The county's Twin Towers Correctional Facility in downtown Los Angeles is a hulking, massive concrete structure. It is also part of the largest municipal jail system in the United States.
On a recent day, four men enter handcuffed with a police escort. The sheriff's deputies assign them cells, and for the duration of their sentences, this is home. The men wear bright blue pants and neon yellow shirts to set them apart from other inmates.
"Here within Twin Towers, we house approximately 3,900 inmates. A majority of those inmates are deemed mentally ill," says Lt. Joseph Badali, a supervisor with the Sheriff's Department.
The United States incarcerates hundreds of thousands of inmates suffering from mental illness, and jails and prisons are struggling to provide for inmates with severe mental health needs.
Los Angeles County is even exploring building a new jail specifically to house and provide treatment for mentally ill inmates. The proposal is estimated to cost more than $1 billion.
Prison Or Hospital?
L.A. County is not unique. In fact, it is far from it. Experts say good numbers are hard to come by, but one estimate calculates there are about 2.1 million annual bookings of persons with serious mental illnesses into jails. That number swells when you count state and federal prisons.
At one time, huge state hospitals housed the mentally ill. When they closed in the 1970s, community-based care was supposed to step in. Instead, with fewer options, the mentally ill were released to the streets, where they often got into trouble. Jails have to take mentally ill offenders in, but they can't force medication.
Psychologist Sara Hough sometimes matches the colors of clothing of the inmates that she calls "clients." She tries to establish a rapport with them.
"It's so important that you take your medication and you comply with treatment, because if you don't, you're going come back here. And we don't want you to come back here," she says to an inmate through glass.
Because of its size, the L.A. County jail system is the country's largest de facto mental institution, and Hough has held a job here for 15 years. She's now the head of the Department of Mental Health at Twin Towers.
The hospital within the prison opened in 1977, right around the height of de-institutionalization, when mental hospitals were closing. About 30 inmates get treatment on this level, but jail officials say they wish they had many times that number of beds to cope with all the acute cases.
"In many ways, we are a hospital," says Hough. "What brought them into the system was an alleged crime, and we certainly at the Department of Mental Health are not here to judge that. But while they are here and they suffer from a mental illness, we will provide care."
The county says it is trying to make the best of a tough situation, but columnist Steve Lopez calls it a crime.
"Yes, for some people maybe it's better than being than on the street," Lopez tells NPR's Jacki Lyden. "But that doesn't mean that a jail is a therapeutic environment, and that doesn't mean that this is good public policy, and that doesn't mean that anyone should find this acceptable."
Lopez, a writer for the Los Angeles Times, has put L.A. county mental health on the radar nationally. A series of his columns about a homeless violinist with mental problems became a film.
Lopez says it's simple: Jail is no place for treatment. According to the Justice Department, people with psychological disorders are much more likely to be sexually victimized by fellow inmates:
"An estimated 3.6 percent of [jail inmates], those identified with serious psychological distress reported inmate-on-inmate sexual victimization, compared to 0.7 percent of inmates with no indication of mental health problems."
The sheer size of this population also makes it a target. There are multiple federal investigations of abuse in the county jail system, including at the Twin Towers and the notorious Men's Central Jail.
In response to the federal investigation, the L.A. County Department of Mental Health told NPR, "We look forward to continuing collaboration in assessing and improving our services."
Life After Incarceration
So what happens to people in need of mental health care when they've done their time and are dismissed? It's a question Lopez has asked a lot.
"The sad news is that the majority of them are turned out onto the streets with no linkage kind of community-based treatment center," Lopez says. "And this is a population that needs regular management."
Lopez says, after release, former inmates can take a short walk from the jail and end up in an outdoor drug market and fall immediately back into the same patterns that got them into jail in the first place.
James Puntar has done just that, many times. The 53-year-old grew up in Southern California. He says he started doing drugs when he was just 9 years old, and his addictions only got worse. "By junior high school, I was eating acid, and by high school, I was smoking PCP," he says.
Puntar is the first person to admit he has made a lot of bad choices with his life. For many years, he was homeless and lived on the streets. He has been arrested for drunken driving and petty theft, and he made money dealing drugs. He's also been in the Twin Towers Correctional Facility.
Puntar also has chronic mental illness and a hodgepodge of diagnoses that he says includes schizophrenia, depression, anxiety and mood swings. "I've seen a lot of doctors," he says.
Inside jail, Puntar says he received medications and therapy. But it can be costly, difficult or all but impossible to stay on a medication schedule unsupervised, once released. Puntar says he soon abused drugs again, but they did not quiet his mind.
There were times when he couldn't find somewhere warm to sleep, or the money to eat. In those moments, he says, he thought about going back to jail, the one place he could always count on.
Puntar says he is now two-years sober. A nonprofit group called the Integrated Recovery Network provides him with housing and mental health services. He's now working toward becoming an addiction counselor. But he says he is taking life one day at a time.
"People my age, they got jobs, they've retired from. They've got houses. They got kids who are grown and married. Me, I've got nothing," he says. "I was married to drugs, and my home that I had built for myself was prison."
Jails Doing What They Can
Linda Teplin has researched incarceration and mental illness for more than three decades. "We have to remember that it is not the jail's choice to take these people," she says.
Teplin, a professor of psychiatry at Northwestern University, suggests that perhaps it is the jails that have come furthest in that time.
"Jails have been very good nationwide now about recognizing the need to screen for severe mental disorders when people come in, and also to provide treatment for people who are in their facility," Teplin tells Lyden.
Teplin says that while this is certainly not a cheaper system, it is easier to get support for new correctional facilities than it is obtain funds to provide mental health care in the community. She also says stigma can play a role in what gets backing, since people with severe mental illnesses on the street are not representative of all people with mental health needs.
"They may engage in bizarre behavior," she says. "Many people are afraid of people with severe mental illnesses. They're not a sympathetic group."
Teplin says it would likely take a major public figure — perhaps with an ill family member — to take leadership in this area for any real policy change to move forward.
"I think that would do a lot to alert the public sensitivity to the plight of people with severe mental illnesses being arrested instead of treated," she says.
There are signs of change, however. Many cities have added training for police, and created mental health courts that divert people from jail. But day centers and community centers around the country often struggle trying to raise funds to improve services and acceptance.
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Transcript
JACKI LYDEN, HOST:
This is WEEKENDS on ALL THINGS CONSIDERED from NPR News. I'm Jacki Lyden.
UNIDENTIFIED MAN #1: Slider one, please.
UNIDENTIFIED MAN #2: Thank you.
LYDEN: The metal doors slide open at the Twin Towers Correctional Facility in downtown Los Angeles. And the concrete towers do loom over the largest municipal jail system in the United States.
UNIDENTIFIED MAN #3: ...A-15, he's in nine.
LYDEN: We watch as four men enter, handcuffed, with a police escort. They're coming in from court. The sheriff's deputies assign them cells. For the duration of their sentences, this is home.
UNIDENTIFIED MAN #4: D-9.
UNIDENTIFIED MAN #3: And D-7.
UNIDENTIFIED MAN #4: All right. Let's go, man.
LYDEN: These men are wearing bright blue pants and neon yellow shirts, which sets them apart. Lieutenant Joseph Badali is a supervisor with the sheriff's department.
LIEUTENANT JOSEPH BADALI: Here within Twin Towers, we house approximately 3,900 inmates. A majority of those inmates are deemed mentally ill.
LYDEN: In this regard, L.A. County Jail is not unique - far from it. And that's our cover story today: the mentally ill, patients and prisoners.
(SOUNDBITE OF MUSIC)
LYDEN: Every year, an estimated 2.1 million people are booked into local jails with a serious mental disorder, often for short stays. Once, huge day hospitals housed the mentally ill. When they closed in the 1970s, community-based care was supposed to step in. But instead, the mentally ill were released to the streets, where they often got into trouble. Jails have to take mentally ill offenders in, but they can't force medication.
SARA HOUGH: It's so important that you take your medication and you comply with treatment, because if you don't, you're going to come back here, and we don't want you to come back here.
UNIDENTIFIED MAN #5: Right.
HOUGH: OK?
LYDEN: Psychiatrist Sara Hough is talking with an inmate through glass. She's chosen to wear a yellow blouse and blue capris today, matching the clothing of the inmates she calls her clients. [POST-BROADCAST CORRECTION: In the audio of this story, as in a previous Web version, we refer to Sara Hough as a psychiatrist. In fact, she is a psychologist. Also, in 2013 she was head of the Department of Mental Health at the Twin Towers Correctional Facility, not the head of clinical psychiatry.]
UNIDENTIFIED MAN #5: All right.
HOUGH: All right. It's good to see you smiling. I'm so happy for you, but keep up the good work...
LYDEN: Because of its size, the L.A. County Jail is the country's largest mental institution. And Hough has held a job here for 15 years. She's now the head of clinical psychiatry.
The incarceration of mentally ill people costs taxpayers many millions of dollars, experts say far more than it costs to treat them in the community. Here in Tower One, a sheriff's deputy is leading group therapy.
UNIDENTIFIED MAN #6: Being a good communicator takes practice. Everyone understand that?
UNIDENTIFIED MAN #7: Yes, sir.
UNIDENTIFIED MAN #8: Yes, sir.
LYDEN: In this pod of the jail, the inmates aren't manacled. They're not considered risky. In another area, the inmates sit handcuffed to a table, quietly watching "Iron Man 3." But two of these men are on suicide watch, and they wear only a heavy blue blanket Hough calls a suicide gown.
HOUGH: It's difficult to shred. It's difficult to manipulate so they can use it as a means of hurting themselves. So it provides greater security.
LYDEN: Ninety percent of the mentally ill at Twin Towers also have a substance abuse issue. For as long as they're here, they'll receive counseling.
UNIDENTIFIED MAN #9: Clear.
(SOUNDBITE OF DOOR CLOSING)
LYDEN: The hospital within the prison opened in 1977, right around the height of deinstitutionalization, when mental hospitals were closing. Gabriel Rodriguez is a registered nurse and works in the unit.
GABRIEL RODRIGUEZ: Most of our patients that come up here are very fragile cases, very delicate. They're very ill. And they're refusing to take medications. They're not following treatment. They're not going to court.
LYDEN: That means the staff is watching some truly at-risk people here, as signs make evident. No sharps, no plastic eating utensils, no wristband, no pencil, no objects patient might use to scratch self.
RODRIGUEZ: Right.
LYDEN: There's a 25-year-old man rocking back and forth in his cell. The staff say he's developmentally disabled, mentally ill and sometimes violent. And he's been in and out of this jail multiple times. And the revolving door syndrome is, to say the least, frustrating for everyone. Again, Nurse Rodriguez.
RODRIGUEZ: I spoke to a family member today who says, you know, we're really burnt out. My brother, he comes off two weeks out of jail, he's doing fine, and then he stops doing medication, and he gets arrested.
LYDEN: Here in the in-patient hospital on the seventh floor, around 30 inmates get treatment. Jail officials say they wish they had many times that number of beds to cope with all the acute cases. I asked Dr. Sara Hough about this.
HOUGH: It just begs the whole question, are we not turning our prisoners into hospitals? In many ways, we are a hospital. What brought them into the system was an alleged crime, and we certainly at the Department of Health are not here to judge that. But while they're here and they suffer mental illness, we will provide care.
LYDEN: The county says it's trying to make the best of a tough situation. Columnist Steve Lopez calls it a crime.
STEVE LOPEZ: For some people, maybe it's better than being on the street. But that doesn't mean that a jail is a therapeutic environment, and that doesn't mean that this is good public policy, and it doesn't mean that anybody should find this acceptable.
LYDEN: Steve Lopez is a writer for the L.A. Times. He's put county mental health here on the national radar. A series of his columns about a homeless violinist with mental problem became a film. Lopez says it's simple: Jail is no place for treatment. And research backs that up. The list of potential harm to the already sick is a long one. According to the Justice Department, people with psychological disorders are much more likely to be sexually victimized by fellow inmates, and the sheer size of this population makes it a target.
There are multiple federal investigations of abuse in the county jail system, and that includes Twin Towers, though it's another jail, the Men's Central Jail, which has attracted notoriety.
In response to the federal investigation, the L.A. County Department of Mental Health told NPR: We look forward to continuing collaboration and assessing and improving our services. Steve Lopez says that once treated, stabilized and released to the outside world, there are no guarantees for the mentally ill population.
LOPEZ: OK. What happens to people when they've done their time and they're dismissed? What then? Well, the sad news is that the majority of them are turned out onto the streets with no linkage to any kind of community-based treatment center. And this is a population that needs regular management. You know, that jail is not far from Skid Row. And somebody who comes out can take a short walk and end up, you know, in an outdoor drug market and fall immediately back into the same patterns that got them into jail in the first place.
LYDEN: We met one man who's done just that many times.
JAMES PUNTAR: My name is James Puntar.
LYDEN: James Puntar is 53. He grew up in Southern California and says he started doing drugs when he was just 9 years old. His addictions only got worse.
PUNTAR: By junior high school, I was eating acid. And by high school, I was smoking PCP. And then...
LYDEN: Puntar is the first person to admit he's made a lot of bad choices with his life. For many years, he lived on the streets, homeless. He's been arrested for drunk driving and petty theft. He made money dealing drugs. He's been in Twin Towers. Puntar also has chronic mental illness and a hodgepodge of diagnoses.
PUNTAR: Schizophrenia, depression, anxiety, mood swings, bipolar. I mean, I've seen a lot of doctors.
LYDEN: Inside jail, Puntar says he got help - medications and therapy. But it can be costly or difficult or all but impossible to stay on a med schedule unsupervised. And Puntar told us he soon abused drugs again outside. They did not quiet his mind.
PUNTAR: I'd be in the store, and I'd have money, and I'd hear people saying, he's in the bathroom, let's rob him. And I would barricade myself into the bathroom in the store. And the manager's out there - come out of there. It's the manager. And I'm like, how do I know it's the manager?
LYDEN: There were times when he couldn't find somewhere warm to sleep or the money to eat. And in those moments, he said, he thought about going back to the one place he could always count on.
PUNTAR: I actually went to the store, and I said, what's like the lowest level offense that I could commit to go to jail? And then I could, you know, have some food and get my head back together.
LYDEN: James Puntar says he now has two years sober. A nonprofit group called the Integrated Recovery Network provides him with housing and mental health services. And he's working towards becoming an addiction counselor. But he is 53 years old, and he says he's taking life one day at a time.
PUNTAR: People my age, they got jobs they've retired from, they've got houses, they've got kids who are grown and married, you know? Me, I got nothing. I ain't never had a wife, never had kids. You know, I was married to drugs, and my home that I had built for myself was prison. It was always there. It's there right now.
DR. LINDA TEPLIN: We have to remember that it is not the jail's choice to take these people.
LYDEN: Dr. Linda Teplin is professor of psychiatry at Northwestern University. She has researched incarceration and mental illness for more than three decades. Perhaps, she suggests, it's the jails that have come the furthest in that time.
TEPLIN: Jails have been very good nationwide now about recognizing the need to screen for severe mental disorder and also to provide treatment. This is certainly not a cheaper system, but it is easier to fund the building of new correctional facilities than it is to obtain funds to provide mental health care in the community.
LYDEN: What role would you say that stigma plays in these decisions?
TEPLIN: People with severe mental illnesses on the street are not the poster child for people with mental disorders. They may engage in bizarre behavior - walking down the middle of the street on a hot July night wearing a ski jacket. Many people are afraid of persons with severe mental illnesses who exhibit these symptoms. They're not a sympathetic group.
LYDEN: People throughout the system have acknowledged for a long time that it's not working properly. What would it take for this policy to change?
TEPLIN: If we had a major public figure take leadership in this area, perhaps because of an ill family member, I think that would do a lot to alert the public's sensitivity to the plight of people with severe mental illnesses being arrested instead of treated.
LYDEN: There are signs of change. Many cities have added training for police and created mental health courts that divert people from jail. But day centers and community centers around the country are often struggling, trying to raise funds to improve services and acceptance. The new Obama health care law may improve access to mental health care. That's certainly the hope. But L.A. County is also exploring another option: building a new jail at a cost of more than $1 billion. It would have one chief purpose: housing and caring for inmates who are mentally ill.
(SOUNDBITE OF MUSIC)
LYDEN: This is NPR News. Transcript provided by NPR, Copyright NPR.
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