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Sep 06, 2023

'Planting Seeds of Change': In Rural Counties, Expanding Jail-Based Mental Health Services is a Community Effort

by Gretel Kauffman

silhouette of a man in a jail cell

Eric Hensley is used to thinking outside the box.

As the chief sheriff's deputy overseeing jail operations in Washington County, Texas — a county of 35,000 people an hour and a half outside of Houston — Hensley has learned from experience that a little bit of creativity and collaboration can go a long way in making the most of limited resources. So when he heard about a psychological telehealth program at nearby Texas A&M University, Hensley immediately began to wonder how the technology could be put to use in the Washington County jail.

Three years later, an estimated 150 people incarcerated in the Washington County jail have participated in virtual group or one-on-one counseling through a partnership between the jail and the Texas A&M Telebehavioral Care program, and two other rural Texas counties have replicated the program in their own jails, too. It's one of a number of steps Hensley and Washington County have taken over the past five years to improve and expand mental healthcare for incarcerated community members.

“Mental health is not going anywhere and the problem is only going to grow larger, so the sooner we get a handle on it the better,” Hensley said. “But a lot of counties are like us: strapped and can't do anything. So we have to think outside the box.”

Reported rates of mental illness are significantly higher among incarcerated people than the general U.S. population, and people held in jails report mental health concerns at higher rates than their peers in state and federal prisons: In one report by the National Research Council, 64% of people in jails reported mental health concerns. In rural counties, where funding is often limited and community mental health resources may be scarce, providing comprehensive mental healthcare to people in jail — and ensuring that they can continue to access care after they are released — can be especially challenging. But rural communities may also have some unique strengths when it comes to assessing and addressing the mental health needs of incarcerated people, experts say.

Isaac Saldivar, PhD, a psychologist working virtually with clients in the Washington County jail and two other rural county jails through the Texas A&M Telebehavioral Care program, describes jail-based mental health services as having the potential to produce a “dramatic domino effect” throughout rural communities.

…the more they heal, the healthier the community becomes.

“These are community members that are hurting and need healing,” Saldivar said. “That's someone's friend, someone's brother, someone's sister, someone's father. And the more they heal, the healthier the community becomes.”

Jail vs. Prison: What's the Difference?

The words “prison” and “jail” are often used interchangeably, but are in fact different kinds of facilities. A prison is a long-term detention center for people who have already been convicted of a crime, and is typically run by the state or federal government. A jail is a short-term facility used to house people awaiting trial or sentencing — or people who are serving a short sentence — and is typically run by the local city or county government.

Identifying a Need

Ideally, experts and program leaders say, people experiencing mental illness would receive care long before entering a jail setting. Research suggests that access to care can play a role in keeping people out of the legal system to begin with: Counties with fewer community treatment resources available were more likely to have larger jail populations per capita, one study found. And some counties have diversion programs in place, such as specialized mental health courts, to keep mentally ill people involved in the justice system out of a jail environment when appropriate.

But in rural communities, mental health providers and funding are often in short supply, making treatment more difficult to access and diversion programs harder to implement.

“If we had somewhere other than the jail to take people and get them the services and treatment they need, we would,” Hensley said. “Jail is no place for somebody with mental health problems. But once they're here we try to help them out as much as we can.”

In Washington County, local mental health providers are hardworking but stretched thin, Hensley said — and a lack of funding and public support has prevented the county from creating specialized courts or other diversion programming.

“The best situation is that they never get into the jail in the first place, but obviously that's not always possible,” said Erin Comartin, PhD, an Associate Professor in the Wayne State University School of Social Work who has studied rural jail populations and mental health services. “If you can identify [people in need of services] and get them into care and treatment quickly, that's the next best thing.”

Some mental health conditions, such as depression, may not always be obvious at first glance — which makes it all the more important that jails have the proper tools to identify people in need of care as soon as they're booked, Comartin said.

“What we've seen in rural communities is that they rarely, rarely identify people coming into the jail who have a behavioral health need,” Comartin said. For smaller counties with limited funds and resources, adopting a standardized screening tool — such as an in-depth questionnaire developed by a psychologist — can often be a prohibitively expensive and complicated process, she noted. In one study Comartin co-authored, two out of three rural jails reported screening for mental illness by having corrections officers ask people a single question at booking time: “Are you currently suicidal?”

“There are people with mental health needs who will never think of suicide, and there are people who don't have mental health needs but who might feel suicidal given the circumstances when they're booked into jail,” Comartin said.

At the same time, rural jail employees may also have some advantages when it comes to identifying not-so-obvious mental health needs, Comartin noted: In a small community where jail staff are more likely to know the people entering the jail or to remember people who have been in the jail before, “You want the officers to be able to have some discretion: 'This person's been to the jail, we know his significant mental health needs, and we can identify him.'”

And once a person's mental health needs have been identified — ideally through a “valid, reliable” screening tool — rural jails can have an advantage over larger facilities in providing effective, sustainable care, Comartin said, especially when a community comes together to coordinate its resources.

Having a smaller community feel where people know each other and trust each other is a good thing.

“This is where rural jails can actually do the best job,” Comartin said. “What we saw in a couple of our papers is that when a jail does identify someone with mental illness, if they are in a rural community they're more likely to get care in the jail and more likely to connect to care after. Having a smaller community feel where people know each other and trust each other is a good thing.”

Disrupting a Cycle

In Marion, Ohio, a city of 36,000 people in the middle of the state, seeing familiar faces in the courtroom was a common occurrence for James Boleyn and his colleagues.

“We were dealing with the same individuals just cycling in and out of the legal system, and there weren't adequate services to address their [mental health] needs while they were out in the community,” said Boleyn, who serves as Director of Specialized Dockets for Marion Municipal Court. “We were running into this situation again and again, and we decided we needed to do something as a community to look at this and say, 'How can we interrupt this cycle and better resource these individuals?'”

In 2021, Marion County signed onto the Stepping Up Initiative, a project by the National Association of Counties that encourages counties to improve and expand mental health resources in their local criminal justice systems. Since then, Boleyn and his team have worked to develop a broad long-term plan to reduce the number of people in the Marion County jail, which includes addressing challenges such as housing and exploring alternatives to incarceration for mentally ill people.

In the meantime, the county is focusing its efforts inside the jail, which hasn't offered mental health treatment services up until this point.

“Historically, our county jail has been a county jail,” Boleyn said. “They're trying to contain episodes while a person's there and keep them stable, but there's not ongoing counseling. There's not ongoing medication analysis or an assessment of whether someone is on the appropriate medication, if medication is provided at all.”

Now, Boleyn and a local organization are working together to change that. OhioGuidestone, a statewide behavioral health agency with a regional office in Marion County, has agreed to offer case management and mental health services to people in the county jail — including individual counseling sessions and groups focusing on anger management and other topics — at no cost to the county. The organization will also provide clinicians to conduct a diagnostic mental health assessment and recommend a treatment plan if necessary for incarcerated people as soon as they enter the jail.

“We recognize that people who end up incarcerated typically have some type of trauma,” said Kasey Bisch, Regional Director for OhioGuidestone. “They didn't just get there by accident — they've usually developed some kind of maladaptive coping skill that got them into the situation they're in. And if they don't receive the treatment they need while they're incarcerated, they're released and repeat those behaviors again because it's how they've learned to survive.

We don't expect extreme change in the short amount of time they're incarcerated. But we hope to plant seeds of change that will encourage that person to further their treatment once they're released.

“If we could disrupt that cycle by working to treat those symptoms and behaviors, we might see very different results when they're released,” Bisch continued. “We don't expect extreme change in the short amount of time they're incarcerated. But we hope to plant seeds of change that will encourage that person to further their treatment once they're released.”

Addressing Trauma

In Texas, Saldivar meets over video call with Washington County jail inmates two days a week, with individual counseling and group options available. He holds two group classes: one focused on anger management and another focused on trauma and substance use.

Saldivar estimates that 90% of the jail clients he works with have “extensive amounts of trauma,” ranging from those who have experienced violence to those who have lost a loved one.

“These things that sometimes people don't conceptualize as trauma are very, very impactful,” Saldivar said. “And even being in jail itself is traumatic.”

To encourage his clients to open up in a jail setting — an environment where vulnerability may be especially difficult — Saldivar shares his own experiences and trauma and welcomes different forms of expression, including poetry and rap. While most sessions are held virtually, Saldivar tries to meet every client in person at least once. And at the end of a ten-week class cycle, participants receive a certificate and hold a class graduation party with pizza and music.

“In my anger group, I had eight men, all tatted-up and big and strong and not used to being vulnerable,” Saldivar recalled of one class. “They had so many barriers up. And at the end of the ten weeks, there was not a dry eye in the room.”

…at the end of the ten weeks, there was not a dry eye in the room.

Since the telehealth counseling program began, Hensley said he's seen positive changes in the jail, including fewer fights.

Shortly after Washington County implemented telehealth counseling for inmates in 2020, two other rural counties in the region expressed an interest in trying the program in their own jails — but had some hesitations about the program's cost. To let the other counties test out the program cost-free, Hensley offered to let people in the other jails join the Washington County virtual group sessions. One of the counties ended up also fully adopting the program this year, with a focus on individual counseling sessions.

“We wanted to help as many people as we could,” Hensley said. “And now every Thursday, that TV screen's full of inmates from all over getting the help and services they need.”

While there are some drawbacks to meeting with clients virtually instead of in person — Saldivar cited not being able to smell if someone has alcohol on their breath as one example — reaching people in small, remote county jails while being based at the university would be much more difficult, if not impossible, without the program's virtual component, he said. As the program is currently structured, it is open to any jail across the state that wants to participate.

A Smooth Transition

Just as it's important to quickly identify what kind of treatment a person will need during their time in jail, it's also important to start planning as soon as possible for when that person leaves, said Carrie Ann Langley, PhD, an Assistant Professor of Practice at the University of Arizona's School of Sociology who studies rural jail-to-community transitions.

“People often don't know how long they're going to be in jail and are given very little information about that transition,” Langley said. “That makes it very difficult to plan for things like transportation and housing and to start planning for care.”

In rural communities where a shortage of mental health providers leads to long wait times for an appointment, people may have to wait weeks or months to reestablish care after leaving jail — a gap that is especially problematic, Langley said, as people leaving jail are often provided with no mental health medication, or only a few days' worth of medication, when they are released. And if a person is already struggling to find housing and meet other basic needs, mental healthcare is likely to fall toward the bottom of their priority list, Langley added.

“These conflicting demands create a lot of stress,” Langley said. “And without coordination in the jail, it really can overwhelm someone quickly.”

While rural communities may have fewer mental health resources available to people who have been recently released from jail, that simplicity can also help to streamline the transition process, Comartin noted. In one rural community she worked with, the mental health center and jail were a parking lot away from each other: “It was really great,” she said, “because when the jail was releasing somebody, they just call over and say, 'Hey, do you want to come to the other end of the parking lot and help this person get back into services?'”

In Marion County, where case managers with OhioGuidestone will help to schedule mental health appointments for people prior to release and give them a ride to appointments if needed, the small size and familiarity of the community is an asset, Bisch said.

At the end of the day, this is the community that we live in. We know who to call and who to collaborate with.

“At the end of the day, this is the community that we live in. We know who to call and who to collaborate with,” Bisch said. “This is where we are raising our children and we want to make an impact for the people who genuinely need help, empowering them to take steps towards a healthier future.”

In Washington County, a discharge planner similarly helps people prepare for release by drafting a plan that includes reestablishing medical and mental healthcare. While the jail used to not provide people with medication upon release, people transitioning back into the community who are on psychotropic medications are now provided with enough medication to tide them over until their prescription can be renewed, Hensley said. After release, the local mental health organization makes home visits, Hensley said, to check on people and make sure they are continuing to receive care.

Participants in the jail telehealth counseling program can also continue to receive free virtual counseling through the Texas A&M Telebehavioral Care center if they wish; counseling sessions with the center's psychologists in training are available at no cost through the center's community clinics in Washington County and other rural communities.

So far, only a handful of people have taken advantage of the free counseling service after leaving jail. But several former clients have gotten in touch with Saldivar to share life updates, he said, after transitioning back into the community and “doing the things they said they were going to do.”

If we can just help one person set their life right and get them the help they need, then the program's worth it in my eyes.

“Hearing that makes us feel like we're making a difference,” Hensley said. “If we can just help one person set their life right and get them the help they need, then the program's worth it in my eyes.”

This article was posted in Features and tagged Access · Criminal justice system · Mental health · Mental health conditions · Ohio · Telehealth · Texas
Gretel Kauffman
About Gretel Kauffman

Gretel Kauffman has been a web writer for the Rural Health Information Hub since 2022. She writes on a variety of rural-specific issues in the Rural Monitor and Models and Innovations. Gretel has a bachelor of arts degree in American Studies from the University of Notre Dame. Full Biography

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