Their names are scribbled on windows along with their diagnosis.
The third, blank.
Behind a trio of locked doors, they sit alone, their cells slightly larger than the wheelchair-accessible stalls of public restrooms. The lingering scent of bleach saturates the air. Just outside their chambers, two police officers slouch on a bench bolted to the cement floor, staring blankly at the afternoon soap operas. The watchmen will rotate soon, but the patients require 24-hour surveillance to prevent them from staining the chipped, whitewashed walls with the blood of their heads.
Down the hall, the scene repeats itself, minus the watchmen, with patients too volatile to mix with others, but less a threat to themselves. One meanders about his stall, combs his long, dark goatee and turns to stare back at the passersby.
Restrictive measures decrease as the procession continues. A patient’s location depends on the diagnosis they received two floors below, where a steady stream gathers outside two nurse offices on the ground floor.
Before they are eligible to receive mental health services here — the largest mental health clinic in North Texas and second largest in the state — patients must don a striped jumpsuit and stand before a judge.
Welcome to the Dallas County Jail, where the psychiatric unit treats more than 1,400 patients a day, nearly a quarter of the jail’s total population. After serving their time, these patients will be discharged with nothing more than three days’ worth of medication in their pocket — no money to make a phone call or to catch the bus.
Nationwide, 64 percent of jail inmates suffer from mental illness, according to a 2006 U.S. Department of Justice report. Many subsist undiagnosed — their illness “self-medicated” or otherwise disguised by illegal drug use — and get caught in a costly revolving door of imprisonment without ever receiving appropriate services.
The asylum era of mental health began its decline in 1963 when President John F. Kennedy signed the Community Mental Health Act. Throughout the 1960s and ’70s, the U.S. Department of Justice shuttered the massive state hospitals of One Flew Over the Cuckoo’s Nest lore. The few remaining hospitals were slashed in size.
The intent was community integration, to end the discrimination of separating the mentally ill from the rest of the population and, instead, provide outpatient care within the community. But because of a lack of funding to community mental health providers, a colossal contingent of mentally ill remain cut off. They wander the streets, hunker down in homeless shelters, and ultimately find their way here.
“We’ve traded hospitals for jails,” said Matt Roberts, president of Mental Health America of Greater Dallas. “If you don’t provide enough money to keep people well, the police get called and they end up in jail.”
The Patient Protection and Affordable Care Act offers relief by expanding access to Medicaid in 2014 and enhancing benefits received by mental health consumers. For the first time, insurers will be required to offer benefits for mental health care that are at least as good as benefits for physical health care.
The impact of increased mental health offerings would be substantial, said Colleen Horton, a policy director at the Hogg Foundation for Mental Health.
“If we could provide more mental health services, we could prevent people from going into the jails in the first place,” Horton said.
Mental health advocates argue that robust mental health services save money in the long run.
“It’s cheaper to pay for the housing, the meds and the support for that person with schizophrenia in a group home than it is to have them in the prison system,” said Dr. Jim Baker, the chief executive officer of Metrocare, the largest public mental health provider in Dallas County.
Yet, the economic climate may prevent those dollars from ever reaching desperate consumers. Medicaid accounts for nearly 50 percent of public spending on mental health care, a number that’s likely to swell in 2014 with the expansion of health care services. States across the nation are already slashing Medicaid budgets to quell fiscal crises, and mental health recently became a target. Public funding for NorthSTAR, the mental health managed care program that serves Dallas and six surrounding communities, was cut $10 million.
Texas is a resource desert for the mentally ill, finishing last in the nation for mental health care spending per capita, according to the National Alliance on Mental Illness in its November report on state budget cuts for mental health. Moreover, 68 percent of Texas counties suffer from a shortage of mental health professionals, according to Hogg Foundation reports. And among the 39 mental health centers funded by the state, Denton’s ranks last in Texas in per capita spending, officials said.
This ballooning predicament — more patients, fewer professionals and dissipating resources — means the county jail is likely to continue as the primary provider of mental health services in most Texas communities.
“So many times, we are the first healing hands who are touching the patients,” says Dr. Waseem Ahmed, medical director of psychiatric services at the Dallas County Jail.
Without treatment and medication, mental illness often yields bizarre behavior or “self-medication.”
“You can imagine they are so deeply involved with the internal world that their psychosis is not allowing them to function properly,” Ahmed says.
He points to a prisoner who is focused on solving an intricate puzzle — one that is only visible to him because he’s hallucinating — but he looks up to wave from his cell.
“Did you see that?” Ahmed asks, excitedly. “He acknowledged us. He’s making progress.”
Prisoners who behave well earn access to a library of religious and self-help books, a place where prisoners’ artwork also lines the walls. Portraits of loved ones, a lakeside log cabin from a favorite childhood memory — painting serves as a treatment to channel positive emotions.
In a corner rests a newly completed painting — a group project. In it, a muscular black man, giant in size and dressed in a tattered Dallas County Jail jumpsuit, is sprawled across the two-lane road near the jail. A foreboding cemetery plot is to his left. The man’s face strains as he stretches across the painted landscape toward a hand that emerges from the opposite corner of the canvas.
But like the mythical Tantalus, tortured by food and drink just beyond his grasp, the prisoner falls short of the outstretched hand.
SERIES AT A GLANCE
• SUNDAY: An overview of health care as it stands today. A look back shows reform isn’t a new concept. Results of Massachusetts reforms show unexpected results.
• MONDAY: Small businesses react to new law. Reform spotlights need for faster results from research.
• TUESDAY: Prevention is key to curing cost concerns. Workers with no insurance take health into their own hands.
• WEDNESDAY: Physicians struggle to maintain their business model. Patients try “accountable care.”
• THURSDAY: Texas lags behind other states in setting up insurance exchange, while reform banks on student loans.
• TODAY: Mental health treatment remains fragmented, affecting physical health care. Texas county jails are primary provider of mental health services.