San Diego County jails make changes to treat mentally ill inmates, curb suicides

May 8, 2017
Dana Littlefield
San Diego Union-Tribune
April 29, 2017


About a year ago, Michelle Moriarty noticed that her husband was acting strangely.

It was right after the San Diego County couple’s anniversary — their 18th — when her husband Heron seemed to change suddenly. His behavior seemed frantic, he wasn’t sleeping and he was talking incessantly, sometimes until 2 or 3 a.m.

“I was begging him to stop,” Moriarty said last week. “He was having all these ideas, and he was starting to say he was a prophet of God. … I just didn’t understand what was happening.

Over the next few weeks, things got worse.

Heron Moriarty, 43, had been a religious family man, a devoted husband and a responsible business owner. Now he was erratic, unpredictable, and as a psychiatrist would later diagnose him: manic with psychosis.

In April and May of last year, Heron Moriarty was hospitalized repeatedly and made threats against himself and others, prompting calls to law enforcement. He was arrested May 25, his wife said, after he threw a table through the sliding-glass door of his brother’s home in Jamul and smashed his vehicle into three cars on the road.

He ended up in the county jail in Vista.

“I was relieved,” Michelle Moriarty said of the arrest. “I was thinking he was going to get the help he needed. This time, it’ll work.”

Days after he was jailed, her husband was found dead in his cell. He had taken his own life.

Suicides like Moriarty’s have prompted the Sheriff’s Department, which runs San Diego County’s jails, to reevaluate how they house and treat mentally ill inmates.

For decades, jails throughout the state have operated as de facto mental health facilities, a trend that intensified in recent years after California changed its laws to keep some offenders out of the state’s overcrowded prison system.

In San Diego County, where there were 12 inmate suicides in 2014 and 2015, Sheriff Bill Gore and his staff have been working to improve mental health services at the county jails to prevent more deaths.

The department has modified the mental health screening process when inmates arrive at jail, created “enhanced observation housing” for inmates at high-risk of harming themselves and started using video-based “telepsychiatry” to expand the ways in which an inmate can see a doctor.

The system is better, Gore said, but he acknowledged that jail is not the best environment for the mentally ill.

“It kind of goes to the state of mental health care in this country. It’s, in my opinion, substandard to say the least,” said Gore, adding that the county’s largest mental health provider is the downtown San Diego jail, an observation his predecessor, Bill Kolender, also made frequently.

“There’s something wrong with that,” Gore said. “That shouldn’t be the case.”

Nowhere to go for some

Authorities cite several reasons why that’s the case, including a massive effort in the 1960s to move mentally ill patients out of state hospitals, as well as inadequate funding and resources for providers in community-based programs.

Usually, people with mental illness who find themselves in the criminal justice system are also dealing with other problems, including homelessness, disability or substance abuse. For some, jail is the place where they are most likely to see a doctor and get the medications they need.

Among San Diego County’s average daily jail population of 5,700 inmates, about a third — 28 percent to 35 percent — are on some type of psychotropic drug. That percentage has been consistent over at least the past three years, authorities said.

“That’s a huge percentage,” Gore said. “That’s a lot of people that we’re medicating every day or that we’re giving some type of psychological services.”

San Diego County jails

Defense attorneys said most of the changes the Sheriff’s Department has made to provide more mental health services for inmates are good ones and show that county leaders are trying to address the issue.

But it’s still jail.

“That’s not a therapeutic environment for the mentally ill,” said defense attorney Richard Gates, chief of the county’s Multiple Conflicts Office, an independent division of the Department of the Public Defender.

“I don’t ever want anyone to believe that a jail is as good as a mental hospital,” Gates said. “It’s not.”

He said he wants to see more being done to provide comprehensive mental health services in the community so mentally ill people don’t go untreated, which can lead to aberrant behavior and cause some to commit crimes.

Also, because of an ongoing lack of available beds in treatment programs throughout the county, dozens of inmates the courts have cleared for release are still sitting in jail.

There’s nowhere for them to go.

“One of the frustrations about what we do is that once a person has been repeatedly incarcerated, due primarily to their mental illness, they feel like they have been thrown away,” Gates said. “And a life with no hope is a sad life.”

Changes in California law

The problem goes back decades.

Starting in the late 1950s, California began shifting patients from state hospitals like Patton in San Bernardino County to nursing homes and board-and-care facilities, a trend referred to as “de-institutionalization.” The patient population in the hospitals went from of a peak of 37,500 in 1959 to 22,000 in 1967, when Ronald Reagan became governor.

That same year, Reagan signed the Lanterman-Petris-Short Act, which ended involuntary commitment of people with mental health disorders, except in extreme cases, and barred the state from committing most patients to the hospitals indefinitely. The law was meant to protect the rights of people with mental illness, while saving the state money.

Over time, changes in the mental health care system — along with inconsistent application of the law in California’s 58 counties — made it more difficult for patients to get psychiatric evaluations and treatment promptly.

By the early 1970s, most of the mentally ill patients had been moved out of the state hospitals, and the patient population dropped as low as 7,000. Today, the Department of State Hospitals serves nearly 13,000 patients each year at five state hospitals and three psychiatric programs inside the state prisons.

“There are some people that need to be institutionalized, probably against their will, so they can get the medical care that they need,” said Gore, whose department runs seven jails. “Unfortunately, in our society now they have to break a law or something. They are involuntarily committed in my jail. … It’s a gigantic challenge for us.”

The situation became especially challenging for county officials after Gov. Jerry Brown signed a law in 2011 that shifted responsibility for housing and supervising certain nonviolent offenders from the state to the counties.

I don't ever want anyone to believe that a jail is as good as a mental hospital. It's not. — Defense attorney Richard Gates

Although the law, known as public safety realignment, did not move any inmates directly from prison to the local jails, it helped the state comply with federal court orders to significantly reduce California’s notoriously overcrowded prisons by allowing some felony offenders to serve multi-year sentences in county jails. (The court orders stemmed from two class-action lawsuits having to do with the state’s inability to provide adequate medical and mental health services to its inmate population.)

Before realignment, the average length of stay for a sentenced inmate in a San Diego County jail was 65 days. Now it’s a year to 18 months.

“We’ve had people sentenced to 12 to 18 years in county jail,” Gore said. “As you can imagine, ours and all the other 57 county jail (systems) in the state of California weren’t built to house those long-term inmates. So we’re all adjusting.”

That wasn’t the only change. In 2014, California voters approved Proposition 47, which reclassified some low-level felonies — such as simple drug possession and petty theft — to misdemeanors, reducing the penalties. Like realignment, the change in the law sent inmates who would have done their time in state prisons to the local jails.

Preventing suicides

More inmates and longer sentences meant Gore had to reevaluate how his department would provide medical and psychological services to this new population, particularly after a rash of suicides. Six were reported in 2014, another six in 2015 and five in 2016.

So far, no suicides have been reported in 2017.

After the deaths three years ago, the Sheriff’s Department launched a suicide prevention program in early 2015 that included specialized housing in each jail for inmates at high risk of harming themselves. The “enhanced observation” housing includes fencing on upper tiers so that inmates can’t jump from them, and surveillance cameras in each of the cells.

“We work every day to try and improve that system,” said Dr. Alfred Joshua, the Sheriff’s Department’s chief medical officer since 2013, referring to the safety program for inmates at suicide risk.

To determine whether someone should be placed in enhanced observation, the inmate would first be evaluated by doctor or a nurse, Joshua said. Once housed in the unit, the person would be seen by another nurse within four hours and another within 24 hours.

Inmates in the enhanced observation module are given special clothing and bedding that can’t be torn into shreds to create a noose and any potential hanging points inside the cells have been eliminated. To be cleared from the unit, an inmate has to be seen by at least two mental health providers.

The average length of stay inside the module is about two days.

“We have not had one suicide in any of our enhanced observation housing units, which shows you we’ve got the right idea,” Gore said. “If we can get them in there, it works. Our challenge still is identifying them at intake, and that’s what we’re working very hard on.”

After inmates are released from enhanced observation, they may go into main housing if the doctors determine they are stable. If not, they could go into one of two other psychiatric units inside the jail.

The department set up a 40-bed psychiatric step-down unit at the Central Jail, which houses male inmates only, that offers further psychiatric treatment and programs for high risk mental health inmates who don’t meet the state’s criteria for an involuntary psychiatric hold, Joshua said.

For those who do meet that criteria, the county has a 62-bed psychiatric inpatient unit — half at the Central Jail and half at the Las Colinas jail in Santee, where most of the county’s female inmates are housed — for people considered to be a danger to themselves, a danger to others or gravely disabled.

The department also provides outpatient mental health clinics at each jail to inmates who need them.

Starting about a year ago, Joshua said, the county introduced group meetings at each of the jails so that deputies, mental health personnel and administrative staff could get together to share information about high-risk inmates and develop treatment plans for how best to help them.

We have not had one suicide in any of our enhanced observation housing units, which shows you we've got the right idea. — Sheriff Bill Gore

For some, the improvements in the jails came too late.

At least seven lawsuits have been filed in recent years against the department by people whose family members committed suicide in jail. Among them are Chassidy Nesmith, the widow of a 21-year-old Camp Pendleton Marine who hanged himself at the Vista jail in February 2015, and Rochelle Nishimoto of Vista, the mother of a 44-year-old man who hanged himself in the jail in September of that year.

They contend the department had ample warning that their family members were at risk of suicide but failed to monitor them properly.

“I have nothing good to say,” said Nishimoto, whose son Jason was diagnosed with schizoaffective disorder and had swallowed a bottle of prescription medication before he was arrested.

Family members said they gave that information to the dispatcher, sheriff’s deputies and a jail psychiatric nurse.

“I cannot see how they can say that they didn’t know,” Nishimoto said.

Nesmith, who lost her husband, Kristopher, said she appreciates that the Sheriff’s Department is trying to improve care for the mentally ill. “They’re making steps in the right way, but not as fast as they should have,” she said.

Michelle Moriarty, who now lives in Oklahoma, said she called the jail 31 times over the five or six days her husband was in custody. She said the nurses gave her updates on how her husband was doing, specifically that he was refusing his medication.

“I kept telling them I was scared for his life,” she said.

Restoring competency

In February, the county signed a contract with Liberty Healthcare Corp., which is now responsible for hiring psychiatrists and other mental health practitioners to work with inmates in the jails and oversee quality control of the mental health programs.

Liberty is also running a new jail-based mental competency program, a 25-bed program launched in March at the Central Jail. Previously, inmates deemed incompetent to stand trial would have to wait for space to open up at Patton State Hospital in San Bernardino County.

Some were waiting as long as eight months.

Defense lawyers say the jail-based program — modeled after a long-running one in San Bernardino — is not an ideal solution, but one they are willing to go along with it if it means their clients’ competency can be restored quickly, sometimes within 60 days.

“We’re hedging our bet here,” Gates said. “We are accepting something that viscerally to me and intellectually is unacceptable, the treatment of the mentally ill in a non-therapeutic setting.”

The county Health and Human Services Department, which connects people with mental health and substance abuse treatment, also inspects and licenses inpatient psychiatric beds inside the jails, Joshua said. It provides about $3.6 million a year to the Sheriff’s Department for mental health services.

The actual cost for those services in the last fiscal year was more than $12 million, according to the Sheriff’s Department. The cost now is closer to $14 million because of the contract with Liberty Healthcare.

A decade ago, it was about $7 million.

The total annual medical budget is $71 million, Joshua said.

They're making steps in the right way, but not as fast as they should have. — Chassidy Nesmith, whose husband committed suicide in the Vista jail

Gates commended the Sheriff’s Department for investing money and resources to try to identify and watch inmates at high risk of harming themselves. He said the changes the department has made seem to have been effective in reducing the number of jail suicides, which he called “the ultimate preventable event.”

But he said much more needs to be done to increase funding for treatment beds in the community and to reduce some barriers to admission so that mentally ill inmates don’t needlessly languish behind bars.

“Jail life is stressful in and of itself,” Gates said. “For the mentally ill, whose coping mechanisms are compromised by their cognitive problems, by their emotional problems, by their fear and paranoia, the stark reality of jail life is very threatening, and there isn’t much a sheriff can do to change that.”

In October, the Public Defender’s Office set up a Defense Transition Unit to help identify which clients could be moved out of jail and into treatment quickly.

“We’re doing as much as we can to help these clients as early as possible,” said Neil Besse, a deputy public defender who heads the new unit, which receives about 80 referrals from public attorneys a month.

Besse said judges have been open to the idea of letting mentally ill offenders serve all or part of their custody time in a residential treatment program, but many of them end up finishing their full sentences in jail before the lawyers can get them into an appropriate program.

“Our goal is that they not hit the street and go out there and unravel,” he said.

Twitter: @danalittlefiel



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