five years, from 5,283 to 5,905. But that increase becomes negligible when taking into account the state’s population increase, from 37 million in 2010 to 39 million 2016.
What’s more, state hospitals, which are operated by the Department of State Hospitals, do not usually serve the general population. About 75 percent of state hospital beds are taken up by forensic cases — people who are found not guilty by reason of insanity or those with severe mental illness who are convicted of a crime or whose competence must be “restored” so they can stand trial.
But because of the shortage of inpatient beds at facilities like Napa State Hospital, inmates often must wait for up to three months before a bed becomes available. These inmates, whose intensive psychiatric treatment has been ordered by the court, are stuck in a kind of limbo.
During a visit to the Sonoma County Jail late last year, Sheriff’s Lt. Dave House, who manages the county’s detention division, said the jail’s mental health unit was at the time housing 30 inmates who had been found incompetent. Of these, 20 had been committed for psychiatric treatment and were awaiting a bed at a state hospital. The rest had not yet gone through the legal commitment process.
These inmates require a level of treatment that is not available at the jail.
“There’s no beds, which is unfortunate. These guys need treatment,” House said.
The county plans to provide restoration treatment in the future after the new mental health jail wing is built. That should reduce the number of people waiting for higher level treatment, House said.
Over the years, county jail officials have made modifications to several units in the main jail to accommodate the growing number of inmates with mental illness. But the jail was never designed to make up for the loss of local psychiatric hospitals.
In May, a statewide disability rights agency alleged serious violations against inmates held in the mental health unit of the local jail, including illegally medicating some inmates and levying excessive solitary confinement and isolation. The allegations were part of a 25-page report issued by Disability Rights California, a nonprofit advocacy organization with federal and state authority to review and investigate government services affecting the disabled.
Randall Walker, the assistant sheriff who oversees the county jail system, said some of the findings in the report were valid. However, he also said anecdotal accounts obtained during the watchdog group’s visit to the jail in 2015 were exaggerated and “over-dramatized.”
But Walker admits that the existing mental health wing at the local jail is no place for someone with severe mental illness.
“Our treatment is primarily based on medication and that’s not the complete treatment process,” he said. “That’s just one part of it. ... I need to create an environment that allows us to do the complete treatment process.”
In early 2008, shortly after Santa Rosa Memorial Hospital announced it would close its psychiatric facility in west Santa Rosa, then-Sonoma County Sheriff Bill Cogbill warned the move would result in more mental health patients ending up in jail. Cogbill said there weren’t “enough mental health services right now” and that jails were becoming “de facto secure mental health facilities.”
That may have been true at the time but is less so now, said Michael Kennedy, the county’s mental health director. Kennedy contends that by increasing the number of beds out in the community, such as crisis residential and supportive housing, the need for local psychiatric hospital beds has been significantly reduced. By his estimates, Sonoma County needs about 16 psychiatric beds to meet the average daily needs of mental health patients under the county’s care.
The county currently has 99 beds in residential housing with supportive services for people with mental illness and 22 such beds for clients facing a short-term crisis. Six peer-run respite beds are expected to come online soon. Kennedy said a 30 to 40 percent increase in community housing for people with mental illness would meet the county’s needs and help reduce mental health logjams in local emergency departments, at the jail and the county’s new Crisis Stabilization Unit, a sort of emergency department for psychiatric patients in west Santa Rosa.
The vast majority of the county’s mentally ill are living peacefully in the community, never coming into contact with law enforcement, Kennedy said.
“Some of our clients they get psychotic but they don’t do anything bad. They’re just delusional,” he said.
Kennedy said the idea that jails are becoming psychiatric institutions is an exaggeration. Most of the county’s mental health clients who become involved with law enforcement are those who use illegal drugs or alcohol, he said. They stop taking their medications and take, for example, methamphetamine, he said. But the same can be said of many others in jail, he said.
“That’s how the general population is,” he said. “You check and see how many people in the jail got in trouble when they were drunk or on meth or on something — the majority of them.”
Nonetheless, Kennedy is concerned that inmates with severe mental illness, such as schizophrenia, are not getting appropriate treatment in the current jail.
“Anybody with serious mental illness shouldn’t even be in that place,” he said. “I’m not saying they shouldn’t be charged with a crime, that’s not what I’m saying. They’ve got to go some place if they’re a public safety risk. What I’m saying is that facility is not suited for those folks. ... It’d be like somebody committing a crime, they had serious cancer, they’re in the middle of treatment and you stick them in jail and you don’t treat them.”
Planning for the future
Jail officials say the new mental health unit, which will be adjacent to the existing jail, will allow for more humane treatment of mentally ill inmates. The $48 million project will be paid for primarily through state funds for local detention facilities.
But some advocates and family members of those with mental illness say jails are inherently not therapeutic settings and rarely do a good job of being a substitute for clinical treatment.
“Why does the state give them money for that but not give our mental health (agency) the money to build an inpatient facility for people that aren’t criminals? What’s up with that?” said Jackie Ganiy of Santa Rosa, whose 30-year-old son was diagnosed as bipolar when he was in high school.
“Why do they throw them in jail when they’re not at fault?” she said. “Believe me, they are not at fault, the vast majority of them. Why are they put in jail? That’s really a barbaric thing to do, take somebody that’s mentally ill, does something while they are mentally ill and put them in jail for it.”
In late 2015, Ganiy said her son spent several days isolated in Marin County Jail after he was kicked out of the secured psychiatric unit of Marin General Hospital. She said the young man, agitated because of a change in his medications, knocked the glasses off a hospital nurse.
Snook, of the Treatment Advocacy Center, said many mentally ill inmates would likely have been treated in a psychiatric hospital prior to what has come to be known as deinstitutionalization, the decadeslong process of emptying out the nation’s state-run psychiatric hospitals and, subsequently, the ongoing closure of public and private psychiatric facilities.
Sonoma County Supervisor Shirlee Zane said the county should not bear the brunt of the blame for the gaps in mental health care. Zane said the private sector health care industry — whether for-profit or nonprofit, including insurance companies and health care providers — has long neglected the needs of people living with mental illness.
“The taxpayer is now having to pay through our jails, our homeless services, our crisis behavioral health services, because we have a health care civil rights issue, with years and years of private health care not treating mental illness on an equal basis, discriminating against people with mental illness,” Zane said.
The result, she said, is that taxpayers are now providing that service in ways that are more expensive and less effective than they would be on the “outside.”
Anne Hadreas, a supervising attorney for Disability Rights California, agrees.
“It is morally and financially advantageous for the system to provide services to that population before they reach the point of needing emergency services,” she said.
Jail officials argue they must deal with the realities before them. Walker, the assistant sheriff, said therapeutic programs in the new jail wing will better prepare inmates for release.
“Our goal is if we can move people through the system faster, get them to competency faster, get them the programming so that they are eligible for things out in the community, then they will get out of custody faster,” he said. “Then you have more room for those who are severely acute and more resources to focus on those people.”
As it is now, he said, those with mental illness can “get stuck in the system.”
Earlier this year, the county entered into an agreement with the Department of State Hospitals that allows the county to be reimbursed for treatment and custody costs at the jail for 10 inmates. County officials said the agreement will reduce the amount of time a mental health inmate is locked up because restoration can begin immediately.
Mary Booher, a county administrative analyst, emphasized that the new jail wing was only part of the county’s larger efforts to reduce the number of people with mental illness who end up in jail.
Programs aimed at stemming the flow of mental health patients into the local jail include the county’s forensic assertive community treatment program, which offers intensive mental health treatment for those who have committed low-level felonies or misdemeanors. Participants are given the option of probation if they agree to mental health treatment.
Booher said treating mental illness in jail “is the most expensive way to treat these people. We’d like to treat them in the community where it’s more appropriate.”
Other programs include mental health court, crisis intervention training for local law enforcement officers and the mobile support team of mental health workers that help peace officers deescalate encounters. Booher said the county recently obtained a $250,000 grant from the U.S. Department of Justice to map the county’s entire criminal justice system, with the goal of identifying gaps in behavioral health as well as all the potential points of diversion.
“We’re not planning for future growth in this population in the jail,” said Booher.
After his arrest, Bozman-Moss’s son waited 4½ months in Sonoma County Jail before he was finally transferred to Napa State Hospital for treatment aimed at restoring his competency. During that time, he was kept in “what most of us would call solitary confinement” in the jail’s mental health wing, Bozman-Moss said.
“They are on their own, all by themselves, 23 hours a day, no socializing, no place to eat together,” she said. “It was set up as a jail. It wasn’t set up for people with mental illness.”
This report was produced as a project for the California Health Journalism Fellowship, a program of the Center for Health Journalism at the USC Annenberg School of Journalism. You can reach Staff Writer Martin Espinoza at 707-521-5213 or firstname.lastname@example.org.