If you read the title of this article and still clicked on it, know that I appreciate you, and your trust in me will be rewarded. I know that the national debt is not a sexy topic, but it’s extremely important to understand in the context of our current mental health crisis. Bear with me for a few minutes because I have to talk money for a while, but I will eventually bring it back to mental health and all will become clear.

US Deficits and the US Debt

So, unless you’ve been living under a rock, you’re probably aware that the United States has accumulated an enormous national debt. At the time of writing, it’s at about $39.5 trillion dollars, which is a little disturbing to me because it’s risen by one trillion dollars since I started making these videos in 2025. The reason the debt is so high is that every year since 2001, the US government has spent more money than it made in taxes. When this happens, it’s called running a deficit. If you look at this graph, you can see how much of a deficit the US has run each year since then.

Now, this graph only shows the deficit spending for each budget year. It does not show the total debt. Every year that the US runs a deficit, it has to borrow money to cover its obligations. This would be like if your paycheck didn’t cover all your bills at the end of the month, so you had to put one or two of your bills on a credit card.

As some of you may know, when you don’t pay off your credit card bill, you have to pay interest on the balance. That is, you owe more money than you originally borrowed, which is basically to compensate the people you borrowed it from for the time they have to go without their money. Credit cards often have rates upwards of 20% annually in the form of interest. So, if you borrowed $1,000 and didn’t pay it back, you would owe $1,200 after a year.

What if you not only didn’t pay back what you owe or the interest, but you kept charging the credit card for more purchases every year? You would quickly find yourself in a compounding interest trap. That is, the amount of money you owe back increases exponentially every year. This is why the US deficit graph looks so much different than the US debt graph, which looks like this:

This is basically what it looks like when America doesn’t pay off its credit card bill for 25 years. Not only is there a mountain of debt - $115,000 for every man, woman, and child in the country, but the interest payment on this debt is now at an all-time high of $1 trillion per year. In other words, if every living person in the US paid about $3,000 per year to the federal government, that would just barely cover our annual interest payment, without anything going toward the principal.

Okay, so I’m another person ranting about the national debt. You hear conflicting and confusing stories about this in the news all the time, so I would understand if you don’t know what to think about the national debt and whether we should be worried about it.

Well, I’m going to clear that up for you. It is a big deal, and you should be worried about it, and the worse it gets, the more your living standards are going to fall, and the worse our collective mental health will be. Allow me to explain.

Your Options if You’re in Debt

Let’s go back to using our credit card analogy. Imagine you owe a lot of money on a credit card – let’s say $80,000. However, your budget is maxed out, and you can’t currently afford to pay anything toward that credit card. What would you do to address the problem? Well, short of declaring bankruptcy, which doesn’t work for our analogy because the US can’t do this, you realistically only have 3 options.

First, you can make more money. If you find a job that pays you more, or you take on a second job, you’ll have more money, and you can put this additional income toward your credit card debt.

Second, you can spend less money. If you find a way to scale back your lifestyle somehow, maybe go from two car payments in your household to one, start packing your lunch every day, or cancel some of your subscriptions, then you might have a little extra money each month to put toward repaying your debt.

Your third option is to kick the can down the road by taking out another credit card to pay off the first one. Note that this last option doesn’t actually solve your problem. It postpones it. But it’s actually worse than that, because whenever you take on new debt, like opening a new line of credit, the people you’re borrowing from will look into your background to calculate how risky it is to lend to you. The riskier you are, the more interest they’re going to charge you to take out another loan. So, what happens is the more times you do this, the riskier you become, and the more creditors are going to charge you in interest on a loan.

Now, if you end up in credit card debt in real life, the smartest thing to do is a combination of the first and second strategies. Cut spending on anything that isn’t critical to your survival, and find a way to bring in more money.

Exploring These Options RE: the US Debt

The US government is in a very similar situation. We have been consistently running a budget deficit for 25 years, and we have accumulated a debt that is roughly the equivalent of our gross domestic product or GDP. If you don’t know what GDP is, a shortcut to understanding it is to think of it as all of the money that everyone in the country spent in a year. So, that’s how much money the US owes to it’s creditors. I used the figure of $80,000 for our analogy, because that’s how much money the median household in the US makes in a year. So imagine if your household made $80,000 in a year, but was also $80,000 in debt. That’s kind of the situation the US is in.

What options does the United States have for dealing with our debt? I’m going to take these in reverse order because you have to understand why options two and three won’t work before we get to option one.

Kicking the Can Down the Road Won’t Work

Option three, we can kick the can down the road. This is what the US has already been doing for the past 25 years. Every time our debt comes due, we take on new debt to pay off the old debt. The government prefers to call this refinancing but it’s essentially the same as using a new credit card to pay off the old credit card. Now, you might be wondering, who is it that keeps lending the US all this money so we can keep putting off our debts?

Well, it turns out that a lot of both individuals and foreign governments have been lending money to the US government. The vast majority of this debt is held in the form of bonds, which are held by investors inside the United States. A bond by the way is just a term for a loan that can be traded back and forth with other people. So, 75% of the US debt is owed to investors inside the US, and the remaining 25% is held by foreign investors and foreign governments.

This point is slightly tangential, but it’s important to note that when the US government runs out of money, it deals with this primarily by borrowing money from wealthy citizens inside the country, and paying them interest for the privilege of borrowing their money. This is basically what buying US bonds is. We will come back to this point in a couple minutes.

Now, the problem with all of this kicking the can down the road, or “refinancing” that the US has been doing, is that, like the person who keeps rolling their credit card debt over into other credit cards, the people lending us money are starting to view the US as a potentially risky investment. This means that people who used to lend us money at one or two percent interest are now expecting five percent interest. At the time of writing in July 2026, 30-year US bond yields are at 5.1%.

This is kind of like having an adjustable-rate credit card. It’s basically a nightmare scenario for the United States. Not only are you fighting exponential compound interest on the mountain of debt you’ve accumulated, but you’re facing a higher interest rate every year.

What ends up happening, which is what’s happening in the US right now, is that each year you have to borrow at a higher rate, which makes you take on debt at a faster rate, which means that next year you’re going to have to borrow at an even higher rate, and so on and so on.

Financial professionals sometimes call this a debt spiral. The longer it goes on, the harder it will be to climb out of the debt, and eventually we will hit a wall where investors believe the US will not be able repay our debts, and people will simply stop loaning us money.

Why We Can’t “Inflate the Debt Away”

Now, some of you may be thinking, “ah, but I know a way out of this.” We can just “inflate our debt away.” What it means when people say this, is that if inflation is high enough, then we can pay back our loans in currency that is less valuable now than it was when we borrowed it. I realize that this concept is confusing so I’ll give you a real-world example.

Let’s say you borrowed $300,000 at 5% interest to buy a house. However, the housing market is booming, and after 10 years, your house is worth $600,000. So, whoever lent you $300,000 at 5% interest would be owed about $490,000…but your house is worth $600,000 now, so you could easily sell your house, pay off your debt, and make a tidy profit. What has effectively happened here is that the value of your house inflated at about 7.2% annually, which was higher than the 5% interest you agreed to pay on the original loan.

This is essentially the concept of inflating away the US debt. We could pay down our debt easier if we let inflation run high, because it reduces the real value of the debt we have to repay.

So, the first problem with doing this is that inflation tends to hurt poor people the most, because they have nowhere to invest their money to protect it from inflation, and because they spend all their money, they can’t cut back on spending. I am not a fan of solving problems by offloading them onto poor people.

Now, the bigger problem with this strategy, and the reason that it won’t work for the US, is that people who lend money, especially in the amounts that we’re talking about, are not stupid. When they see the US inflation rate starting to rise, or if they even read a news story suggesting that it’s going to rise, they will respond by refusing to lend the US money unless we pay a higher interest rate.

So, to summarize, we cannot choose option 3, to kick the can down the road, because it forces us into a debt spiral which terminates in the US losing the ability to borrow any more money. This leaves us with options one and two.

Cutting Spending Won’t Work

Option two, if you recall, is to cut spending. Unfortunately, the US budget is extremely tight as it is. In 2025, the executive branch created the Department of Government Efficiency, which was tasked with cutting federal spending by any means necessary, rooting out any redundancies, and maintaining only critical spending. Billionaire Elon Musk was up on stage with a chainsaw apparently trying to demonstrate how aggressively he was going to cut wasteful spending. Ironically, the most generous analysis found that this new department only reduced spending by about two billion dollars, which is less than one one-hundredth of a percent of the federal budget, while the most critical analysis concluded that it saved no money, and ended up wasting about 20 billion dollars.

So, I think the reason that the government was unsuccessful here goes back to what we spend our money on. Our government spends about 21% of the budget on social security, 15% on Medicare, 11% on Medicaid, 14% on Defense, and 14% on interest on our enormous debt. This leaves about 25% of the budget remaining to be spent on education, transportation, research, agriculture, law enforcement, national parks, and so on. There’s really not a lot to cut.

The bulk of the spending is either on things that keep our population alive and healthy, or things that are essentially necessary investments in our future like education and research spending. I’m not the expert in defense spending, but this seems like something that could be trimmed. However, the defense sector is, other than the healthcare or financial sectors, probably the most entrenched lobby in Washington, so I don’t think you’d be able to cut that spending significantly even if you wanted to. And even the most ardent political hawks have been afraid to go after social security or healthcare spending for decades because they know this is a third-rail issue for their voters.

My point here is that option two, cutting spending, is not realistic. We tried it last year, it only ended up costing us more money, while cutting valuable services. This means that the only option remaining is option one: find a way to make more money.

We Need to Make More Money

Remember that governments make money through taxes. Making more money means making more from taxation. There are two ways to do this. First, you can increase overall economic growth in your country (the primary metric for this is GDP which we discussed earlier). If GDP goes up, this implies that on average, people in your country are making more money, which means that you as the government will collect more in taxes.

You Can’t Grow Your Way Out of This

So…I’m just gonna go ahead and rip the band-aid off now and tell you that increasing GDP in order to increase tax receipts isn’t going to work. The US has been growing at a very fast rate (something like 2.5-3% annually) for the past 40 years. The problem with that is that if you’re already growing very quickly, it’s hard to significantly increase your growth rate. It’s basically unheard of outside of a huge national event for a country to have growth rates higher than 3%, and when it does happen, it’s not sustained. On top of this, US GDP for the past several years has actually been falling, and as of the end of 2025 was only at 0.5% year-over-year.

Okay, so you can’t grow your way out of your debt. This leaves you with only one option. You have no choice but to increase tax rates. It’s literally the only thing that you can do. Even if you play kick the can down the road for another 5 years, you’re eventually going to hit a wall where you have still have to increase tax rates, and the longer you wait, the higher you’re going to have to set those rates.

You Can’t Tax Ordinary Working People

My question for you, is who are you going to tax? Are you going to tax working families who are already struggling to make ends meet? Go back to episode 1 of this series. This is why I started making these videos in the first place. Take a look at the financial situation of the average young person in the US. Now, are you telling me that you want to increase taxes on these people who are already financially underwater? They couldn’t pay your taxes even if they wanted to. So, you can’t increase taxes on working people.

I mean, I guess you could, but it’s probably not gonna end well. Ordinary people in the US are already upset that their living standards are falling. Putting additional taxes on them might make them feel like they have nothing left to lose. When this kind of thing happened in France in 1789, ordinary people overthrew the government and killed their leaders. I’m not advocating for this, I’m just telling you what happened.

Taxing Wealth is Our Only Option

So, where does this leave us when it comes to the US debt? We can’t do nothing. We can’t cut spending. We can’t tax the working class. This leaves us with literally only one viable option to address this problem. We have no choice but to implement a tax on wealthy people. Now, I have discussed this option, why we need to do it, how we need to do it, and myths saying that it can’t be done, several times on my channel. And I’m going to keep discussing it until everyone understands it.

The difference between taxing ordinary people and taxing the extremely wealthy is that the latter group will not change their spending patterns if you tax them. Wealthy people have a such a small marginal propensity to spend that you could tax them at significantly higher rates and you wouldn’t see any change in their behavior. It wouldn’t negatively impact the economy in the way that it would if you taxed working or middle-class families.

So - this is not optional. We literally either do a wealth tax, or our living standards will continue to decline just as they have been declining for the past 45 years. The debt will continue to grow until we eventually have to completely eliminate Social Security, Medicaid, Medicare, education spending, and every other program that keeps us afloat. How do you think that’s going to impact the mental health of our friends and neighbors? Every year that we drag our feet on this, our collective mental health declines.

How do you think it makes young people feel knowing that they’ll never buy a house? How do you think it makes parents feel when they can’t afford to feed their kids or turn the heat on? How do you think it makes kids feel knowing that their parents are working two jobs, and still can’t afford Christmas presents?

It’s Not Getting Bad; It is Bad

This isn’t some hypothetical situation that we’re in. More than a third of US adults can’t cover a $400 emergency. Household debt both in terms of housing debt and non-housing debt are both at all-time highs. One in three households are now cost-burdened, meaning that they spent more than 30% of their income on housing. More than 40% of people are in debt because of medical care they couldn’t afford. The percentage of our country’s wealth owned by the top 1% has grown from 22% in 1980, to 30% in 2025. In other words, one percent of the population owns 30% of the entire country. The US fertility rate is at an all time low of 1.6 per adult woman, because people are too poor and too discouraged to have kids. Almost a third of adults in their 50’s have literally nothing saved for retirement. Thirty-eight percent of Gen Z have used buy now, pay later apps to buy their groceries on installments.

Knowing all this, should we be surprised that homelessness, depression, and suicide are at their highest rates since World War 2? Our jails are filling up with people who are mentally ill because they’re poor, and because we keep cutting the social safety net every year. The percentage of jail inmates with a mental illness in 1980 was about 7%. These days we’re looking at rates of mental illness in jails closer to 40%.

Closing Thoughts

Things aren’t getting bad in the United States. Things are bad. We have arrived at the terminus of bad. And as the US debt grows every year, and we don’t do a wealth tax, which as I have explained is the only viable way to address the problem, more of our social programs are going to be cut, and living standards are going to continue to fall. So the question isn’t are things going to get worse. The question is, how much worse are we going to allow them to get before we do something about it?

Now, despite how depressing this all is, I am actually slightly more optimistic about this today than I have been in recent months. It seems like the collective frustrations of people in the US are starting to coalesce around this idea of wealth inequality. You are starting to see new faces on the political landscape who are winning their primaries on promises of taxing wealth, reducing inequality, and improving living standards. This is exactly what we need.

I think it’s fine for the left, right, and center to have their disagreements about various policies. But what we should all want, and all demand, from our leaders, is a serious plan to address the cost of living crisis, which includes a plan to address the national debt, which is slowly siphoning away our public resources every year. And the only way to do that, my friends, is to tax wealth.

My favorite show when I was in college was the Wire on HBO. Which, if you haven’t seen it, is the best show in the history of television. On the wire, there is a scene in which one detective is giving advice to another detective on a case they’re working together. He says…

This will be the first in a series of videos that I’ll do from time to time called “follow the money,” where I present an issue, and I explain what the monetary incentives are and who benefits. Since this is Jail Psychologist, I will also explain how each issue impacts or interfaces with the criminal justice and mental health systems.

For our first issue, I wanted to talk about universal school vouchers, sometimes referred to as “school choice,” also known as education savings accounts (or ESAs). I’m gonna say off the bat that if you have not done a deep dive into school vouchers in the past that pretty much everything about these things is confusing. There are lots of types of vouchers and tax credit programs and some of them are for specific purposes like helping students with disabilities, others are universal, some are federal while most are state funded, and every state is a little different. For our purposes, I am going to be looking primarily at state-level universal school vouchers and ESAs, which are basically the “no-strings-attached” version of government funding for private education.

When researching for this essay, I ran across a lot of misinformation. The issue of school vouchers has been highly politicized, with non-partisan monitoring groups, pro-education groups, and political think-tanks all publishing content that not only draws very different conclusions about universal vouchers, but sometimes can’t even agree on how much the programs cost.

Here is how I will approach this, which is the same way I approach every issue on this channel. I am going to evaluate this topic as objectively as I can and ask a simple question: Is this policy likely to improve the lives of ordinary people? Wherever that analysis leads, that’s where I’m gonna go. If the conclusion happens to align with one political party, that’s incidental. If you watched the first five videos in this series then you know that I have problems with both political parties in the US because they’ve both contributed to wealth concentration and the collapse of our living standards.

How Public Schools are Funded

Before we get into vouchers, I need to explain the basics of the public school system and how it’s funded. Public schools in the United States are funded by all three levels of government: federal, state, and local. The exact ratio of funds differs by state and sometimes even by school, but generally speaking, the state government covers about 45% of costs, local governments cover about 45% of costs, and the federal government covers the rest.

It’s worth noting that most states collect taxes in the form of income and/or sales taxes, while most local governments collect taxes via property taxes. This is relevant for us because it means that if property values in an area are low, then they don’t have much money for their local schools, while areas with high property values will have more money to fund their public schools. This creates an incentive for parents who want to send their kids to a good public school. If they buy or rent a home in a wealthy area, their kids will usually end up at better schools. In fact, this phenomenon of public school funding being tied to local property values means that in some extremely wealthy areas, public schools themselves are funded better than the vast majority of private schools.

The funding afforded to public schools is determined partially by how many students the schools have. The more students in the school, the more funding the school receives. For the purpose of today’s discussion, let’s say we have a public school with 500 students, and the school receives $5,000 annually for every student they have enrolled. This hypothetical school therefore has a budget of $2.5 million annually.

Now, it’s important to understand that since this school is funded by tax dollars, everyone in the community is paying for it, regardless of how many kids they have or don’t have in the school. You’re allowed to send one kid, 3 kids, or however many you have to the public school, and there is no direct charge to you as a parent for doing this. The taxes you pay are the same, even if you don’t have any children in the school. You don’t get to say, I want my tax money back because I don’t have any children and therefore am not using the school.

This would be a nonsensical thing to ask for anyway. Public schools are a public good that provides a public service. It’s not like you would call the city and ask for a tax refund from the fire department because you didn’t use the fire department this year.

We need these public services because not having them is potentially catastrophic. Think of what would happen if you had no public schools at all. No public schools means that poor families couldn’t afford to educate their children. Given that about half of US families are so financially stretched that they couldn’t cover a $1,000 emergency, this suggests that about half of the country’s school-age children would suddenly be without an education, and their parents would have to find someone to watch them during the day.

Even if you’re fine with that, remember that if the young people in your community are growing up without an education, that businesses are not going to want to move to your community because your workforce is uneducated. If these young people can’t find work, or can’t find work that pays a living wage, then they’re going to turn to crime and/or drugs to meet their needs. Once you consider all the costs from additional policing, incarceration, and lost productivity, I think you’ll find that skipping the investment in public education ends up costing taxpayers more than if they had just funded public schools from the beginning.

What are School Vouchers?

Let’s say you’re a parent. Your kid just turned 5-years-old, and will be eligible to start kindergarten at the local elementary school in the Fall. What if you don’t want your child to attend the local elementary school? The most common reasons for this would be if you either thought the public school was under-performing relative to other schools, or because you wanted your child to attend a religious school.

Let’s say you would rather send you child to a private school. Well, you’re actually welcome to do that. The US has no law banning the education of children in private schools. Note - I’m going to set aside homeschooling for the rest of this article because it’s kind of niche and interacts with universal vouchers in inconsistent ways depending on what state you’re talking about.

If you want to send you child to private school, you can. The cost of private schools for K-12 varies wildly depending on the grade and the school, but the cheapest private schools cost between $5,000-$8,000/year in tuition (depending on grade level), while the more “prestigious” schools cost as much as $30,000 or more annually. So, if you were to put your children in private school for the entirety of their K-12 education, your out-of-pocket costs would be between $65,000 and $390,000 per child. For reference, about 10% of all children in the US attend private school.

How do school vouchers play into this? School voucher programs basically say, “if you choose to send your child somewhere other than their assigned public school, then you will receive a voucher or coupon for roughly the amount of money that your assigned public school would have received to educate that child, which you may then spend on whatever private school you wish.”

How Vouchers Harm Public Schools

In our hypothetical school example where the school has 500 kids and receives $5,000 per student – imagine that 50 of these students decide to leave the public school in order to take a voucher and go to private school. The school’s budget will be reduced by 10%, from $2.5 million annually to $2.25 million. On this surface, this seems fine, because the school is still getting the same amount of money per student, so the cost to educate them should be the same. However, this reduction in students, and associated funding, does create a significant fiscal problem. That is, a lot of the costs of running a school are what we call “fixed costs.” That is, they just cost what they cost no matter how much you use them.

For instance, let’s say the school has a bus that takes some of the kids back and forth from home to school. You have to pay for the bus, and you have to pay for a driver. That cost is the same regardless of whether the driver picks up 5 kids or 20 kids. The same is true of things like maintenance on the school roof or the use of air conditioning. These things don’t cost less money because you have fewer kids in the school. What happens when public schools lose money because kids are taking vouchers to go to private school, is that the school is forced to reduce costs, but can’t reduce fixed costs. This means that they have to cut things like teacher positions, school counselors, or extra-curricular activities.

My point here is that the cost of running the public school, on a per student basis, is going to go up if a bunch of the students leave the school. So don’t be surprised if a school voucher program starts and the costs of public schools on a per-student basis go up, this is exactly what you should expect to happen.

Why Vouchers are so Expensive

Now, let’s talk about what I would consider the most fiscally problematic aspect of introducing a universal school voucher program. Remember our school with 500 kids in it? It turns out that about 50 additional kids lived in this school zone, but were already going to private schools before the school voucher program was introduced. When the state said that anyone can get $5,000 in school vouchers if they don’t go to public school, all 50 of these kids now get a school voucher, which increases the total cost of education for the government by $250,000, or 10% of their total spending, annually. Note that the anticipated return on this investment, from a taxpayer perspective, is essentially $0, because you’re not educating any more kids, or providing a higher quality education, than you were prior to the voucher program. The taxpayer is simply subsidizing a private choice that some citizens were already making prior to the introduction of the voucher program.

Following the Money in Arizona and Iowa

What we’re doing in this episode is following the money, right? Let’s look at who school voucher programs have benefited the most. I want to take Arizona as our example state, because they were the first state to adopt universal school vouchers.

A study by the non-partisan Grand Canyon Institute released in February of this year looked at the students who were receiving vouchers in Arizona once the program had been implemented. What they discovered was that about 75% of the students who received voucher money (to the tune of about $872 million) were students who were already being educated in private schools. In other words, the vast majority of the money that the government spent on vouchers went to wealthy families who didn’t really need it.

You could argue that this was unintentional. Like, “oh no we didn’t realize that this was a big taxpayer subsidy of wealthy families!” But this program has been in place for more than 3 years now. The Arizona legislature knows how this is working. The redistribution of public money to wealthy families is a feature of school voucher programs, not a bug.

Arizona is just one example of this. If you look into the universal voucher programs in Iowa, Florida, Arkansas, or Ohio, you find a similar pattern.

To make my next point, I want to move to Iowa, which implemented their universal school voucher program the year after Arizona. The average voucher in Iowa pays about $8,100 per student.

Imagine for a moment that you are in charge of a private school in Iowa. Let’s say that your annual tuition prior to the universal voucher program was $9,000, which is fairly typical for private high school tuition. What would you do if you learned that your state was going to cover the cost of the first $8,100 of tuition for every student, regardless of their family income?

Let’s consider your options and incentives:

· Your first option is to do nothing. You keep your tuition and services the same, and your students and their families get some financial relief.

· Your second option is to raise tuition, because you already know that the families of the children at your school could afford to pay the full tuition before the vouchers, so they can definitely afford to pay it with an extra $8,100 annually.

If you do raise tuition, you want to keep it modest. If you were to raise tuition by $8,100 then the families at your school would be furious because their school vouchers would be entirely eaten by this price hike. What you would want to do is increase tuition moderately so that at the end of the day the families attending your school still get a financial break, and your school can pocket some of that free government money.

How do you think Iowa private schools responded to these incentives? It turns out we don’t have to guess, because there’s a research paper which tracked changes in private school tuition after Iowa implemented their voucher program. It turns out that after the state’s voucher program went live, the average private school in the state increased their tuition by about 23%.

So before school vouchers, if the average school tuition was $9,000 annually, then families paid $9,000 annually. After school vouchers, the average school increased tuition by 23%, so for the sake of our example, to $11,070, and families paid $2,970. So, the family saved about $6,000 annually on tuition, and the school’s profits rose by 23%. I can’t tell you what the school did with that extra 23% in revenue. Maybe they increased teacher salaries, upgraded their facilities, or simply paid it out as bonuses to administrators. The thing about private schools is…they’re private.

To summarize what we’ve discussed so far, universal school vouchers significantly increase the cost of educating children, drain resources from public schools, subsidize wealthy families, and enrich private institutions. None of these things seem like desirable outcomes for a government program, especially in states where a lot of elected officials claim to be fiscal hawks. On top of this, since these programs effectively make the rich richer and the poor poorer, these universal vouchers contribute to the big problem that we’re always talking about on this channel, which is wealth inequality, otherwise known as asset concentration.

A quick refresher on how this works: If you give a starving family $8,100, they’ll buy food with it. If you give a working family $8,100, they might fix their fence, upgrade their appliances, or pay down their mortgage. If you give a wealthy family $8,100, they don’t really need it, so they’re just going to use it to buy assets. Go back to episodes 1-5 if you need a refresher on how this behavior causes wealth concentration and how wealth concentration causes population-wide mental health problems.

School Vouchers in the Context of the Criminal Justice and Mental Health Systems

How would we expect the criminal justice system to be impacted by school voucher programs which expend public resources while reducing the quality of public education?

We know that several variables are associated with increased academic achievement and increased graduation rates for students. These include: smaller class sizes, more experienced teachers, more access to mental health resources like social workers and psychologists, more extra-curricular activities, more school support staff, and better facilities. If increases in these variables means increases in graduation rates, then it stands to reason that decreases in these variables would be associated with decreased graduation rates. The introduction of universal vouchers tends to decrease all of these variables for public schools, reducing the chances that public school kids will graduate from high school.

What do you suppose happens to students with low academic achievement who fail to graduate from high school? They have reduced lifetime earnings, are significantly more likely to live in poverty as an adult, are significantly more likely to be incarcerated, are more likely to develop a substance use disorder, and have significantly higher rates of all-cause mortality. On top of all of this, data from the CDC indicates that failing to graduate from high school increases the risk of suicide by 30%.7

In other words, a kid not graduating from high school is basically a disaster, and the number of times this happens is undoubtedly going to increase because of school vouchers, which are simultaneously spending taxpayer funds to subsidize the education of wealthy families, and contributing to a mental health epidemic.

Summary and Conclusions

So…universal school vouchers are ultimately…bad. I mean, I’ll explain this one more time. 75% of the money from these very expensive, taxpayer funded school vouchers, is going to families who are already doing well enough financially to be able to spend thousands of extra dollars per year to send their children to private school.

The government is funded by taxpayer dollars, with a mandate to serve everyone. When it does this kind of thing, and spends public money to give gifts to wealthy citizens, the richest of whom don’t even pay income taxes anyway because of the buy-borrow-die loophole we discussed in episode 5, it makes it obvious to anyone paying attention, that rather than serving everyone, the government is primarily serving wealthy interest groups. This kind of government capture, by the way, is both a cause of, and a product of, extreme wealth concentration.

I make videos about how economic policies impact mental health. What do you think it does to the mental health of ordinary citizens, many of whom are struggling to feed their kids and pay their rent, to learn that their government is effectively stealing money from them and giving it to wealthy people? You don’t have to be a psychologist to answer that.

The solution to this problem is basically just to repeal all of the universal voucher laws. Vouchers themselves arguably have a place. I’m not actually against targeted school vouchers as a concept. I think they can be useful when they are made available to financially needy families who have children with special needs.

Let’s say you had a poor family who had a child who was deaf. Even the best-resourced public schools don’t have a lot of teachers who know sign language. In niche cases like this, I think it’s perfectly fine for the state to provide voucher support so that this child can go to a special school for deaf children where the entire academic environment is shaped to support their needs. I’ve been to some schools for deaf students, and if I were deaf, I would definitely prefer these schools over a public school.

That’s school vouchers and how they contribute to our collective economic and mental health problems. I think what you’ll see as we do more of these episodes in the future, is that a lot of the policies we’ll look at that have these very-well paid PR campaigns designed to make them look good, are, when you actually look at where the money is going, programs designed to redistribute wealth from ordinary people to the very rich. School vouchers happen to have the knock-on effect of de-funding the education of ordinary children, which is a nice bonus if you’re a rich person because these ordinary kids will grow up not knowing enough about what you’re doing to them to be able to fight back.

Fortunately, some of us, which now includes you dear reader, have enough education to see through this propaganda. The way we fix it is to vote better people into office. So…tell your friends, tell your family, tell your neighbors, tell your elected officials, not to support universal school vouchers.

Today we’re going to talk about the competence crisis. I’ll explain what the competence crisis is, why it’s a problem for state and county governments, and finally, why all the national organizations and task forces trying to address the crisis are, and I say this respectfully, wrong.

I want to preface this by saying that there are a lot of very smart and compassionate people working on this problem, who care just as much about our brothers and sisters struggling with mental illness as I do. And, just because I disagree with them about how to solve the competence crisis does not mean that I don’t respect them or that I’m not willing to work with them.

What is Competence?

Let’s start by explaining what competence is for our purposes and why we have a competence crisis on our hands. In the criminal justice system, everyone has a right to a fair trial. This includes your right to understand the charges against you, and to aid in your defense. If you cannot understand what you are being charged with, or you are for whatever reason incapable of aiding your attorney in your defense, then you are considered “incompetent.” You can technically be incompetent to do a number of things such as take a plea or waive your rights, but for our purposes, we’re talking about defendants who are deemed “incompetent to stand trial.”

An example of someone who is incompetent to stand trial might be someone who is psychotic and thinks his attorney is involved in a conspiracy with the president or someone who with an intellectual disability who can’t speak in complete sentences. When someone is found incompetent to stand trial by the court, everything basically stops until the issue of competence is resolved.

How do you know someone is incompetent? Basically, what happens is when one party in the case suggests that the defendant might not be competent, the judge will order two independent competence evaluations by mental health experts. This is usually a psychologist, but can also be a psychiatrist or a master’s level provider depending on the charges in the case and the state in which the trial is being held.

These two clinicians will meet with the defendant, conduct their assessment, and file a report with the court opining about whether the defendant is or is not competent to stand trial. As long as these two clinicians agree, the judge will confirm the finding. If they disagree, the judge will order a third competence evaluation as a sort of tie-breaker. Now, this is all boiler plate stuff but for the sake of completeness, it’s worth mentioning that the final decision about whether or not a defendant is competent is a legal decision and therefore up to the judge. In my experience, a judge has never overruled the findings of the assigned clinicians.

Competence Restoration

If the defendant is found competent, the case proceeds as usual. However, if the defendant is found incompetent, then the court has to issue an order for “competence restoration.” Traditionally, this involves sending the defendant to a state psychiatric hospital for 30 to 90 days where he will participate in activities designed to help him understand the legal system and work with his attorney. Competence restoration may, and in my experience almost always does, also include the administration of psychotropic medications. If the defendant refuses, these medications will be administered involuntarily.

If the state hospital can “restore competence,” the bar for which is not very high by the way, then the individual will then return to jail and his trial will resume. In the event that the hospital cannot restore competence, the individual will remain at the hospital and they will continue to work toward this goal. I have seen some patients spend years at state hospitals and then return to the jail to finish their trial, and I have seen some go to the hospital for 9 years and counting. However, in my experience most state hospital stays for competence restoration are about 3 or 4 months long.

That’s competence and competence restoration in a nutshell.

The Costs of Incompetence to Stand Trial

Why is it problematic for defendants to be found incompetent to stand trial and to require competence restoration? Well, if it only happened once in a while it wouldn’t be a problem. The issue is that it is happening much more frequently over the past 10 years or so. We’ll come back to the crisis part, but for now let me tell you why incompetence itself is a problem.

Like pretty much everything I talk about on this channel, this is a problem of money and incentives. What does this mean when it comes to competence? Well, it costs anywhere from $50 to $300/day to keep someone in jail, depending on which jail we’re talking about. Let’s just call it $100 to keep the math simple. It costs between $1,000 and $2,000 per day to keep someone in a state psychiatric hospital. Let’s again just call it $1,000 per day for simplicity.

When a person is found incompetent, they spend additional time, usually about 30 days, in jail at $100 per day billed to the county or municipal jail, while they’re waiting on a hospital bed. Then when they go to the hospital, they’re usually there for about 3 months at $1,000 per day. So just based on this, you’re looking at a cost of $3,000 to the county and $90,000 to the state every time someone is found incompetent to stand trial. So if you had say 500 people per year in your state who were found incompetent to stand trial, the cost of incompetence findings would be 1.5 million annually spread throughout the various county and municipal jails, and 45 million annually for the state. This is quite expensive by itself.

But, we’re not here to talk just about competence, but about the competence “crisis.” The rate at which people are being found incompetent to stand trial has been increasing nationwide, and dramatically in some states. For instance, just in my state, the rate of incompetence findings has increased by 477% between 2013 and 2025. This means that if the state had been paying 45 million a year for state psychiatric hospital services in 2013, they would need about 260 million in 2025 to provide the same level of services. You can see why the state is extremely concerned about his ballooning cost.

But, as it turns out, things are actually a little bit worse than this, because the states have generally not been keeping up with this rising level of need. In my state, while the number of people found incompetent increased by 477%, and I can’t finds specific numbers of beds for 2013 or 2025, but according to the Treatment Advocacy Center, my state actually lost beds between 2016 and 2023. So as the problem has gotten worse and we need more resources, we are actually losing resources.

And just like a pot that boils over on the stove, now we have a bigger mess than we started with, because the lack of resources relative to the need for those resources has created long wait times in jails for competence evaluations, and long wait times for state psychiatric beds. This is extremely frustrating for people like me, who have to manage some very sick patients in a jail setting for up to 5 or 6 weeks while they wait for competence evaluations, and then another 3 or 4 or sometimes longer months for a state psychiatric bed to become available.

This bottleneck of incompetence also causes problems for prosecuting and defending attorneys who have to keep showing up for continuances just to say on the record that, “Your Honor we’re still waiting on that competence evaluation” or “all parties are still waiting for transportation to a hospital when a bed becomes available.”

I’ve talked before about the problems this causes jails who are often overcrowded as it is. Jail populations are on the rise nationally, by the way. It even creates problems for the state psychiatric hospitals themselves, which are not only operating understaffed in many cases, but faced with increasing pressure to restore competence as fast as possible so that they can open another bed for someone else who has been waiting.

This Impacts All of Us

Now at this point you might be thinking, it’s a good thing I’m not in jail so this problem doesn’t impact me. But guess what? First of all, you’re a taxpayer. These increased costs at both the local and state level are ultimately coming out of your pocket. Second, the dramatic rise in demand for competence restoration means that more of the limited bed space at the state hospitals is taken up by competence restoration cases rather than mental health cases. The state hospitals were originally designed to help people who were placed there by the civil court because of severe mental health issues that couldn’t be treated in the community. But now, very few of these beds are available for that purpose, because so many are being used by the courts. In my state, something like 80% of the admissions to the state hospital thus far this year have been for competence restoration. So, if you have a loved one who really needs the services of the state psychiatric hospital, you would, ironically, have an easier time getting them in the hospital if they committed a crime than if you tried to pursue a civil commitment. The wait time for civil commitments by the way is higher than for forensic commitments, which most if not all states prioritize.

Now we know that a lot more people are being found incompetent today than 10 years ago, and we know that this is dramatically increasing costs for the states, and significantly increasing costs for local and county governments. And this is a national phenomenon by the way. It’s not just my state, and some states have more problems than mine.

National Organizations Tackling the Competence Crisis

There are several task forces and agencies that have been working on this problem. In preparation for writing this episode I read three publicly available papers and presentations on this. First, the 2025 PowerPoint presentation entitled “Forensic Issues in the State Mental Health System” by the National Association of State Mental Health Program Directors. Next, the 2025 report from the State Judicial Task Force to Examine State Courts’ Response to Mental Illness. Finally, the 2024 report from the Treatment Advocacy Center entitled, “Prevention Over Punishment: Finding the Right Balance of Forensic and State Psychiatric Hospital Beds.”

I want to give some constructive feedback about these reports. Once again, all due respect to the authors and contributors. I think they are trying really hard to solve a complicated problem. That said, respectfully, I think all of these reports come to the wrong conclusions. Now, they are extremely well-written and the descriptive statistics are phenomenal. But this is a systems issue, and I think that the people preparing these reports were treating the competence crisis as a problem to be solved, rather than seeing it as a symptom of a much more serious problem, which is why their plans to address it will ultimately fail.

Before I explain my reasons for this opinion, I want to first draw an analogy for you. Let’s say you have two buildings that were constructed right next to each other. The building on the left is a hospital. The building on the right is a factory. If someone gets hurt in the factory, they have to go next door to the hospital to get treatment.

Now imagine that every year, the number of injuries at the factory increased. Let’s say that between 2013 and 2025, the number of annual injuries at the factory had increased 477%. How do you address this problem? If it’s me, my first thought is, “what the hell is going on in that factory?” Why are so many people getting injured, and why are injury rates increasing?

Now, if you apply this analogy to what we’re seeing in the competence crisis, it seems to me that all of these work groups are trying to find ways to make the hospital more efficient, to triage injuries in the field, and to refer patients to other hospitals. None of them seem to be asking why so many people are getting injured.

So, I want to touch on each of the reports I mentioned, and then I will explain why so many more people are being found incompetent and what we will need to do to reverse this trend.

NASMHPD PowerPoint from 2025

So first, the PowerPoint from the NASMHPD. They actually collected quite a bit of data here and everything is laid out in charts and easy to understand. They have correctly identified the symptom we’ve been discussing as something that is widespread across the United States. They’ve also done a good job highlighting the rise in forensic beds and the fall in civil commitment beds. Take a look at the graph on page 18. That is striking.

The number of non-forensic admissions to the state hospitals fell by half in only 7 years. And think about this for a minute... The US population has been rising during that time. Where do you think all those people who didn’t get into a state psychiatric hospital went? I’ll tell you where they went. They can’t get a state psychiatric hospital bed, so they end up wandering around in the street untreated, often psychotic, until they get in trouble with the police and end up with me in the county jail. A lot of the same people who went to the state hospital 10 or 15 years ago on a civil commitment are now going back to the state hospital on a forensic commitment, because they didn’t have access to treatment resources when they needed them.

Later in this PowerPoint the authors list some statutory and policy changes impacting competence restoration. Most of them are fine. There are two things I wanted to comment on. First, on page 25 when they talk about conducting competence evaluations in outpatient settings. I really don’t think this is going to work and it’s probably not worth your time trying to do this. I’ve worked with literally hundreds of patients who have been evaluated for competence. I can’t think of any off the top of my head who were both stable enough to be in the community and would voluntarily come to an outpatient office for a competence evaluation.

Now, I know that some people used to do this, and maybe still do. About 14 years ago I worked with Dr. Stephen Ross in Fort Wayne, Indiana who is a well-known forensic psychologist out there. He used to have corrections officers transport patients from the jail to his outpatient office to conduct evaluations. But that was 14 years ago, and 2026 is a very different time. Jails nationwide are short-staffed, often by 20% or more. And given the number of inmates who need competence evaluations, there’s no way most jails are going to have the manpower to get a team of two officers together, transport the patient to an outpatient office, sit there for an hour or two for this evaluation, and then drive the patient back. It’s just a logistical nightmare. If a clinician wants to do a competence evaluation in my jail, they can either physically come into the jail or we can set them up on Zoom/Teams/Etc. I suspect most modern jails have a similar policy.

The other thing I wanted to mention was on page 28. The third bullet point, and maybe I’m reading this wrong, but it seems to be saying that because of the competence crisis, costs are being shifted from the counties to the state governments? If this is what they’re saying then I disagree with this. In fact, I would argue that it’s the opposite. The fact that state governments have reduced the number of available psychiatric beds by about 96% over the past 60 years has resulted in a massive shifting of both costs and liability from the state onto county and municipal governments, because now they have a bunch of people with mental illness roaming around the community and no way to get them into a long-term treatment bed. These people end up in the local jails, treated by my team, who I have to remind you is not allowed to bill Medicaid for services and has to pay for our medications at monopoly retail prices, and guess who foots the bill for that? County and municipal governments, as well as ordinary citizens and business owners who end up the victims of violence, theft, or property damage because there were no treatment options available for someone who is chronically mentally ill. So anyway, if I misinterpreted your PowerPoint slide, I apologize.

National Judicial Task Force Report

Let’s move on to talking about the report from the National Judicial Task Force to Examine State Courts’ Response to Mental Illness. This report was well-written, well-organized, and fairly comprehensive. I liked the statistics and the fact that they cited all their sources so I could read them myself. It was also nice to see so many organizations working together on this; page 19 lists a lot of organizations that I’ve heard about independently prior to reading this report.

Overall, I liked the spirit of this report and I don’t really disagree with any of their recommendations. However, this report is almost 60 pages long, and I didn’t see any mention of addressing the root causes of the competence crisis. If you think back to my analogy about the factory and the hospital…This report was focused exclusively on how to make the hospital more efficient and reduce hospital costs. It doesn’t address why the injury rate at the factory is going through the roof.

To some extent, I get this. You can only control what you can control. But if we don’t identify and address the cause of the problem, and instead we only try to react to it after it’s happened, then we’re ultimately wasting our time.

Imagine your roof was leaking and you had water coming in. And we’re over here making plans for how to get more buckets to catch the water and how to get more efficient mops, and how we can buy high quality towels to clean up all the spills. But ultimately, you have to fix the roof. I would like to see more discussion from the task force on how to fix the roof. After reading this report, it’s not clear to me that they know why the roof is leaking.

Treatment Advocacy Center (TAC) Report

Finally, let’s touch on the report by the Treatment Advocacy Center. Of the resources I reviewed, this was the one I liked the most. And this is because they come the closest to actually identifying the problem causing the competence crisis. I actually suspect that the writers at TAC may know what the problem is, but for political reasons they’re not saying it out loud. Anyway, the report itself is phenomenal, and it’s worth your time to read it.

A couple of things I wanted to highlight. On page two they give a nice overview of how many psychiatric beds the country has lost. Now, even if this was the only thing that has changed, it would be sufficient to explain why the system is clogged up. The math is simple, the US lost 96% of its psychiatric bed capacity in the last 60 years, while the US population has increased by about 80%. You don’t have to be a genius to see that by eliminating almost all of our state psychiatric beds we now have a crisis because demand far outstrips supply.

A lot of these reports focus on little tips and tricks to avoid moving people to the state hospital. But the thing is, the state hospitals were built for a reason. It was to take care of people who cannot function independently in society, and there will always be people who fit this description. So, in my opinion, anyone who thinks they’re going to solve the competence crisis without dramatically increasing the number of state psychiatric hospital beds is not a serious person. Don’t get me wrong, I like the creativity of some of the solutions discussed in these reports. I made a video on my channel about AOT and why I think it’s important. But you cannot just gloss over the fact that we have a catastrophically low number of state hospital beds. I won’t rehash my arguments from before, but if you want to know why we don’t have enough state psychiatric hospital beds, go watch my video from last month explaining this.

The other thing I wanted to highlight from the TAC report was on page 15. According to the report, 94% of state hospitals are reporting staffing shortages, and the reason for this is…surprise surprise, low wages.

I have done multiple episodes were I talked about this – I refer you back to episode 9 where I said that the primary reason for the correctional officer staffing shortage nationwide was low wages. To any legislators out there in charge of budgets: you have to pay market rates if you want competent people to come and work for you. You can’t say “we’re going to pay $15/hour for mental health technicians and $25/hour for corrections officers,” and then act surprised when no one wants to work for you. If you pay people what they are worth, I guarantee you will not have these kinds of staffing problems.

So, those are my thoughts on the reports we talked about.

Why We Have a Competence Crisis

When I said in the beginning of this article that the people working to resolve the competence crisis are wrong – I didn’t mean that their suggestions are bad, I just meant that they’re addressing the symptoms of the problem rather than the problem itself. The real problem is that a lot more people are being referred for competence evaluations in the first place.

So, now I’m going to explain to you why this is happening. I’m going to move kind-of fast here, so if you want a more thorough explanation then go read/watch episodes 1 through 5 of this series. The real problem we have is that economic conditions in the United States, for ordinary people, have been getting significantly worse over the past 45 years, which is causing a collapse in their living standards. And as I have repeatedly explained, living standards are strongly correlated to mental health outcomes. So, as you see more families struggling to make ends meet over time, you’re going to see a concurrent increase in the number of people experiencing mental illness.

The cost of inelastic goods and services in the US, and by that I primarily mean housing, healthcare, childcare, and groceries, have all outpaced wage growth, especially among low income families. This is going to continue to get worse every year – see my video from last week where I explained the data that will prove this.

I think that, a lot of the time, people like us… That is, academics who are looking at this problem from 30,000 feet, don’t have a visceral understanding of how economic pressures are weighing on everyday people. If you have a doctorate like me, or if you’re a judge, or if you’re a politician, you are not getting financially squeezed in the same way that ordinary people are. I’m not saying I know exactly how it feels either. But, I have 45 acutely mentally ill inmates in my special needs unit right now, and even if I could snap my fingers and cure their mental illness today, most of them would leave the jail homeless, with no job, looking at rents close to $2,000/month for a basic apartment. How could a person not be mentally ill in that situation?

So, the more financially squeezed people are, the more evictions you’re going to see, the more homelessness you’re going to see, the more incarceration you’re going to see, the more mental illness you’re going to see, and finally, the more findings of incompetence you’re going to see. And thus far, the data bear me out on this. All of these things are increasing.

So, what this tells us, is that in order to actually solve the competence crisis, you need to solve the underlying economic problems that are causing it in the first place. You need to find a way to either increase wages for ordinary people, or decrease living costs, preferably both. And as I have discussed previously, there’s basically no way to do this without implementing a tax on wealth, enforcing antitrust legislation, and rebuilding the social safety net. And unfortunately, our government has, for the past 45 years, and especially in the past 18 months, been doing the exact opposite of all of those things.

I’m going to try not to be too dramatic about this, but this is very frustrating. I’m sitting here knowing exactly what the problem is and what we need to do to solve it. But because other people don’t understand it, or aren’t willing to actually do anything about it, I have to just sit here and watch it burn.

I don’t really know what to do, honestly. I started this channel to explain exactly all of these things. I thought if only people could understand what is happening then they would get on board. Every two years I watch people continue to gleefully vote themselves into poverty, ruin their children’s futures, and continue to perpetuate a mental health epidemic.

So, I guess I’ll keep making videos because I don’t know what else to do.

If anyone actually wants to help fix this problem then feel free to reach out to me and we can put our heads together. You can email me - jailpsychologist@gmail.com.

I’ll be back with another article in a couple weeks - I’m sure I’ll find another systemic deficiency in our economy or criminal justice system to point out.

Over the past several videos, I’ve laid out a theory about the relationship between wealth concentration and mental health. The basic argument is that rising concentrations of wealth don’t just affect the economy—they affect how people feel about their lives, their futures, and their place in society.

I’ve received some feedback on these videos. Some people found the economic concepts difficult to follow, while others questioned whether this theory can actually explain what we’re seeing in the real world.

That’s a fair criticism. A theory is only useful if it helps us understand reality. More importantly, a good theory should allow us to make predictions.

Before making those predictions, it’s worth briefly reviewing the mechanism.

The Domino Effect

I think of this process as a line of dominos.

The first domino is wealth concentration. The last domino is population-level mental health.

Everything in between is the chain reaction.

Imagine a society in which a relatively small percentage of people control most of the assets. By assets, I mean things like stocks, businesses, investment properties, and other forms of wealth that generate income.

Assets produce profits. The more assets someone owns, the more money those assets generate.

At a certain point, wealthy asset owners begin earning far more money than they could ever reasonably spend on themselves. If someone earns a billion dollars per year from assets, they don’t suddenly start consuming a billion dollars worth of goods and services. Most of that money gets reinvested into additional assets.

This creates a feedback loop.

The people who already own large amounts of wealth continually acquire more wealth-producing assets. As demand for assets rises, asset prices rise as well. Housing is one example. Houses are places to live, but they are also assets.

Businesses are assets too.

The managers of those businesses are expected to maximize returns for shareholders. Since labor is often one of a company’s largest expenses, businesses have strong incentives to keep wages as low as possible while still maintaining a workforce. At the same time, they are incentivized to keep prices as high as the market will tolerate.

As wealth becomes increasingly concentrated, large firms gain the ability to acquire competitors, increasing market concentration. This creates opportunities for monopolies and oligopolies, which can drive prices higher for consumers. It also creates opportunities for monopsonies, which can put downward pressure on wages.

The result is a feedback loop in which the cost of living rises while the purchasing power of ordinary workers declines.

That is the key point.

High concentrations of assets create a system that tends to drive the cost of living up while simultaneously limiting wage growth.

At first, this creates instability for low-income households. Eventually it begins affecting the middle class as well.

People find it harder to buy homes. Harder to raise children. Harder to save money. Harder to retire.

As these pressures accumulate, more people begin to realize that their economic circumstances are unlikely to improve. They work hard but continue to fall behind. Over time, that creates a sense of helplessness and pessimism about the future.

In my view, that is one of the primary pathways through which wealth concentration contributes to rising rates of depression and other mental health problems.

In short:

Wealth Concentration → Declining Living Standards → Economic Insecurity → Helplessness → Population-Level Mental Health Problems

How We Know Wealth Taxes Are Necessary

If asset concentration is the problem, then reducing asset concentration must be part of the solution.

That doesn’t necessarily mean eliminating wealth inequality altogether. It does mean finding ways to prevent assets from becoming concentrated in fewer and fewer hands over time.

My view is that some form of wealth tax is necessary to accomplish this.

Without it, the cost of housing, healthcare, education, childcare, and other necessities will continue to rise faster than wages. Living standards will continue to decline for ordinary people, and rates of depression and suicide will continue to increase.

That is the theory.

Now comes the part that matters most: the predictions.

Economic Predictions

If the United States does not implement some form of wealth tax, I predict the following.

1. Housing and Healthcare Will Continue to Outpace Wages

Housing and healthcare costs will continue rising faster than wage growth.

If homeownership feels out of reach today, it is likely to become even less attainable in the years ahead.

2. First-Time Homebuyers Will Get Older

The average age of first-time homebuyers will continue to increase.

I also expect parental financial assistance to become increasingly necessary for people purchasing their first home.

3. Institutional Ownership of Housing Will Increase

A larger share of single-family homes will be purchased by private equity firms and other institutional investors, while first-time homebuyers will make up a smaller share of the market.

4. Birth Rates Will Continue to Fall

Young adults are increasingly delaying or avoiding having children because of economic pressures.

I also expect fertility rates to become increasingly stratified by wealth. Wealthier families will maintain relatively stable fertility rates, while the largest declines will occur among middle- and working-class households.

5. Marriage Will Be Delayed

The average age of first marriage will continue to rise.

People generally do not like entering marriage when they feel financially unstable.

6. Multigenerational Housing Will Become More Common

As housing becomes more expensive, more families will share living space.

I expect multigenerational households to become increasingly common over time.

7. More Older Adults Will Remain in the Workforce

Retirement is becoming increasingly difficult to achieve.

As a result, labor force participation among people aged 65 and older will continue to increase as more individuals work longer to maintain financial stability.

8. The Stock Market Will Continue to Outperform the Economy

One of the most direct indicators of asset concentration is the persistent tendency for asset prices to rise faster than the broader economy.

I expect the stock market to continue outperforming both economic growth and inflation.

The reason is straightforward. Wealthy asset owners have a low marginal propensity to consume. They simply cannot spend all of the income generated by their assets. Most of that money gets reinvested.

At the same time, much of the money flowing into financial markets is used to purchase existing assets rather than create new productive businesses.

As a result, asset prices can continue rising even when ordinary people are struggling with affordability.

9. The National Debt Will Continue to Increase

I expect the national debt to continue growing.

In my view, there is little political appetite for significant spending cuts, and ordinary households are already under considerable financial strain. That leaves policymakers with limited options.

Without some mechanism for redistributing wealth, I don’t see a realistic path toward reversing the long-term growth of the national debt.

10. Household Debt Will Continue to Increase

Credit card balances, household debt, and buy-now-pay-later debt will continue rising.

Savings rates will continue falling.

I also expect increases in mortgage defaults, vehicle repossessions, and other signs of financial distress as households struggle with affordability.

Mental Health Predictions

If the economic trends above continue, I expect corresponding changes in population-level mental health.

11. Depression Rates Will Continue to Rise

This is the central prediction of the theory.

As wealth concentration increases and living standards decline, more people will become pessimistic about their future prospects. I expect rates of depression to continue increasing as a result.

12. Young Adults Will Report the Highest Levels of Depression

I expect depression rates to remain highest among young adults.

Older adults often possess assets, home equity, or retirement savings that provide at least some protection from economic instability. Young adults, by contrast, are facing the full force of rising housing costs, declining affordability, and increasing uncertainty about the future.

13. Suicide Rates Will Continue to Rise

If people become increasingly hopeless about their future, I expect suicide rates to continue increasing as well.

14. Homelessness and Evictions Will Increase

As affordability continues to deteriorate, I expect homelessness and evictions to rise.

15. Mental Illness Within the Criminal Justice System Will Increase

This prediction is somewhat more difficult to test, but I expect several trends to emerge.

I expect the percentage of incarcerated individuals with serious mental illness to increase.

I expect jail suicide rates to increase.

I also expect the number of forensic and civil referrals to state psychiatric hospitals to continue rising.

I may only be able to collect reliable data on some of these measures within my own state, but I intend to monitor them over time.

A Theory Is Only Useful If It Can Be Tested

These predictions are admittedly bleak. But if my theory is correct, these are the outcomes I would expect to see over the next several years.

The good news is that these predictions are measurable. We don’t have to guess. We can look at housing affordability, fertility rates, depression rates, labor force participation among seniors, household debt, homelessness, and other indicators to see whether the theory holds up.

That’s ultimately how science works. We develop theories, make predictions, and compare those predictions against reality.

For those of us who work in mental health, understanding these broader economic forces is especially important. If economic insecurity is contributing to the mental health problems we see every day, then we need to understand that relationship. Otherwise, we risk treating symptoms while ignoring the conditions that helped create them.

Whether you agree with my conclusions or not, I think these are conversations worth having. And if the predictions above prove accurate, we will need to take the problem of wealth concentration much more seriously than we do today.

Why Are There So Few Long-Term Psychiatric Beds?

I work with a lot of families of people living with serious mental illness. One question comes up over and over again:

“My loved one has been struggling for years. He keeps cycling between jail, psychiatric hospitals, and homelessness. He’s clearly unable to care for himself. Why can’t I find a long-term facility where he can stay?”

It’s not just families asking this question. Mental health providers, medical staff, law enforcement officers, and correctional workers often ask some version of the same thing. Most people instinctively assume that there must be long-term psychiatric facilities for people who are chronically disabled by severe mental illness. What surprises them is how difficult those facilities are to access—and how few of them actually exist.

The short answer is that America has dramatically reduced its long-term psychiatric treatment capacity over the last several decades, and we have never replaced it with anything capable of meeting the need.

The Small Group of Patients Who Need More Than Outpatient Care

Most mental health conditions can be treated successfully with therapy, medication, or a combination of both.

However, there is a smaller group of patients for whom that isn’t enough. Some repeatedly stop taking medications that are necessary to keep them safe. Others remain unable to care for themselves even when treatment is available. Mental health professionals often refer to these individuals as being gravely disabled by their illness.

People who become dangerous or incapable of functioning when they are not receiving treatment typically require regular supervision. In practice, that means a facility with around-the-clock care and some mechanism to prevent patients from simply walking away when they are too ill to make safe decisions.

Community psychiatric hospitals provide this type of care—but only temporarily.

The reason is simple: insurance companies, including Medicaid, generally limit how many days they will pay for psychiatric hospitalization. Once coverage runs out, pressure builds to discharge the patient, whether or not the underlying problem has truly been resolved.

The Facilities We Need Already Exist—Sort Of

The closest thing we have to a long-term psychiatric treatment system is the state psychiatric hospital.

These facilities are designed to serve people with severe mental illness who are not responding to treatment in the community. Unlike community hospitals, they are not intended to operate on a strict timetable. Patients can remain there for extended periods if necessary.

At least in theory.

In practice, there are several major problems.

1. We Don’t Have Enough Beds

The United States has lost roughly 95% of its state psychiatric hospital beds since the deinstitutionalization movement began in the 1950s.

The result is exactly what you would expect: demand far exceeds supply.

Recent research suggests that the United States would need to at least double its state psychiatric bed capacity to meet current needs. Because there are so few beds available, wait times can stretch for months. In some areas, waiting four or five months for a state hospital bed is not unusual.

When families ask why their loved one cannot be admitted to a state hospital, the answer is often frustratingly simple: there is no room.

2. Hospitals Face Pressure to Discharge Patients Quickly

State psychiatric hospitals do not impose strict time limits on treatment, but that does not mean patients can stay indefinitely.

There are important legal safeguards. Courts regularly review cases and require hospitals to justify continued hospitalization. Patients also have opportunities to challenge their commitment if they believe they are ready for discharge.

Those protections are necessary.

The more significant issue is the pressure created by bed shortages.

When dozens—or hundreds—of people are waiting for admission, administrators and treatment teams face constant pressure to move patients through the system. Every occupied bed is a bed that cannot be offered to someone else.

As a result, some patients are discharged before they are truly ready to live independently in the community. I’ve seen this happen multiple times. If more beds were available, treatment teams could focus solely on clinical readiness instead of balancing patient needs against lengthy waiting lists.

3. Psychiatric Beds Are Increasingly Occupied by Forensic Patients

State hospitals do not serve only civil psychiatric patients.

They also house individuals who have been found incompetent to stand trial.

The Constitution prohibits criminal prosecution of someone who cannot understand the charges against them or assist in their own defense. When that happens, courts often order the person to a state psychiatric hospital for competency restoration treatment.

These patients receive treatment and education designed to help them understand the legal process well enough to participate in their case.

The problem is that competency restoration patients are competing for the same limited bed space as people with severe mental illness in the community.

According to a 2024 report from the Treatment Advocacy Center, forensic patients now occupy more than half of all state psychiatric beds nationwide. In my state, the figure is closer to 75%.

That means community mental health patients are competing against court-ordered referrals for an already scarce resource.

The Problem Is Not Complicated

At its core, the psychiatric bed shortage is a supply problem.

We have more people who need long-term psychiatric care than we have places to put them.

There are two obvious solutions:

1. Build more state psychiatric hospitals or expand existing ones.

2. Change insurance regulations so patients can remain in community psychiatric hospitals for as long as treatment is medically necessary.

Most people agree these ideas make sense.

The obstacle is not conceptual. It’s political.

Why Haven’t We Fixed This?

Like many public policy problems, the answer comes down to incentives.

Expanding psychiatric treatment capacity costs money. Not an enormous amount by federal budget standards—but enough that someone has to decide to pay for it.

A recent estimate suggested that the United States could largely solve this problem by increasing annual spending on state psychiatric hospitals by roughly $14 billion per year.

For most people, $14 billion sounds enormous. In the context of a federal budget measured in trillions, it is relatively modest.

It’s also worth considering the costs we already absorb when people with serious mental illness do not receive adequate treatment. Jails, emergency rooms, homeless service systems, law enforcement agencies, and families all end up carrying part of that burden.

The question is not whether we pay for untreated mental illness. We already do.

The question is whether we want to pay for treatment instead.

The Politics of Mental Health Funding

Most legislators want to remain in office. Their decisions are heavily influenced by what they believe voters will support.

Public opinion creates a difficult balancing act.

Surveys consistently show that Americans believe the country is experiencing a mental health crisis. Large majorities support improving mental health services.

At the same time, large majorities also believe their taxes are already too high.

This creates a familiar problem: people want better services, but they often oppose the mechanisms required to fund those services.

As a result, broad tax increases are politically difficult. Any effort to expand psychiatric bed capacity would likely require either reallocating money from other parts of the budget or creating a targeted funding source.

Both options come with political challenges.

Military spending, healthcare spending, correctional spending, and other large budget categories all have powerful constituencies that resist reductions.

One Possible Funding Approach

One potential solution would be targeted taxes on alcohol and, in states where it is legal, cannabis products.

Based on current sales figures, even a relatively modest tax could generate enough revenue to substantially expand psychiatric bed capacity nationwide.

There is also a policy argument for linking funding to these products. Alcohol and cannabis can contribute to addiction and mental health problems for some users, creating costs that are ultimately borne by taxpayers through healthcare, social services, and the criminal justice system.

Critics would correctly point out that these taxes are regressive, meaning they place a proportionally larger burden on lower-income individuals.

If the goal is a progressive funding mechanism, we could simply tax wealth, as I have repeatedly suggested in previous articles. I won’t get back on that soapbox today.

The Bottom Line

America’s psychiatric bed shortage is not a mystery.

We dramatically reduced long-term psychiatric capacity over several decades. The remaining facilities are overwhelmed. Many of their beds are occupied by forensic patients, and the system lacks the resources needed to meet current demand.

The result is a revolving door that many families know all too well: psychiatric crisis, hospitalization, discharge, homelessness, arrest, jail, hospitalization again.

The solutions are not especially complicated. We know how to build psychiatric hospitals. We know how to fund healthcare systems. We know how to expand treatment capacity.

The challenge is deciding that the problem matters enough to invest in solving it.

Until we do, families, hospitals, jails, and communities will continue to bear the consequences of a mental health system that simply does not have enough places for its sickest patients to go.

Today I want to talk about probation. For those of you who haven’t been following along up to this point, let me start by explaining what probation is. Probation is a form of supervision by the court. There are two primary ways a person gets on probation. The first way is what’s called a pretrial diversion agreement. If a person is charged with a small crime like a misdemeanor or a low-level felony, the prosecutor will sometimes offer them a deal – you voluntarily accept court-supervision, and in return, your case is dismissed at the end of the supervision period – assuming you complied with all of the terms of your supervision. The other way a person can be placed on probation is through a plea deal or sentencing. This is basically the same thing as the first way, but the difference is that once it gets to this point you’ve plead guilty to a crime, which means you’ll have the crime on your record, rather than a dismissal.

Technically, a judge could give you probation as a sentence when you go to trial and lose. But here’s a little insider information for you. This basically never happens. This is because first - courts are not going to spend their time and money on a trial over a misdemeanor; they’re just not. What they’re gonna to do is keep continuing your court date over and over until you’ve spent so much time in jail that they can eventually just let you out on a time-served plea. I’ve worked in a large jail with an ADP of 1,000 for 9 years, and I have never seen a misdemeanor case go to trial. The second reason you don’t see probation assigned is that if you force a judge to hold a trial, and then you lose, they’re going to hit you with a significant sentence which I guarantee will be more than probation. This is because trials are expensive in terms of both time and money, and the court is not going to look kindly on you wasting their time by making them have a trial over something that a jury of your peers convicted you of. Does this disincentivize people taking their case to trial? Yes. Is that ethical…ehhh. But like it or not, this is usually how the system works.

Okay with that aside over, how long is probation and what are the conditions? Well, there isn’t really a one-size fits all answer here. It’s going to depend on several variables like the laws in your state and municipality, the culture of your legal system, the judge assigned to your case, the options available for supervision (for example, not every jurisdiction has the ability to put probationers on ankle monitors or alcohol monitors), and finally, the structure of the probation system in your jurisdiction. I know that’s a lot but nationally, probation is a bit like the wild west and every jurisdiction does it a little differently.

That said, I’ll give you a general roadmap. Probation is most often assigned for a period six months or one year. During that time, you’ll be expected to meet regularly, usually once a week or once a month with your probation officer. This could be remote depending on your jurisdiction but in-person meetings are much more common. The reason for this is that drug testing is routine for most probation departments, and you can’t do a drug test remotely. Might as well get it done at the same time you’re meeting with your PO.

Typically, probation is structured in such a way that your supervision is tight in the beginning, and you gradually get more freedom as you demonstrate compliance with the conditions of your probation. For example, you might start off living in community corrections, with an ankle monitor, and meeting with your PO once per week. After 3 months you get to move home and your meetings with your PO are once every two weeks. After 6 months you get to take your ankle monitor off. After 9 months you meet with your PO once per month. Again, this isn’t how probation is always structured, it’s just a basic example to give you a feel for how it works.

The general idea of probation is that a lot of people do something bad one time, but are not necessarily bad people, and if you can avoid putting them directly in jail then you can spare the county the jail costs while also allowing the individual to continue to live and work in the community. This is, conceptually, a win-win for everyone. I know I’m usually making videos were I’m dunking on policies, but I do think the concept of probation makes sense. It should exist. I’m not trying to abolish probation.

But the thing about probation is, it only works if you do it right. Think of it like surgery. A surgeon makes a plan for an operation. He doesn’t just blindly start stabbing around and hoping for the best, and doesn’t treat every patient the same. Good probation is strategic, well-thought-out, and tailored to the risks and needs of the probationer.

So here is the part where I explain how probation can go off the rails and end up creating the very problem that it was intended to solve. Remember when you’re evaluating a program or policy, you should always be thinking in terms of economics and incentives.

Okay so the first thing to keep in mind about probation is that most of the time when people get their probation revoked, it’s due to technical violations, not because they committed new crimes. A technical violation is basically any breaking of the rules that are set in your probation. It could be that you missed an appointment, failed a drug test, didn’t pay your fees, stayed out past curfew, or were out-of-bounds on your ankle monitor. Now – the consequence of a single technical violation is going to depend on circumstance, the culture and procedures in your jurisdiction, and the attitude of your probation officer. Sometimes a single violation can get your probation revoked. Other times your PO might give you a warning or petition the court to modify the conditions of your probation – this is sort of like them tightening the rules on you because you broke them.

In any case, if you get too many violations your PO or judge are eventually going to revoke your probation and send you back to jail. From a systems perspective, having a lot of probation revocations is a bad thing. This is because you essentially wasted the court and everyone else’s time and money to setup probation, and then you end up sending the person back to jail which costs more time and money.

So – how is this relevant for our discussion? If you make the conditions of probation too cumbersome for the probationer, then you’re basically setting them up to fail, which will result in them being incarcerated once again, and causes your criminal justice system, ultimately, to spend more time and money than it would have if you never had a probation program in the first place.

So what does this look like in practice? What are some examples of probation conditions that are overly cumbersome? Well, there are several – but for the sake of time I just want to highlight two of them, which are probation fees and drug testing.

So, probation fees are very common across the country. The idea of probation fees is two-fold. First, they are supposed to generate revenue for the criminal justice system. Someone does a crime, gets probation, and paying fees is sort of like a way of making restitution. The logic is, if you’re the one whose behavior required the use of public resources, then you should bear the cost of reimbursing the public. Second, it gives the probationer some “skin in the game” if you will. They can’t just sit at home not working or doing anything. The need to pay fees means the probationer needs to work, and gives them an incentive to get off of probation.

The problem is that probation fees accomplish neither of these things and their main effect is to make it more likely that people go back to jail. This of course increases the cost of the criminal justice system as a whole, thereby defeating the whole purpose of probation.

Let me explain. The core argument for probation fees rests on the assumption that the probationer is financially stable enough to make these payments. If the probationer is having financial problems, then piling probation fees on top of these financial problems puts the probationer in a no-win situation. He can either pay his rent or pay his probation fees. If he skips the fees, he goes back to jail. If he skips rent, then he gets evicted, which will almost certainly cause him to lose his job, and since, as we discussed in the previous episode, it’s no longer legal to sleep in public places in many jurisdictions, he will be arrested for being homeless.

Effectively, if you run out of money, you go to jail. This is basically how America works. Probation fees simply make this outcome more likely than it would have otherwise been. In short, probation fees really shouldn’t exist because they generally do more harm than good. However, if a government insists on using probation fees, they should make absolutely sure that the probationer can afford them. As we said earlier, probation conditions need to be surgical and tailored to the probationer.

Now, for another example of how probation conditions can be overly cumbersome, let’s talk about drug screens. Conditions of probation often require probationers to submit to drug screening to prove that they have not been using illegal substances. The idea here, which is not totally without merit, is that drug use is associated with criminal activity. If you could somehow ensure that probationers were not using drugs, then the assumption is that they are less likely to be committing new crimes as well.

And the problem here isn’t drug-testing per se, but it’s charging probationers for drug screens, and sending them back to jail for positive drug tests. The fees are problematic for the same reason that probation fees are problematic. People on probation are often financially strapped as it is – the last thing they need is to be spending what little money they have on drug testing.

Now, the other problem is that a lot of judges will violate someone’s probation for a positive drug screen. This doesn’t really make sense to me. First, relapse is part of substance addiction. If it were easy to quit, we wouldn’t call it an addiction. Second, you have to remember that substance abuse is not a core problem, but rather a symptom of a larger psychological issue. I’ve never met a patient whose life was just fine and they randomly developed a substance use problem. Substance abuse is almost always a response to unprocessed trauma.

The example I often use to explain this is the Vietnam war. In a 2017 study, Hall and Weier reviewed opioid use rates among soldiers in Vietnam, and then looked at opioid use disorder rates among soldiers once they had returned to the United States. They found that 34% of US soldiers in Vietnam used opioids and 28% met the criteria for an opioid use disorder. However, once they returned home to the United States, the rate of opioid use disorders among soldiers fell to only 1%. Soldiers moved from an extremely chaotic and scary environment, to a safe environment with friends, family, and predictability. This, to me, is very strong evidence for the argument that people develop substance use disorders primarily due to stress, anxiety, and depression.

So, the point of this digression is that putting people back in jail because they used drugs, which they’re probably doing because they have emotional problems and/or lack better coping skills, is antithetical to both the treatment process and the concept of probation.

My advice based on this, is that you shouldn’t charge people fees for being on probation or charge them for mandatory drug tests. The probation itself is the sentence, don’t add a financial burden to people who are trying to get their lives back on track.

Now, the last thing I want to talk about here are for-profit probation management companies. Some counties, because they lack the time or the technical know-how, will farm out their probation department to third-party for-profit companies. These companies handle everything from managing the probationers, setting appointments, setting and collecting fees, and reporting on progress to the courts. There are two very obvious problems with farming out your probation to a third party.

First, the whole point of these companies is to make money. The way that they make money is by charging more for the service than it costs to provide it. So, no matter how you look at it, it would be cheaper for the taxpayer if you just established your own probation department and ran it yourself.

Second, there is a mismatch in incentives between the legal system, the welfare of the probationer, and the profit motive of the private probation management company. The legal system, primarily, wants people to stop getting in trouble and to stay out of jail. However, the private probation management company financially benefits from having people on probation for a long time. The longer someone is on probation, the more fees the company can collect. Meanwhile, the probationer is saddled with a greater financial burden than he would have otherwise had, which, paradoxically, causes him to be more likely to end up back in jail.

Now, in case you’re wondering if this is just me being prejudicial against for-profit companies, I’ll give you a real-world example of how this works. The town in question is Greenwood, Mississippi. I’m just going to give you the cliff notes here but I will link the full article from the Atlantic that goes into more detail. In 2015 Greenwood was financially struggling, and a private company called Judicial Corrections Services came to them with an offer they couldn’t refuse. The company offered to run their probation department for them for free. The town wouldn’t have to pay anything, and the company would pay for their services through fees collected from probationers.

How did this work out? Well, within 8 months of Judicial Corrections Services taking over probation services, a full 10% of the town was on probation. For context, nationally, about 1.1% of citizens are on probation. So Greenwood had a probation rate almost 10 times higher than the national average. The reason for this was that Judicial Corrections Services was hitting people with so many fees that they couldn’t afford to pay, that people quickly fell behind, and when people couldn’t pay their fees, this was considered a violation of their probation, which caused them to be placed in jail, creating this vicious cycle where they accumulate probation debt without being able to work enough to pay it off. I have more examples of private probation companies that behave in this way so reach out to me if you need them, but we’re already running a bit long on this video.

So, so summarize what we’ve talked about today. Probation as a concept is fine. It makes sense to give people a little extra support and supervision after they’ve been in trouble with the law. However, probation is a balancing act, and you have to be careful not to overburden people with onerous conditions, especially financial ones, or else you end up creating the very situation probation was designed to avoid – sending people back to jail.

Transcript (I’m experimenting with posting the video transcript rather than just giving the bullet points. Let me know if anyone has feedback or liked the other approach better):

Welcome back to Jail Psychologist. Today I want to talk about bans on homeless encampments and the impact these are likely to have on jails, municipal budgets, and people with mental illness. As is typically the case here, I’m not gonna to weigh in on whether banning homeless encampments is morally right or wrong – I’m just going to talk about whether they’re gonna work and the consequences of their implementation.

So there was a supreme court case in 2024 – Grants Pass v. Johnson in which the Supreme Court ruled that municipal and state governments can, if they so choose, make it illegal to camp, in other words, to live, on public property. This decision is a bit problematic because if you can’t afford a house or an apartment, and you can’t setup camp on public property, this effectively makes it illegal to be poor.

But – set that aside for the moment. The reason all of this has become a hot button issue in the past few years is that 1) homelessness has been rising, and 2) businesses and people who are a little more affluent do not like having to see or walk around homeless people in the ordinary course of their days. According to the US Department of Housing and Urban Development, homelessness has increased by 40% in the past 10 years. There are lots of hypotheses about why this is happening – but my experience tells me that the most likely explanation is that the cost of living has been outpacing wages since the 1970s. If I am correct, we are going to see homeless continue to worsen until our government makes some of the changes I mentioned in Episode 5 of this channel.

So – at least 48 states now have some sort of law on the books banning homeless encampments. And this is another one of those situations in which I don’t really have to speculate on what will happen when local governments start enforcing these bans. One of the reasons that I’m perennially frustrated by some of the policy issues we talk about on this channel is that it’s sort of obvious that these policies don’t work. All you have to do is search the internet for how these strategies have worked in the past, and then read the policy analysis.

From the plethora of research in this area, I want to highlight the Herring, Yarbrough, and Alatorre article from 2020, which I will link in the description. This is a paid article but fun fact – if you email one of the authors of the article, and you ask nicely, they are allowed to send you a pdf of the article for free, which is how I was able to read it. The authors of this article found that attempts to arrest or remove people from homeless encampments did not actually reduce homelessness, but basically just moved the homeless people from one place to another, usually somewhere less visible. I also recommend the 2019 paper from the National Law Center on Homelessness and Poverty, which I will also link in the description. The authors of that paper essentially came to the same conclusion.

And for some people – this is probably fine. They aren’t so much concerned about homeless people as they are about visible homeless people. But even if this was your goal, we need to be honest about how expensive this is.

When you criminalize homelessness, you’re putting increased pressure on the entire criminal justice system. First, your police officers now have to spend their time enforcing encampment bans. This means either more police, more overtime, or less time policing things that are actually dangerous. All of these outcomes have a pricetag.

Second, the courts are now gonna have to take on more cases related to petty crimes of public order like Trespassing and Disorderly Conduct. I don’t know about your court system but where I live, courts are already saddled with very high caseloads. This costs money in all sorts of ways. You need more judges, more public defenders, and more prosecuting attorneys. These are all paid for on the public dime.

Third, the people who are arrested in these situations have to be housed in local and county jails, which are often overcrowded and under-staffed as it is. Not only that, but people who are homeless have higher rates of serious mental illnesses like Schizophrenia and Bipolar Disorder, which often require expensive psychotropic medications to treat – and don’t forget that we learned in previous episodes that the jail has a constitutional obligation to provide treatment and that jails have to buy medications at full retail prices.

So homeless encampment bans don’t reduce homelessness, but they do increase costs for the police, courts, and jails. In other words, these policies don’t eliminate homelessness — they just transfer the responsibility for managing it from housing systems to the criminal justice system.

And on top of all of this, think about the circular logic of arresting someone because they’re poor. A person who gets arrested often loses his job if he had one. It’s impossible to make any money while you’re in jail. So what happens when the person who was arrested for being homeless gets released from jail? Well, he still has no money and no job. He’s still going to be homeless. Only this time he no longer has his tent or whatever limited possessions he had. If he had any food saved up, that’s gone now. You’re basically putting him in a position in which he is incentivized to get rearrested, because at least if he gets arrested he’ll have food, medical care, and a warm place to sleep.

So if homeless encampment bans don’t work – why do politicians keep pushing them? I think that the reason is this: Businesses and residents in close proximity to homeless encampments put a lot pressure on elected officials to “do something” about the problem. Actually doing something about the problem, such as the steps taken in Houston, involves a lot of organization and subsidizing public housing. Building coalitions and organizing a systemic solution takes a long time, and subsidizing housing is politically unpopular. Simply doing a “sweep” and moving homeless people to another location appears to solve the problem immediately. If the homeless encampment in front of Starbucks disappears, the policy looks like it worked. In short, politicians know that these bans don’t reduce homelessness and silently increase the cost of the criminal justice system, but they have a political incentive to take action, and this is the quickest and easiest action for them to take.

Now, it’s not all doom and gloom. There is one example of a city that banned homeless encampments AND reduced homelessness. The city of Houston, Texas, like many cities, has laws banning homeless encampments. However, Houston is unique in that it also has a robust public housing and homelessness response policy. Between 2011 and 2023, Houston documented a 60% decrease in the number of homeless people in the city.

How did they do this? They adopted a research-based strategy called “Housing First.” This philosophy simply says that the fastest way to put someone on a path out of homelessness is to give them a place to live. When you think about it, this conclusion is both obvious and inescapable. For example, consider how you would go about finding a job if you don’t have a place to sleep, shower, and change your clothes. It’s just not realistic. Housing first is about getting someone a place to live, then working on getting them work and whatever else they need. As they stabilize, many people begin working and gradually take on more of their housing costs.

Subsidizing housing in this way wasn’t the only strategy Houston used. They also implemented a coordinated entry system which allowed them to keep track of people who needed housing and other services. This allowed all of the various social service organizations to combine their efforts to curb homelessness and provide resources, rather than just having a bunch of different siloed systems or the every-man-for-himself approach that a lot of local governments have.

The Houston model has proven over the past 15 years that it works. But it’s the exception that proves the rule. Homeless encampment bans are a net negative for society…unless they’re paired with housing-first initiatives, a coordinated service-delivery system, and subsidized public-housing options.

And for those who argue that these things are too expensive – Houston has been doing it for 15 years. It’s not too expensive for them. And if you think your city or county are different, and you can’t afford this – ask yourself how much you’re paying by not doing it. The cost of a month in jail is over $3,000. For that same price, you could easily pay for someone to stay in an apartment.

Once again – it’s your money. Cities and counties can spend money on housing people — or spend a lot more money policing, prosecuting, and incarcerating them.

Medicaid work requirements are often presented as a way to reduce government spending and encourage employment. But when policies like this are implemented, the real-world consequences are often more complicated—and sometimes far more expensive than expected.

In July of 2025, the president signed legislation mandating that states implement work requirements for Medicaid recipients. In simple terms, most adults who want to remain on Medicaid will need to prove that they are working or volunteering for at least 80 hours per month.

Supporters of the policy argue that these requirements will reduce waste, save taxpayer money, and encourage employment.

But we already have a real-world example of how these policies play out.

The Arkansas Experiment

In 2018, Arkansas implemented work requirements in its Medicaid program. Several studies of the program found that the policy did not increase employment. Instead, it primarily reduced Medicaid enrollment.

Roughly 18,000 Arkansas residents lost their Medicaid coverage during the program’s implementation.

In practice, “work requirements” functioned less as an employment policy and more as a mechanism for removing people from the program.

A Population That Falls Through the Cracks

Many Medicaid recipients live with serious mental illnesses such as schizophrenia or bipolar disorder. With the right medication and support from family or community members, many of these individuals are able to function relatively well in everyday life.

But functioning with treatment does not necessarily mean someone is capable of maintaining regular employment.

When Medicaid work requirements go into effect, many of these individuals risk losing their health insurance.

Antipsychotic medications that might cost nothing—or perhaps a small copay—under Medicaid can easily exceed $1,000 per month without insurance coverage. Most people on Medicaid simply do not have the resources to absorb costs like that.

Once coverage disappears, medication adherence often disappears with it.

The Disability Exemption Problem

Supporters of work requirements often point out that exemptions exist for individuals who receive Social Security disability benefits.

This is true.

But the majority of people with serious mental illness are not receiving Social Security disability benefits. Obtaining approval for SSDI can be a lengthy and difficult process, even for individuals with severe conditions.

As a result, many people with serious mental illness remain in a gray area: too impaired to maintain steady employment, but not formally classified as disabled under federal standards.

These individuals are particularly vulnerable to losing Medicaid coverage under work requirement policies.

What Happens Next

When people with serious mental illness lose access to their medications, their symptoms often return.

Individuals who had been relatively stable in the community can quickly experience increases in psychotic or manic behavior. Unfortunately, situations like this frequently end with police involvement—and eventually, jail.

Once someone enters the jail system, the financial dynamics change dramatically.

Under the Constitution, incarcerated individuals have a right to healthcare. Jails must provide necessary medical and psychiatric treatment to the people they detain.

However, jails operate under very different purchasing conditions than Medicaid.

Medicaid programs negotiate drug prices on a large scale. Jails generally do not have that leverage. As a result, the same medication that might cost taxpayers roughly $100 per month through Medicaid can cost a jail $2,000 per month when purchased at retail rates.

Housing costs add another layer. Someone who may have been living with family members in the community—at essentially no cost to taxpayers—now becomes the responsibility of the local jail system. Housing an inmate often costs counties around $100 per day or more.

The Cost-Shifting Problem

Consider a simplified example.

A Medicaid work requirement removes someone from coverage, saving the state approximately $100 per month in medication costs.

But if that same individual decompensates, is arrested, and ends up in jail, the county may now be paying roughly $2,000 per month for the same medication, plus about $3,000 per month in incarceration costs.

What began as a $100 monthly savings at the state level can quickly become a $5,000 monthly expense at the county level.

For taxpayers, this distinction is largely meaningless. Whether the bill is paid through state taxes or local taxes, the same public ultimately bears the cost.

The question becomes simple: would we rather pay $100, or $5,000?

The Likely Outcome

When Medicaid work requirements take effect nationwide in January of 2027, the most likely outcome—based on available evidence—is not a surge in employment.

Instead, we are likely to see large numbers of people lose health insurance coverage. Among those affected will be individuals with serious mental illness who rely on Medicaid to maintain stability in the community.

For some portion of that population, untreated symptoms will eventually lead to police contact and incarceration.

The result will be increased pressure on local jail systems, higher medical costs for counties, and a significant transfer of financial and legal responsibility from state governments to local governments.

In other words, what appears to be a cost-saving policy at the state level will ultimately increase the total cost borne by taxpayers.

A Misallocation of Resources

Policies that shift costs rather than reduce them rarely represent real savings. More often, they simply move expenses from one part of government to another while making the underlying problems worse.

Medicaid work requirements appear poised to do exactly that.

Over time, policies that generate higher costs and worse outcomes tend to be reconsidered. The real question is how much money—and how much unnecessary instability—we will tolerate before that reconsideration occurs.

In a prior piece, I discussed the problematic incentive structure between many municipal governments and county governments. Here, I want to focus on a related issue: why city and town courts often do not evaluate defendants for competence to stand trial.

This is not an indictment of municipal governments. I have friends and colleagues who work in municipal systems. The point here is not to attack individuals, but to examine structures and incentives—and the downstream consequences they create.

What Is Competence to Stand Trial?

In the United States, a person cannot be legally tried for a crime, nor can he accept a plea agreement, if he is not competent to do so.

The legal definition of competence comes from the 1960 Supreme Court case, Dusky v. United States. The Court established what is commonly referred to as the “two-pronged test” for competence. To be considered competent, a defendant must:

1. Understand the nature of the charges against him, and

2. Be able to aid his attorney in his defense.

If a defendant cannot do either of those things, he is legally incompetent. This applies regardless of whether the alleged offense is a felony or a misdemeanor.

In a criminal case, any party—the prosecution, the defense, or the judge—can raise the issue of competence. If there is a reasonable question about a defendant’s competence, the court will typically order one or two independent forensic evaluations. The exact procedures vary by state, and some jurisdictions allow a single evaluation in misdemeanor cases.

If a defendant is found incompetent, the court generally orders competence restoration. Most often, that means a transfer to a state psychiatric hospital for a period of treatment, typically lasting a few months. If competence is restored, the defendant returns to court and the criminal case resumes where it left off.

If competence cannot be restored, things become more complicated. In many jurisdictions, including my own, the court must hold periodic review hearings—often every 90 or 180 days—to determine whether continued hospitalization is warranted. In practice, this can mean that some individuals remain in the state hospital system for years through repeated extensions. There is significant nuance here, but that is the basic framework.

It’s important to note that having a serious mental illness does not automatically make someone incompetent. Many individuals with diagnoses such as schizophrenia or bipolar disorder function well with appropriate treatment. Competence is a legal question, not a diagnostic one. The issue is whether the illness impairs the defendant’s understanding of the proceedings or ability to assist counsel—not whether a diagnosis exists.

County Courts vs. Municipal Courts

County-level courts are generally familiar with these procedures and budget for them. They typically allocate funds to pay outside clinicians to conduct competence evaluations when needed. If a defendant is found incompetent, court staff coordinate with the state hospital system and arrange transfer once a bed becomes available. Some jurisdictions experiment with jail-based restoration programs, but hospitalization remains the norm.

Municipal courts operate differently.

As I’ve discussed before, city and town courts often exist to retain local control and generate revenue. Competence evaluations are expensive. A relatively brief evaluation might cost $500 to $1,500. A more comprehensive evaluation can run $3,000 to $6,000. In larger jurisdictions, annual expenditures on competence evaluations can reach into the hundreds of thousands of dollars.

Most municipal courts do not maintain dedicated budgets for this.

Technically, a court cannot proceed if a defendant is incompetent. The constitutional options are clear:

• Pay for a competence evaluation,

• Transfer the case to a court capable of addressing the issue, or

• Dismiss the case if it cannot proceed.

There are circumstances where each of these solutions makes sense. But in practice, county courts are not always eager to accept transfers that come with the added financial burden of a competence evaluation and possible hospitalization.

As a result, some municipal courts rely on strategies that exist in a legal gray area.

Two Common Workarounds

The first strategy is simple: proceed without formally raising competence.

Unless someone goes on the record to question the defendant’s competence, no evaluation is required. If neither the defense, prosecution, nor judge formally flags the issue, the case can move forward.

There is an obvious risk that a conviction could later be overturned if it becomes clear that the defendant was incompetent. In reality, that risk is often low. Many defendants in these circumstances lack the resources, awareness, or legal assistance needed to file a meaningful appeal.

The second strategy involves delay.

Municipal courts may repeatedly reset court dates and continue cases for months. This may or may not be intentional. A defendant might fail to appear. A judge may not fully recognize the extent of a defendant’s mental illness. But the effect can be the same: the defendant sits in jail for three to six months while the case drags on.

Eventually, the court may offer a “time-served” plea agreement.

In many jurisdictions, defendants receive credit for time spent in jail—sometimes at a two-for-one rate. Six months in custody can translate into credit for a full year, which is the maximum sentence for a misdemeanor in nearly every state.

At that point, the case resolves without a formal competence determination.

The Downstream Costs

These practices create two serious problems.

First, they undermine the spirit of constitutional protections. The right at stake is the right to a fair trial—not the right to be processed through a legal system you do not understand, or to sit in jail for months because you are mentally ill and no one raised the issue.

Second, these strategies can create significant financial burdens—often shifted to the county taxpayer.

Consider a defendant who spends six months in county jail on a low-level charge. At $100 per day in housing costs alone, that is roughly $18,000. Add in psychiatric medications that may cost $2,000 per month, and the total can approach $30,000 for a case that began on a Trespassing charge.

The municipal court avoids the immediate expense of a competence evaluation. The county absorbs the jail costs. The constitutional issue is quietly bypassed.

Everyone technically followed procedure—at least on paper. But the incentives have produced an outcome that is both costly and troubling.

The Broader Issue

The right to a fair trial should not depend on the size of a town or the size of a court’s budget. It is a constitutional safeguard.

When competence determinations are quietly sidestepped because they are expensive, we do more than shift costs from one level of government to another. We weaken the integrity of the justice system itself.

If we care about fiscal responsibility and constitutional integrity, this is a gap we cannot afford to ignore.

I want to talk about city and town courts — and the way they interact with county jails in a way that creates a serious structural problem.

This is not an attack on municipal courts. I have friends and colleagues who work for town and city governments. Many of them are thoughtful, ethical public servants. The issue I’m describing is not about bad people. It’s about incentives.

We’ve discussed before how costs can cascade downward in government — federal decisions increase state costs, state decisions increase county costs, and so on. But the flow doesn’t always move in one direction. Sometimes decisions at the local level create financial burdens at higher levels of government.

Municipal courts are a good example.

When Towns Choose to Run Courts

Some states do not allow towns and cities to operate their own courts. Others mandate that they do. But in many states, municipalities have the option.

These local courts typically handle misdemeanor crimes, traffic infractions, and ordinance violations.

If you’re an elected official in a town, you might reasonably ask: why would we run our own court system when the county already operates one?

In most jurisdictions, counties must run courts. They don’t get to opt out. So from a purely financial perspective, a town could simply allow the county to handle its cases and avoid the overhead.

On the surface, towns appear to have a disincentive to operate their own courts. Yet many of them do.

Why?

Revenue.

How Municipal Courts Generate Revenue

Local courts generate revenue through fines, fees, and bail.

If someone is arrested and bail is set, the court requires payment for release. If the person fails to return to court, the money is forfeited. Even if they do return, courts often impose fines and administrative fees. Those funds go to the municipality.

There may be other motivations — local control, administrative efficiency — but revenue retention is powerful.

And here’s the key: to maximize revenue, overhead must stay low. One judge. One court day per week. Minimal staff.

By limiting expenses while collecting fines and fees, the court becomes a revenue center.

There’s also a political advantage. Property tax increases are highly visible and unpopular. Court fees are not. Most residents have no idea how much revenue their town generates through its court system.

In effect, municipal courts allow towns to bring in money without explicitly raising taxes.

You could argue that fines, fees, and cash bail function as a form of regressive taxation. That’s a conversation worth having. But even setting that aside, there’s a deeper structural issue.

The Cost of Jail

Municipalities may operate courts. But in most cases, they do not operate jails.

County governments do.

Counties pay for jail construction, maintenance, staffing, medical care, food, transportation — everything. Jails are expensive. In many jurisdictions, incarceration costs exceed $100 per inmate per day. In my jail, it’s closer to $120.

At $100 per day, per inmate, a 1,000-bed jail costs roughly $36.5 million per year.

County officials know this. In my county, I participate in our Justice Reinvestment Advisory Committee, where department heads regularly review jail costs and strategies to reduce them.

Counties have a clear incentive: keep people out of jail when possible, and minimize length of stay when incarceration is necessary.

Municipal courts have a different incentive: generate revenue.

That’s where the conflict emerges.

A $250 Bail, A $3,000 Bill

Imagine someone — let’s call him Homer — is arrested for trespassing in a town.

The town police bring him to the county jail. The town judge sets bail at $250 and schedules the next court date one month out.

The town is implicitly assuming Homer will pay the $250 to get out. If he fails to appear later, the court keeps the bail. If he does appear, the court may impose fines and fees. Either way, the municipality generates revenue.

But what if Homer cannot afford $250? He remains in the county jail for 30 days awaiting his court date. At $100 per day, that’s $3,000 in county expenses — in order to potentially collect $250.

This is not about accusing judges of malicious intent. It’s about recognizing that the incentive structure produces outcomes where bail forfeiture becomes revenue and detention costs are externalized.

And this isn’t only about money. When someone sits in jail for 30 days over $250, they can lose employment, housing stability, access to medication, and community supports. The people least able to afford bail are often already on the margins — homeless, mentally ill, or both.

When their court date arrives, they may fail to appear. That generates a bench warrant. The cycle begins again.

In more extreme cases, I have seen municipal courts hold individuals in county jail for six months pretrial on low-level, non-violent charges because they could not pay $250 in fees. Six months at $100 per day is $18,000.

County taxpayers spend $18,000 while the town attempts to collect $250 from someone who is already destitute.

It would be difficult to design a system that misallocates resources more dramatically.

The Incentive Mismatch

The problem is straightforward:

• Municipal courts generate revenue from fines and fees.

• Counties absorb the cost of incarceration.

• Municipalities are not financially responsible for the jail time their court decisions create.

This is a classic incentive misalignment. Towns pursue revenue while counties bear the expense.

A Simple Structural Fix

There are multiple ways to address this, but one reform stands out because it simply realigns incentives.

Counties could charge municipalities a per diem fee for housing individuals in jail on behalf of municipal courts. If a town had to pay, for example, $30 per day for each person it keeps in the county jail, the financial calculus changes quickly.

Trying to collect a $250 fee while paying $30 per day means that after about a week, most of the potential revenue is gone. After that point, continued detention becomes a financial loss. Municipal courts would still exist. They could still enforce ordinances and impose fines. But they would be incentivized to resolve cases quickly and avoid unnecessary detention.

Nothing in this proposal prevents enforcement. It simply ensures that the level of government creating the jail bill shares responsibility for paying it. Some municipal courts already operate efficiently and collaborate productively with county officials. The issue arises when financial incentives are misaligned. When incentives align, systems stabilize. When they don’t, taxpayers pay more and vulnerable people sit in jail longer than necessary.

And that is not a good outcome for anyone.

Assisted Outpatient Treatment (AOT), also known as outpatient civil commitment, is one of the most misunderstood tools in modern mental health policy.

It sits at the intersection of psychiatry, law, and public safety. It’s gaining momentum across the country. And it addresses a very specific — and very costly — gap in our treatment system.

If you want a deep dive into the policy side, the Treatment Advocacy Center is the de facto authority on AOT and has extensive resources available. What follows is a practical explanation of how AOT works, why it exists, and what problems it does — and does not — solve.

The Gap in the Treatment Continuum

There is a giant gap in the mental health treatment continuum between outpatient care and the state psychiatric hospital.

Outpatient care is for people who have a mental health problem or two but are generally able to function day-to-day. They see a therapist. They take medication voluntarily. They live in the community.

State psychiatric hospitals are, at least on paper, designed to treat the sickest individuals — people who require intensive, long-term stabilization.

But what about the people in between?

What about someone whose symptoms are too severe for routine outpatient care, but not quite severe enough to justify a long-term stay at a state hospital?

Before AOT, the only real option was short-term emergency hospitalization at a community psychiatric facility.

Most people don’t realize how short-term those hospitalizations actually are. In the movies, someone checks into an inpatient psych hospital and emerges two months later, transformed.

That is not reality.

Most psychiatric hospitals discharge patients within three to seven days. That works if someone is normally stable and experiencing a temporary crisis.

It does not work for someone with a chronic and serious mental illness who does not believe they are sick.

Anosognosia and the Revolving Door

Roughly half of individuals with schizophrenia-spectrum disorders have impaired insight into their illness. This condition is called anosognosia.

If someone does not believe they are ill, they will not voluntarily take medication.

Without treatment, their symptoms escalate. They become too unstable for outpatient care. They are detained under emergency commitment statutes. They stabilize briefly in the hospital. They are discharged within days. They stop medication again.

And the cycle continues.

Community (often homelessness).
Hospital.
Jail.
Repeat.

This merry-go-round is extraordinarily expensive and destabilizing — for the patient and for the community.

Where AOT Comes In

Assisted Outpatient Treatment interrupts that cycle by leveraging the civil court system.

AOT wraps therapy, medication management, and case management around the patient — backed by a court order.

In plain terms, the judge says: You can participate in treatment in the community, or you can be hospitalized.

It is coercive. That’s not something to gloss over.

But in most states, to qualify for AOT, the petitioner must show that the individual has a serious mental illness and a history of deterioration or dangerousness without treatment. There must be a documented pattern. There must be evidence.

If those criteria are met, the ethical question shifts. Allowing someone to repeatedly decompensate, cycle through jail, and deteriorate further is not morally neutral.

If moral arguments don’t move you, consider the fiscal ones. It costs over $100 per day to house someone in jail. It can cost $2,000 per day to keep someone in a state psychiatric hospital. The financial burden of untreated serious mental illness is immense — and that’s before considering the human cost.

AOT is designed to prevent that downward spiral.

How the Process Works

Forty-seven states have outpatient civil commitment statutes, but procedures vary. Here’s how it works in my county.

There are two primary referral pathways: community referrals and jail referrals.

Community Referral

A therapist or prescriber submits a referral to the AOT liaison at the local community mental health center. The case is reviewed for three criteria:

1. Is there a serious mental illness?

2. Is the person dangerous or gravely disabled without treatment?

3. Is there a documented history of treatment refusal leading to deterioration?

If those criteria are met, the team considers practical factors like housing, transportation, and family involvement. These aren’t deal-breakers, but they affect planning.

An MD must sign the civil commitment petition in my state. Once signed, the petition is filed with the civil court.

Jail Referral

Inside the jail, referrals can come from therapists, attorneys, judges, or me. I review cases from both a clinical and legal perspective.

The legal piece matters. The goal is often to secure dismissal of criminal charges upon commitment to AOT. That means the prosecutor’s office, the court, and the community mental health center all need to align.

Judges are not going to release someone charged with serious violent felonies into AOT. The appropriate candidates are typically individuals facing misdemeanors or low-level felonies whose criminal behavior is clearly linked to untreated mental illness.

Notice how many systems have to coordinate for this to work.

The Court Hearing

Once filed, the court schedules a hearing. The petitioner presents evidence. The patient has representation and can contest the petition.

In my experience, most patients are cooperative by the time we reach this stage. Occasionally the hearing is adversarial.

If the court approves the commitment, treatment begins immediately. In my county, a case manager attends the hearing. When court adjourns, the patient can meet their case manager on the spot. Sometimes housing placement or treatment initiation happens the same day.

Every petition I’ve filed has been approved. That’s not a flex. It reflects careful screening and evidence-based filing. When you bring a well-documented case to court, judges tend to take it seriously.

Enforcement and Review

AOT orders are time-limited and reviewed regularly — often monthly.

If the patient participates, the system works as intended.

If the patient stops participating, the judge has options. Depending on state law, that may include ordering medication as part of the treatment plan or temporarily hospitalizing the patient for involuntary medication.

As a last resort, the court can order full inpatient commitment to a state hospital.

That is not the goal. It exists primarily as leverage. Given the choice between hospital confinement and community-based treatment, most individuals choose to remain in the community.

What AOT Is — and What It Isn’t

AOT is not a cure-all. It will not solve homelessness. It will not fix every case of serious mental illness. It will not eliminate incarceration entirely.

It is a targeted intervention for a narrow but high-impact population: individuals with serious mental illness who repeatedly deteriorate because they refuse treatment and lack insight into their condition.

It is not about controlling people.

It is about preventing the cycle of jail, hospital, street, repeat.

For the patients it works for, AOT provides stability, continuity of care, and a real chance to live safely in the community. It also saves substantial money for local and state governments.

If you’re interested in starting or improving an AOT program in your area, feel free to reach out. I’m happy to help you think it through.

On the surface, cutting taxes and smoking methamphetamine don’t seem to have much in common. One is a fiscal policy decision. The other is a powerful stimulant that ruins lives.

But when you look at the behavioral economics of tax cuts and the psychology of methamphetamine use, the parallels are uncomfortable—and surprisingly strong.

To make the case, we need to understand both.

Methamphetamine, Briefly

I’ll start with a disclaimer: I’ve never smoked meth. But I know many people who have.

Methamphetamine, like all amphetamines, is a stimulant. It increases energy, motivation, and cognitive speed. That last part is important: speed, not accuracy. If you’ve ever talked to someone who is high on meth, you’ve probably noticed that they speak very quickly, but what they’re saying often doesn’t reflect good judgment or coherent reasoning.

Meth also floods the brain with dopamine. It feels very good—temporarily. When the high wears off, you’re right back where you started, except now you’re poorer and often worse off than before.

That’s the basic pattern: intense short-term relief followed by longer-term harm.

Tax Cuts, Simplified

Now let’s talk about tax cuts.

There are many types of taxes and many ways to cut them. The U.S. tax code is roughly a thousand pages long. To keep this simple, imagine a hypothetical income tax set at 20% that gets cut in half to 10%.

What happens next?

There are two major effects.

First, taxpayers get more money in their pockets. If you earn $50,000 per year, a 10% cut means an extra $5,000 to spend.

Second, the government now has $5,000 less to spend on public goods and services—things like roads, schools, fire departments, and emergency services. These aren’t optional luxuries. They’re the infrastructure that makes modern society possible.

In short, tax cuts provide immediate liquid cash by diverting money away from shared investments and into individual hands.

Who Actually Benefits?

At first glance, tax cuts feel like a win. Cash in your pocket is cash in your pocket.

But tax cuts don’t affect everyone equally.

A person earning $50,000 a year gets $5,000. A person earning $2 million a year gets $200,000 from the same cut. The money flowing into private pockets would otherwise have funded public services, and the largest share of that diversion goes to the highest earners.

Two things matter here:

1. A tax cut isn’t free money—it’s money taken from public services.

2. Tax cuts disproportionately benefit wealthy individuals.

A Simple Town Example

Imagine a town with ten residents.

Nine earn $50,000 per year. One earns $2 million.

After the tax cut:

• The nine average earners each save $5,000.

• The high earner saves $200,000.

Total lost revenue: $245,000.

Now look at the town’s expenses:

• Road maintenance: $100,000

• Police department: $200,000

• Fire department: $100,000
  Total: $400,000

Before the tax cut, revenue covered these costs. Afterward, it doesn’t. The town has to cut services.

Let’s say road maintenance is eliminated entirely, and the fire department absorbs the remaining cuts.

At first, nothing dramatic happens. But over time, the roads deteriorate.

One morning, you hit a pothole on your way to work and destroy your suspension. Repairs cost $3,000. A few weeks later, a small brush fire spreads because the fire department can no longer staff full coverage. A public park that cost $25,000 to build is lost.

Between car repairs and public losses, you’re now down $500—even after your tax cut.

The pattern should feel familiar.

Borrowing From the Future

This is where the meth analogy starts to matter.

Smoking meth feels good immediately. The consequences arrive later. By the time they do, the relief is gone and the damage remains.

Tax cuts work the same way. They offer short-term relief while quietly degrading the systems that make daily life affordable and functional. Eventually, both your body (with meth) and your community (with tax cuts) end up worse off than before.

So why do people support tax cuts when the benefits are so uneven?

Most people aren’t irrational or stupid. They’re stressed. They’re operating with incomplete information and very short time horizons.

Hyperbolic Discounting and Social Disconnection

Two well-established behavioral patterns help explain this.

The first is hyperbolic discounting: when people are under stress, they prioritize immediate rewards and discount future consequences.

The second is social disconnection: people who feel disconnected from their communities are more likely to focus on short-term gains rather than long-term collective outcomes.

Most people who use meth are stressed, depressed, and lonely. Meth provides temporary relief. Long-term damage feels abstract when survival feels urgent.

Tax cuts appeal in the same way. People who are financially stable and socially connected tend to support long-term investments in public goods. People who are struggling and disconnected want immediate cash relief. In both cases, what’s happening is the same: borrowing happiness from tomorrow.

Why the Cycle Repeats

Meth becomes addictive because the brain adapts. The more dopamine you flood it with, the more it needs just to feel normal.

Tax cuts follow a similar cycle.

Joe gets a $5,000 tax cut. The roads deteriorate. He pays thousands in repairs. The services still aren’t fixed. He’s stressed, broke, and desperate.

So what does Joe support next?

Another tax cut.

The more public services erode, the more relief tax cuts seem to offer—even though they’re causing the problem. Like meth, tax cuts become more “necessary” the more damage they cause.

Withdrawal Is the Hardest Part

Eventually, both systems hit bottom.

Meth withdrawal is brutal. Recovery requires enduring short-term pain for long-term stability.

Tax withdrawal works the same way. By the time communities realize they need to restore funding to function, many residents are already financially exhausted. Convincing desperate people to accept higher taxes becomes extraordinarily difficult—even when it’s necessary.

Where the U.S. Is Now

This isn’t theoretical.

As of February 2026, U.S. national debt exceeds $38.5 trillion. Decades of overspending combined with repeated tax cuts have left public systems strained and households stressed. The financial benefits have flowed overwhelmingly to the wealthiest Americans. The social costs have landed on everyone else.

Is There a Treatment?

There is.

If you rule out higher taxes on working people and rule out endless borrowing, the remaining option is taxing accumulated wealth.

A wealth tax doesn’t touch paychecks. Income isn’t wealth. Wealth taxes redirect a portion of highly concentrated assets back into public systems—schools, healthcare, infrastructure, and the social supports that young adults now lack as depression rates hit historic highs.

Like addiction treatment, it isn’t painless. But it works.

What we know won’t work is continuing the behavior that created the problem in the first place.

If you want more context, episodes 1–5 of this series go deeper into these dynamics. As always, I’m open to questions, pushback, and suggestions for future topics.

This article is part of our introductory series on jail mental health. The goal here is to explain what mental health treatment in a jail actually looks like, how it differs from treatment in the community, what it would look like in an ideal system, and why it almost never works that way in practice. The discussion also highlights the single biggest structural problem in jail mental health care: care coordination.

Mental Health Treatment in the Community

In the community, mental health treatment is usually structured and voluntary. For many diagnoses, the standard treatment is three to six months of weekly therapy. That timeline is not universal. Some people may need therapy twice per week, while others may need treatment for a year or longer depending on symptom severity and treatment goals.

If therapy alone is not sufficient, or if someone experiences severe symptoms such as psychosis or mania, medication may be needed. All of this typically happens voluntarily and at the patient’s own pace. Compared to what happens in jails, community treatment is relatively organized and predictable.

Why This Model Does Not Work in Jails

This model breaks down almost immediately in a jail setting.

First, jails do not have enough therapists. The therapists who are available are responsible for many mandatory tasks beyond therapy, including mental health evaluations, suicide risk assessments, segregation assessments, sick call requests, and urgent clinical issues. At the same time, roughly one-third of most jail populations probably need therapy. In a jail with one thousand inmates, that translates to approximately three hundred people needing services.

Even if a jail somehow had one therapist for every one hundred inmates, which most do not, that would still mean each therapist would be responsible for thirty therapy patients in addition to a full workload of other required duties. Weekly therapy for everyone is simply not possible. In most jails, the best-case scenario is a brief monthly check-in for some patients. While there are exceptions in particularly well-funded or grant-supported facilities, this is how jail mental health operates in the vast majority of jails.

Second, therapy must fit within the jail’s operational schedule. Jails are busy environments with constant competition for time and space. On any given day, medical staff, mental health staff, correctional officers, attorneys, child services agencies, reentry services, and the courts may all need access to the same inmates. Jails also operate on rigid schedules with multiple daily lockdowns for meals and inmate counts.

In practice, this means that for a therapist to see a patient, several conditions must align: no other department can need that inmate at the same time, confidential meeting space must be available, officers must be available to move the inmate, and the inmate must be willing to participate. Many individuals who need mental health services in jail refuse them even when they are offered.

Between these logistical constraints and short lengths of stay, it is rare for a therapist to meet with the same patient for multiple sessions. In many cases, the patient is released before a second appointment can occur.

There is one narrow set of circumstances in which therapy can happen more consistently: when a patient is severely ill, housed long-term on a mental health unit, facing serious charges that prevent rapid release, and when the jail has interns available who are not overwhelmed with other responsibilities. Outside of these conditions, individual therapy in jails is uncommon.

Group Therapy in Jails

Group therapy is more feasible than individual therapy in jails, but it comes with its own limitations.

Traditional psychodynamic or process-oriented groups do not work in jail settings. These groups depend on trust and vulnerability among participants, neither of which is realistic in a custodial environment. As a result, jail-based groups tend to focus on surface-level skills such as anger management, emotional regulation, communication, or parenting.

Group therapy also requires that participants be housed in the same area of the jail. It is not operationally realistic to transport multiple inmates from different housing units to a group session each week. Additionally, groups must be appropriate for all participants. Some therapeutic group formats, such as moral reasoning exercises, require a level of cognitive and emotional stability that many patients on mental health units do not have.

This creates a persistent dilemma. Individuals are housed on mental health units because they are acutely ill or suicidal. Once they stabilize enough to meaningfully participate in groups, they are often moved back to general population to make room for sicker patients. As a result, the people most capable of benefiting from group therapy are often no longer housed where groups are offered.

Some jails and prisons have step-down units for recently stabilized patients who are not yet ready to return to general population. These units are where the most effective group therapy tends to occur, but they are not common in jails.

Overall, group therapy exists in some facilities, but individual therapy is rare. Therapists in jails primarily serve as assessors, diagnosticians, and gatekeepers for higher levels of care rather than traditional treatment providers.

Behavior Modification as Treatment

Another non-medication intervention commonly used in jails is behavior modification. This approach uses structured incentives and consequences to encourage adaptive behavior without coercion. For example, an inmate might earn extra recreation time for keeping their cell clean or participating in programming.

Behavior modification can be effective for many patients, particularly those without severe psychosis or mania. While it is not a solution for all mental health conditions, it can promote stability and cooperation when applied consistently.

Medications in Jail Mental Health

Psychotropic medications are the backbone of mental health treatment in jails. This is largely because they can be administered quickly and efficiently. A single medical assistant can distribute medications to multiple patients in minutes, whereas therapy requires extended one-on-one time.

Most jails administer medications two or three times per day and can provide urgent medications when needed. The majority of mental health patients receive antidepressants or low-level anxiolytics. A smaller but more complex subset requires antipsychotics or mood stabilizers.

Patients taking antidepressants typically comply with treatment. Patients requiring antipsychotics or mood stabilizers are more likely to refuse medication, which introduces significant legal and ethical complexity.

Involuntary Medication in Jails

Jails are not hospitals, but they house individuals who may be more dangerous or disabled than patients in psychiatric hospitals. At the same time, many jail inmates have not been convicted of a crime and retain strong civil rights protections. This tension becomes most apparent when clinicians believe a patient requires medication but refuses it.

Involuntary medication is avoided whenever possible due to ethical and safety concerns. Delusions or hallucinations alone are not sufficient justification. The patient must pose an imminent risk of harm to themselves or others, or be gravely disabled. For practical purposes, grave disability typically means the inability to care for basic needs or communicate meaningfully due to mental illness.

In emergencies, clinicians may administer a one-time dose of short-acting medication such as haloperidol and lorazepam without patient or court consent. These situations are considered medical emergencies.

Problems arise when emergencies recur daily. Repeated involuntary injections increase the risk of injury to patients, officers, and medical staff. In these cases, long-acting antipsychotic injections may be safer, but they require additional authorization because their effects persist for weeks.

The most common path to approval is a court petition requesting permission to medicate involuntarily. Courts may approve, deny, or hold a hearing. While hearings allow patients and attorneys to object, they often reinforce the clinician’s case when the patient is visibly unstable.

An alternative pathway exists under the Supreme Court case Washington v. Harper¹, which allows approval through an independent medical review committee. In practice, this approach is nearly impossible to implement in jails due to logistical and financial barriers. As a result, most facilities rely on court authorization.

Care Coordination and the Revolving Door

Care coordination is the most significant failure point in jail mental health systems. Individuals with serious mental illness are frequently released back into unstable environments with little support. Many are homeless, impoverished, socially isolated, and lack transportation.

Shelters often refuse individuals with severe mental illness due to safety and resource limitations. Hospitals are reluctant to admit homeless psychotic patients because of low reimbursement rates, behavioral challenges, and Medicaid’s lifetime cap of 190 inpatient psychiatric days. EMTALA requires hospitals to accept emergencies, which has led to a system where suicidal statements become the only reliable pathway to admission.

State psychiatric hospitals are largely unavailable due to systemic underfunding and capacity issues. We will get into this in a future article.

When a patient leaves jail, medication adherence often collapses. Without follow-up care, relapse is common, and rearrest frequently follows within days or weeks.

Ideally, jails would provide a short supply of medication at release, but cost barriers usually prevent this. The best alternative is early discharge planning and collaboration with community mental health providers. Some communities offer jail-based intake, mobile response teams, or field-based medication reinitiation, but these services are inconsistent.

Mental health courts and assisted outpatient treatment programs can help bridge these gaps, though they are not universally available.

Conclusion

Mental health treatment in jails is shaped far more by structural constraints than clinical best practices. While medications and limited programming can stabilize patients temporarily, the lack of continuity of care ensures that many individuals cycle repeatedly through the system. Understanding these limitations is essential for anyone interested in meaningful reform.

If you have questions or would like to see deeper coverage of any of these topics, let me know, and I can get into more detail in future articles and videos.

The Medicaid Inmate Exclusion Rule is often described as a way to save taxpayer money. In practice, it does the opposite. It shifts federal and state healthcare costs onto local governments, forces jails to purchase care at inflated prices, and ultimately redistributes public money upward to pharmacies and pharmaceutical companies.

To understand why, it helps to start with what Medicaid is and how it works.

Medicaid is a government health insurance program created to help low-income individuals access medical and mental health care. As of September 2025, approximately 77 million people in the United States were enrolled in Medicaid. For the purposes of this discussion, Medicaid does two important things.

First, it subsidizes the cost of care. Medical and mental health services are expensive, and these subsidies make treatment far more affordable for patients. Second, and more important here, Medicaid negotiates and sets rates for medical services and prescription medications. Those negotiated rates are substantially lower than what providers/manufacturers charge on the open market.

Some examples make this easier to see.

Consider a basic medical service, such as an X-ray for a suspected rib fracture. With Medicaid, a patient might pay around three dollars out of pocket, while Medicaid pays approximately twenty dollars to the provider. The total cost of the X-ray is roughly twenty-three dollars. Without insurance, the same X-ray could cost around two hundred dollars, nearly ten times as much, because the patient is charged the full retail rate rather than the negotiated Medicaid rate.

The same pattern applies to mental health medications. A thirty-day prescription for an ADHD medication might cost a Medicaid patient two dollars out of pocket, with Medicaid paying an additional five dollars, for a total of seven dollars. Without insurance, that same prescription could cost around forty dollars out of pocket.

In both cases, the total amount paid for care is dramatically lower when Medicaid is involved.

This brings us to the Medicaid Inmate Exclusion Rule.

The rule states that when a person who is enrolled in Medicaid is incarcerated in a jail or prison, their Medicaid benefits are suspended for the duration of their incarceration. Even though the individual was insured at the time of arrest, jail medical staff are prohibited from billing Medicaid for any services or medications provided. For billing purposes, the incarcerated person is treated as if they have no health insurance at all.

This rule has existed since Medicaid was created in 1965. The original rationale was that if a local government chose to arrest someone, that government should be responsible for providing medical care during incarceration.

That logic breaks down quickly under scrutiny. Local governments do not decide which behaviors are criminalized. They are responsible for enforcing laws passed by state legislatures and Congress. This creates a mismatch between who makes the laws and who bears the financial burden of enforcing them. States and the federal government define crimes, while counties and cities absorb the costs of incarceration and constitutionally required medical care. This is an unfunded mandate in practice, even if it is not labeled as such.

When this issue is raised, a common reaction is to frame it as a moral argument. Some people respond by suggesting that allowing Medicaid billing in jails means giving criminals free healthcare, or shifting costs unfairly from counties to state governments. Neither claim holds up.

First, many people in jail are not criminals. Most jail inmates are pre-adjudicated, meaning the court has not yet determined guilt or innocence. People can spend weeks or months in jail awaiting trial, and jails are constitutionally required to provide medical and mental health care during that time. Denying access to negotiated insurance rates before any finding of guilt raises serious fairness concerns.

Second, there is no such thing as free healthcare. Medicaid is funded by taxpayer dollars. Jail healthcare is also funded by taxpayer dollars. The question is not whether taxpayers pay, but how much they pay and who benefits from the system.

Because Medicaid negotiates lower prices, care provided through Medicaid is significantly cheaper than care purchased without insurance. The Inmate Exclusion Rule forces jails to buy medications at full retail prices, often five to ten times higher than Medicaid rates.

As a result, the rule does not reduce healthcare spending. It shifts costs onto local governments while dramatically increasing the price they must pay for the same care.

The beneficiaries of this arrangement are not taxpayers. Treatment providers benefit to some extent, but the largest winners are pharmaceutical companies and large pharmacy contractors. Because jails are barred from using Medicaid’s negotiated rates, they must pay monopoly retail prices for medications.

This becomes especially costly for certain populations. HIV medications and long-acting antipsychotics routinely cost jails thousands of dollars per month per patient. A single inmate prescribed a brand-name antipsychotic can add six thousand dollars to a jail’s monthly pharmacy bill. A brand-name HIV medication can add another five thousand dollars. Some inmates require multiple medications, and it is not uncommon for a single individual’s prescriptions to exceed ten thousand dollars per month.

If that same individual were in the community with Medicaid, their out-of-pocket cost might be ten dollars, and Medicaid itself might pay around one hundred dollars total. Exact figures are impossible to provide because privacy laws limit access to detailed Medicaid reimbursement data for specific medications.

The practical effect of the Inmate Exclusion Rule is that cities and counties pay far more for care than state or federal governments would pay for identical treatment in the community. The rule extracts money from local taxpayers and transfers it upward to drug manufacturers and large healthcare corporations. At the same time, these inflated costs strain county budgets, making it harder to raise employee wages, maintain facilities, or fund other essential public services.

The most straightforward solution would be to allow incarcerated individuals to retain Medicaid coverage during incarceration. That approach would immediately reduce costs and align jail healthcare spending with community healthcare spending. However, state budgets are already under pressure from numerous federal mandates, and many states would struggle to absorb these additional costs.

A more practical middle-ground solution is possible.

One option is to allow jails and prisons to bill Medicaid for services and medications, while requiring them to reimburse Medicaid for the full cost of those claims, plus a fixed surcharge, such as ten percent. This approach preserves local responsibility for paying for care while allowing jails to access Medicaid’s negotiated rates. It would dramatically reduce county healthcare expenditures while creating a modest new revenue stream for state Medicaid programs without raising taxes.

This model would not incentivize overbilling, since counties would still be responsible for the costs. Medicaid utilization review and existing oversight mechanisms could remain in place to prevent abuse.

The Medicaid Inmate Exclusion Rule does not save money. It wastes local tax dollars, inflates healthcare costs, and channels public funds to private corporations for no clear public benefit. Understanding how this system works is the first step toward fixing it.

For policymakers interested in addressing this issue, practical solutions exist. I am happy to discuss them further with anyone interested in reforming this policy.

Today’s article is about managing mental health crises in jails. This article will cover what constitutes a crisis, typical responses and solutions, and common problems that arise.

Before getting into the details, it is important to start with a disclaimer. What follows is a discussion of jails in general, and what constitutes a crisis relative to the other issues jails deal with every day. If a particular diagnosis or experience is described as “not a crisis,” that is not meant to minimize or invalidate anyone’s experience. The goal here is to explain how jails prioritize limited resources, not to comment on what symptoms do or do not deserve attention.

Defining a Mental Health Crisis in Jail

Mental health issues in jail exist on a spectrum. For practical purposes, inmate problems can be divided into three tiers.

Tier One: Situational Stressors and Low-Level Mental Health Issues

The lowest tier consists of what can best be described as situational stressors. These include anxiety, depression, irritability, and insomnia that did not exist prior to incarceration.

These reactions are normal and predictable consequences of jail. Incarceration involves a sudden loss of freedom and autonomy. Inmates lose access to family and friends, employment, income, housing stability, personal routines, privacy, and basic choices such as what to eat or when to sleep. At the same time, they are facing uncertainty about their legal case, potential sentences, plea negotiations, future employment, and relationships.

Feeling depressed, anxious, angry, or unable to sleep in this environment is not pathological. These emotions, by themselves, do not constitute a crisis.

In my jail, if someone is struggling to adjust and requests to speak with a counselor, a counselor will see them. What will not happen is removing the inmate from general population, housing them in the mental health unit, or prescribing medication simply to suppress a normal emotional response to incarceration.

Pre-Existing Mental Health Diagnoses

This same tier includes most inmates who had a diagnosed mental health condition prior to incarceration. When an inmate enters jail with a documented diagnosis, they are typically evaluated by a therapist and/or prescriber to assess current symptom severity and determine whether previously prescribed medications should be restarted.

Some medications are unlikely to be continued in jail. Prescription stimulants for ADHD are rarely provided because of their high trade value. Benzodiazepines and hypnotics for anxiety or sleep are also typically discontinued due to safety risks and diversion concerns. In some cases, non-stimulant or alternative medications may be considered, but these issues are generally low priority.

Jails are more concerned about conditions such as major depressive disorder, PTSD, bipolar disorder, and psychotic disorders like schizophrenia or schizoaffective disorder. As long as inmates with these diagnoses are stable and medication compliant, they are typically housed in general population regardless of diagnosis.

Panic Attacks

Another common low-level issue involves panic attacks. Officers frequently report that an inmate is “losing it” or “flipping out,” only for mental health staff to find someone having a panic attack. Panic attacks are extremely uncomfortable, but not dangerous. People often fear they will pass out, which is essentially impossible during a panic attack due to elevated adrenaline levels.

Panic attacks are common in jail because jail is a stressful environment. They are also highly treatable with education and reassurance. Medication is generally not recommended, as it tends to worsen the problem over time.

In the event of a panic attack, a counselor should respond and help the inmate calm down. A panic attack is not a crisis and does not warrant removal from general population.

Tier Two: Issues That Require Intervention but Are Not Always Crises

None of the issues discussed so far constitute a crisis in a jail setting. The second tier includes situations that may or may not represent a crisis but usually still require intervention.

Suicidal Statements and Malingering

The most common mental health call in jail involves inmates stating that they are suicidal. If you watched/read previous articles, you know that jail’s do everything they can to avoid suicides, and that suicides are one of the biggest sources of liability. Inmates are well aware that saying they are suicidal is the fastest way to get attention. As a result, jails constantly deal with suicidal claims.

In my experience, the majority of these claims are not associated with genuine suicidal intent. They are often motivated by secondary gain, such as changing housing, escaping lockdown, resolving conflicts, or accessing privileges. Clinically, this behavior is referred to as malingering.

A major role of jail mental health staff is distinguishing genuine risk from malingering. If suicide risk is anything other than low, the inmate should be placed on suicide watch. If malingering is suspected, the counselor will attempt to address the underlying issue. Sometimes this can be resolved by changing housing assignments, moving the inmate to protective custody, or providing case-related information (e.g. who is the inmate’s attorney, when is his next court date, and other basics). If the behavior continues, the inmate is usually placed on suicide watch anyway.

This is not done for clinical reasons. It is done for behavior management and liability reduction.

An inmate who is malingering may escalate behavior if ignored, including flooding cells, starting fires, or constructing ligatures to “prove” seriousness. There is also the risk of accidental death during a staged suicide attempt. In the aftermath, investigators will see only a suicide, not an accident, and mental health staff will be scrutinized.

Therapists cannot predict suicide. Risk assessment does not work that way. Nevertheless, liability considerations dictate conservative responses.

Hallucinations

Hallucinations may or may not represent a crisis. People with genuine hallucinations often do not voluntarily report them, so self-report raises red flags for possible malingering. That said, some individuals do recognize their hallucinations.

Mental health must assess the quality of the hallucinations for severity and functional impairment. If hallucinations do not interfere with functioning and the inmate is willing to remain housed in general population, relocation is usually unnecessary.

When it comes to hallucinations, content matters. Hearing comforting voices is not a crisis. Hearing voices commanding violence or self-harm, suggesting the jail food is poisoned, or other paranoid content is usually a crisis, and requires removal from general population, assuming malingering has been ruled out.

Kites and Bizarre Behavior

Mental health is sometimes called when inmates are “kited out” of a housing unit. A kite is an anonymous note passed to staff warning that an inmate is behaving bizarrely and/or is at risk of being harmed.

Mental health must determine whether the behavior is genuinely psychiatric or whether other dynamics are at play. The response may involve moving the inmate to a mental health section, protective custody, or another general population unit.

Other Non-Crisis Situations Requiring Special Housing

Some inmates are not in crisis but may still require alternative housing, including individuals with intellectual disabilities, autism, blindness, deafness, or transgender inmates. These situations typically involve classification decisions, sometimes with mental health input.

Tier Three: Acute Mental Health Crises

The highest tier of mental health crises includes situations requiring movement to the mental health unit, involuntary medication, restraints, seclusion, or hospitalization.

These situations involve inmates who are suicidal, violent, or gravely disabled due to mental illness.

Examples include:

• Suicide attempts or active self-harm

• Command hallucinations to harm others

• Refusal to eat due to delusional beliefs

• Severe paranoia preventing basic functioning

• Inability to maintain hygiene or coherent communication

Immediate Response and Housing

The first step is relocation to the mental health unit or medical unit. Extremely small jails without such units may need to transport inmates to hospitals.

Suicidal inmates are placed on suicide watch. Homicidal inmates require separation from peers, and are often treated as suicide watch for the purpose of observation and monitoring. Psychotic or gravely disabled inmates should be housed in the mental health unit with appropriate supervision.

Involuntary Medication

Each state has its own legal standards and each jail has their own policies for involuntary medication. Mental health or medical staff must determine whether criteria are met.

Correctional staff should not override these decisions. Interfering with emergency treatment transfers liability to the officer involved. Once authorized, supervisors determine whether special operations teams are required. All interventions must be recorded with handheld and body cameras. Cameras do not add liability; they protect jail staff.

Attempts should be made to obtain voluntary compliance before forced administration. If unsuccessful, officers secure the inmate, and medical administers the injection. With experience, this process takes only a few minutes.

For repeated episodes, long-acting antipsychotic injections may be petitioned through the court. (Some jails may be large enough to establish a Harper Committee [See Washington v. Harper] for the purpose of authorizing involuntary medication, but for most jails this burden is impractical).

Clinical Restraints

Clinical restraints may be necessary when inmates are actively attempting to harm themselves or others. The two most common methods for restraint are restraint chairs and four-point restraints.

Restraints are unpleasant but not inherently uncomfortable when applied correctly. Many inmates calm down or fall asleep in restraints once their adrenaline subsides. However, restraint use still carries some risks and requires proper training and policy adherence.

Not all restrained inmates require medication. Some inmates (most notable those with substance use disorders) will deliberately act-out in order to obtain benzodiazepines. Automatic medication can reinforce this behavior, leading to more clinical restraints (and wasting resources).

During restraints, continuous monitoring, vital checks, circulation checks, and regular reassessment are required. In my experience restraints rarely exceed one hour. Longer durations require continued one-on-one monitoring. Following restraint use, inmates are typically placed on suicide watch.

Clinical Seclusion

Some inmates pose a risk to others but not themselves. Padded seclusion rooms (if your jail has them) provide a safe space for brief containment. These rooms are designed to prevent injury and are used for short durations only.

That pretty much wraps it up for this one. Come back next week for a discussion on the Federal Medicaid Inmate Exclusion Rule and how it ostensibly saves taxpayers money, while in practice it does the opposite.

The Scope of the Staffing Crisis

Let’s start with the data. According to the U.S. Census Bureau, local jails lost approximately 17,000 correctional officers between 2013 and 2023. The Bureau of Labor Statistics expects this trend to continue, projecting a 7% reduction in correctional officers by 2034.²

Some jails are operating at truly alarming levels of understaffing.
One jail in Atlanta is currently short 59% of its authorized staffing.
A jail in Virginia has been operating at roughly 50% staffing for five years.

These are extreme examples, but nationally it’s common for jails to operate 20–30% short-staffed.

Why Understaffing Is So Dangerous

Running short-staffed in a correctional facility is not just inconvenient — it’s dangerous.

Short staffing leads to:

• Longer shifts

• Mandatory overtime

• Increased officer burnout

• Reduced safety

• More frequent lockdowns

Lockdowns increase inmate frustration, which leads to more mental health crises, more violence, and more disciplinary issues. From the officer’s perspective, you’re working long hours in a dangerous environment, often alone, supervising inmates who are stressed, mentally ill, and angry.

In an Associated Press article on the Fulton County Jail, officers reported situations where one officer was responsible for monitoring up to 200 inmates at once. This is an objectively terrible working condition.

Turnover and Overtime

Unsurprisingly, correctional facilities experience 20–30% annual staff turnover.
That means your entire workforce turns over every 3–5 years.

Because jails can’t close, governments are forced to rely heavily on overtime to keep facilities operational. In some states, overtime costs reach hundreds of millions of dollars annually. Nationally, overtime spending almost certainly reaches into the billions.

Some Facilities Have Fixed This — How?

Here’s the key question: if staffing is such a problem, why aren’t all jails understaffed? Some facilities maintain staffing levels of 95% or higher. Let’s look at what they’re doing differently.

Case Study #1: Utah Department of Corrections

In February 2024, Utah was short about 400 officers. Within a little over a year, they hired approximately 350 new officers and now report having more applicants than openings.

What changed?

• Officer pay increased by 40%

• Improved recruitment advertising

• Streamlined hiring process

Case Study #2: Wisconsin Department of Corrections

In early 2024, Wisconsin had a 56% vacancy rate. Within a year, they reduced that vacancy rate to 17%.

Their strategy?

• Officer pay increased by 65%

That’s it.

Case Study #3: Arapahoe County Jail (Colorado)

Arapahoe County regularly operates at 95% staffing capacity. I reached out to them directly, and a big thank-you to Jon at the Arapahoe County Sheriff’s Office for taking the time to speak with me.

According to Jon, their success comes from:

• Starting salaries near $80,000 per year

• Predictable schedules (primarily four 10-hour shifts)

• Strong workplace reputation

• Streamlined hiring with frequent applicant communication

• Using the jail as a pipeline into police positions (they generally only hire police who have worked in their jail)

The Common Thread

Every successful example has the same core solution:

They pay officers enough to make the job competitive. Advertising and hiring efficiency help — but compensation is the foundation.

“Pay Doesn’t Matter” — Does It?

Some organizations argue that higher pay doesn’t improve staffing. The Prison Policy Institute has made this claim, noting that inflation-adjusted wages rose between 2013 and 2023 while staffing declined. They argue the solution is reducing jail populations rather than increasing staffing.

Here’s my rebuttal — in three parts.

Rebuttal #1: Wage Growth Was Minimal

Between 2013 and 2023:

• CPI inflation was 31%

• Nominal correctional officer wages rose 35%

That’s a real wage increase of about 3% over ten years — effectively nothing.

Rebuttal #2: CPI Misses the Real Cost of Living

CPI measures consumer goods — not housing.

Between 2013 and 2023:

• Median rent increased by 50%

If your wages increase 35%, consumer prices increase 31%, and rent increases 50%, your standard of living has declined. Officers are worse off today than they were a decade ago.

Rebuttal #3: Jail Populations Are Already Reduced

Jails have been reducing populations for years — especially since COVID. At this point, many facilities have already released their lowest-risk individuals. What remains is a population that is more violent, unstable, and resource-intensive.

You can want fewer people in jail and want safe staffing for the people who remain. These positions are not mutually exclusive.

Opportunity Cost and the Labor Market

This brings us to a key economic concept: opportunity cost.

People don’t buy jobs with money — they buy jobs with time. Taking a corrections job means giving up every other job you could do with that same time. So how does corrections pay compare?

According to the Bureau of Labor Statistics:

• Median correctional officer salary: ~$53,000

• Comparable to truck drivers and bus drivers

• $5,000–$10,000 less than police officers

Now compare corrections to other non-degree careers:

• Crane operators: ~$65k

• Railroad workers: ~$75k

• Electricians: ~$62k

• Plumbers: ~$63k

• HVAC techs: ~$60k

Corrections pays 15–20% less than many alternatives — and with worse working conditions.

Pay Growth and Job Quality

Corrections also lacks meaningful wage growth. Officers with 20 years of experience often make only marginally more than those with five. Promotions add responsibility without proportional compensation.

Combine that with:

• Dangerous environments

• Trauma exposure

• Poor lighting and infrastructure

• Mandatory overtime

• Public stigma

Low pay + hard job = predictable staffing crisis.

Adam Smith explained this centuries ago. Dangerous, unpleasant, stressful jobs require a wage premium. Corrections does not offer one.

Why Can’t Local Governments Fix This?

If low pay is the problem, why not just raise wages? Because local governments are broke. They must fund jails, police, schools, fire departments, EMS, roads, and more — with limited revenue. Raising wages means either cutting other services or raising taxes.

And here’s the problem: states often prohibit local governments from raising taxes.

How We Got Here: Block Grants and Unfunded Mandates

Since the late 1970s, the federal government shifted from fully funding programs to issuing block grants — fixed sums that don’t adjust for inflation or demand.

Programs like:

• TANF

• Mental health services

• Substance use treatment

Many of these block grants are worth 40% less in real terms than when they were created. Yet the mandates remain. When governments are required to provide services without adequate funding, that’s called an unfunded mandate. States then pass these costs down to counties and cities — while simultaneously limiting their ability to raise revenue.

Cost Shifting and Liability Dumping

States cut expensive services — like psychiatric hospitals — which pushes people with severe mental illness into jails. Local governments absorb the cost. Then, when something goes wrong, lawsuits target:

• Jail administrators

• Mental health staff

• County governments

This is called liability dumping.

The Bottom Line

Your jail is understaffed because officers are underpaid. Officers are underpaid because local governments are poor. Local governments are poor because costs are pushed downward while revenue is capped.

Ending on a Hopeful Note

None of this can be fixed quickly — and it certainly can’t be fixed at the jail level alone. This is the result of decades of federal and state policy decisions. But it can be fixed. If we address the economic distortions discussed earlier in this series and begin stabilizing public finances, this problem is solvable — albeit slowly, over decades. The longer we wait, the harder it becomes.

Suicide prevention is one of the most important responsibilities of jail mental health systems. In this article, the focus is on why suicide is such a significant risk in jails, how to build a layered suicide prevention system, and what suicide watch should look like in practice.

This discussion approaches suicide prevention from an operational perspective. It is not a tutorial on how to conduct a clinical suicide risk assessment. That topic will be addressed in a separate article.

The First Three Rules of Jail Mental Health

Jail mental health has a few core rules.

The first rule is that no one dies in the jail.
The second rule is that no one dies in the jail.
The third rule is to remember that suicide is statistically the most likely way someone will die in a jail.

With those rules in mind, suicide prevention must be approached as a system with multiple overlapping layers of protection.

Intake Screening and Early Warning Signs

The first layer of suicide prevention begins at intake. Medical staff should ask arresting officers whether the individual made any suicidal statements or engaged in concerning behavior during the arrest.

The inmate should then be asked directly about suicidal thoughts during the nursing intake assessment. At the same time, medical staff should remain alert to behavioral and physical indicators of self-harm risk, even if the inmate denies suicidal intent.

These indicators may include:

• Cuts or scars on the wrists, arms, or legs

• Flat affect, vacant expression, or marked withdrawal

• Statements suggesting hopelessness or a lack of desire to live

Examples of passive suicidal statements include phrases such as “I just want to go to sleep forever” or “I will never leave this place.”

Any of these signs or statements should result in the inmate being held in a location where they can be observed until mental health staff complete a more thorough evaluation.

Placing an Inmate on Suicide Watch

If mental health staff determine that an inmate is at risk for suicide or self-harm, the inmate should be placed on suicide watch. Some facilities refer to this as Close Observation, which is a more flexible term that allows observation for reasons beyond suicide risk.

At this point, the inmate should be housed in a mental health unit if one exists. If not, the inmate may be placed in a medical unit or another designated observation area. Whenever possible, the inmate should be housed in a suicide-resistant cell.

Suicide-Resistant Cell Design

A suicide-resistant cell is designed to minimize ligature opportunities. Ligature-based hanging is the most common method of suicide in jails, making ligature points the primary environmental hazard.

Key features of a suicide-resistant cell include:

• Minimal or no ligature points

• A single bunk made of composite material without sharp metal edges

• No desks, chairs, or tables

• No electrical outlets

• Bright lighting controlled from outside the cell

• A secure door with no gaps that could be used to anchor fabric

• A metal mirror rather than glass

The cell should contain only a bed and a toilet.

Fire suppression systems also deserve attention. Tamper-resistant sprinkler heads are not tamper-proof. If an inmate damages a sprinkler head, the exposed fixture can become a ligature point. In such cases, the inmate should be moved or the cell repaired immediately.

The Role of Cameras

Cameras in suicide-resistant cells serve two purposes. First, they provide secondary observation. Cell feeds can be displayed in officer booths or counseling offices, increasing the likelihood that concerning behavior will be noticed quickly.

Second, cameras act as a deterrent. Inmates who know they may be observed are less likely to attempt self-harm. This mirrors the logic behind the Panopticon design (watch the video to learn more), where uncertainty about observation discourages dangerous behavior.

Although cameras reduce privacy, courts have consistently held that inmate safety outweighs privacy concerns in these contexts.

When Suicide-Resistant Cells Are Not Available

Facilities without suicide-resistant cells may need to house inmates on suicide watch in traditional cells. In those situations, housing suicidal inmates together can provide an additional layer of protection.

It is difficult for an inmate to attempt suicide without interruption when another person is present. Cellmates are likely to alert staff if they observe dangerous behavior.

Observation Checks and Timing

The primary method of monitoring inmates on suicide watch is direct visual checks, often referred to as checks or clocks. Staff physically observe the inmate at random intervals ranging from every 7 to 15 minutes.

This timing is intentional. Approximately 90 percent of jail suicides occur through hanging or self-asphyxiation. Irreversible brain injury can begin after approximately five minutes without oxygen, with death or severe injury likely after ten minutes.

Randomized checks prevent inmates from timing suicide attempts between observations. Some facilities layer additional officer rounds on top of mental health checks, increasing observation frequency even further.

Clothing and Property Restrictions

Inmates on suicide watch are issued suicide-resistant smocks, typically made of durable canvas material that is difficult to tear or fashion into a ligature. Footwear is limited to soft shoes or sandals.

Initially, inmates may have only a mattress and no additional property. As risk decreases, privileges can be gradually reintroduced. Suicide watch is inherently restrictive and uncomfortable. While these conditions reduce risk, prolonged exposure can worsen mood, so restrictions should be eased as soon as it is clinically safe to do so.

Daily Clinical Contact and Treatment

If staffing allows, an advanced-level mental health provider should meet with inmates on suicide watch daily. These visits are often brief but provide continuity and monitoring.

Medication management may be part of treatment, though medications are not typically forced. Antidepressants are commonly prescribed when appropriate, while recognizing that medication alone is not a complete solution to suicide risk.

Authority to Place and Remove Suicide Watch

Any staff member should be able to initiate suicide watch temporarily if there is concern for safety. The inmate should remain under observation until mental health staff complete an evaluation.

Decisions to discontinue suicide watch should, at a minimum require approval from both a licensed prescriber. In my jail, I instituted a policy which requires both a licensed prescriber and a behavioral health supervisor to agree to rescind suicide watch. Requiring two clinical approvals provides both safety and accountability.

Step-Down and Follow-Up

After removal from suicide watch, inmates should transition to a step-down housing unit if available. If not, temporary placement in mental health or medical housing may be appropriate.

Follow-up appointments are essential. A common model includes check-ins after one day, three days, and one week to monitor for recurrence of suicidal thoughts.

Movement and Release Considerations

Any movement of an inmate on suicide watch should require approval from a licensed mental health staff member. This includes court appearances, transfers, hospital visits, and release.

Release presents particular risk. Individuals released from jail experience suicide rates significantly higher than the general population during the first year after release.

If an inmate is released while on suicide watch, a mental health evaluation should occur immediately. Depending on findings, this may include safety planning, family involvement, or emergency psychiatric detention if necessary.

Summary: A Layered System

Effective suicide prevention relies on multiple overlapping protections:

• Intake screening

• Staff awareness and reporting

• Mental health evaluation

• Suicide-resistant housing

• Frequent observation checks (or clocks)

• Video monitoring

• Clinical follow-up

• Controlled movement and discharge planning

No single measure is sufficient. Each layer reduces risk incrementally, making suicide less likely and more difficult to carry out.

This layered approach is how jails reduce the most common cause of death in custody and uphold the most important rule of jail mental health: no one dies in the jail.

In this episode of the Jail Mental Health introduction series, we focus on the medical intake process and why it is often the most important ten minutes a person will spend in jail.

The Booking and Intake Process

When someone is brought to jail, several steps must be completed before they are admitted. These include fingerprinting, photographing, inventorying personal property, and completing a medical evaluation.

The medical evaluation serves a critical function: the jail must decide whether it can safely accept custody of the arrested person. If medical staff identify a serious issue—such as a suspected fracture, internal bleeding, or other acute medical instability—the jail may refuse to accept the individual until they receive hospital care and medical clearance.

Although it may seem counterintuitive, jails are legally permitted to refuse admission when a person is medically unstable. In these cases, the arresting officer must transport the individual to a hospital before the jail will accept them.

Prescreen vs. Full Medical Evaluation

Jails typically use one of two approaches to intake medical screening.

The first is a brief prescreen, often lasting one to two minutes. Its purpose is to determine whether the individual can safely remain in the jail. Once the prescreen is completed, the arresting officer may leave, and the inmate waits in a holding area until a full evaluation can be conducted later. The second approach is a full medical evaluation conducted immediately upon arrival.

The prescreen model prioritizes efficiency for law enforcement, while the full evaluation model prioritizes efficiency for medical staff. Neither approach is inherently wrong. The decision reflects whether the facility prioritizes returning officers to duty quickly or reducing duplication of medical work.

Who Conducts the Evaluation

In many jails, intake evaluations are conducted by registered nurses. Other facilities may use medical assistants, EMTs, nurse practitioners, or similar professionals. Using physicians for routine intake evaluations is rare simply because they’re expensive and in short-supply.

Core Components of the Medical Intake

A proper intake evaluation should cover several areas:

• Current medical conditions

• Prescribed medications

• Allergies

• Recent injuries

• Mental health diagnoses and treatment history

If the individual reports taking psychiatric medication, staff should determine whether they are actively engaged in treatment and identify the pharmacy used to fill prescriptions.

When contacting a pharmacy, staff should document:

• The name of the pharmacy employee

• Medication names and dosages

• Administration instructions

• Most importantly, the last refill date

It is common for inmates to report medications they have not taken recently or were never prescribed. Verification ensures that prescribers can make informed decisions about whether to restart or temporarily bridge medications during incarceration.

Substance Use Screening

Substance use screening is a critical component of intake. At least half of all jail admissions involve individuals with a diagnosable substance use disorder. Substances such as alcohol, benzodiazepines, and stimulants interact with many prescription medications and can cause serious withdrawal syndromes.

Underreporting and Risk Management

Inmates frequently minimize or deny substance use due to fear of self-incrimination or stigma. As a result, clinicians should assume underreporting. For example, someone reporting two to three drinks per day is likely consuming significantly more. In correctional settings, caution is essential. Alcohol withdrawal is especially dangerous, and failure to identify it during intake can have fatal consequences.

Why Not Drug Test Everyone?

Routine drug testing at booking seems reasonable, but it has limitations. First, inmates cannot generally be compelled to provide urine samples, and blood testing typically requires strong justification and often a court order.

Second, standard urine drug screens are limited. Many do not reliably detect:

• Synthetic cannabinoids

• Kratom

• Certain benzodiazepines

• Gabapentin

• Xylazine

• Ketamine

• Some hallucinogens

• Fentanyl and other synthetic opioids

A negative drug screen does not rule out intoxication, withdrawal, or substance-induced psychosis.

Editorial Aside: Ethics and Economics of Drug Testing

Some jails avoid routine drug testing due to cost, time constraints, or concerns about triggering additional detox protocols. This raises ethical concerns. If half of all admissions involve substance use disorders, and we know underreporting is common, there is a strong argument that facilities should at least attempt drug screening for every inmate.

From a financial perspective, the cost is modest. At roughly $30 per test, screening 10,000 admissions would cost about $300,000 annually.

This must be weighed against the cost of a death in custody. Even when no wrongdoing occurs, litigation defense alone can exceed $100,000. Many jurisdictions settle lawsuits simply because it is cheaper than trial, even when liability is unclear. Viewed this way, drug testing is often a cost-containment strategy rather than an expense.

Mental Health and Suicide Screening

Intake evaluations also include mental health and suicide screening. The primary goal is to determine whether mental health staff need to be involved immediately.

At a minimum, inmates should be asked whether they are currently thinking about harming themselves or others and whether they have a history of suicide attempts. Positive responses require referral for a more comprehensive mental health assessment.

It is important to acknowledge limitations. Some suicides are impulsive. Others involve individuals who deliberately conceal suicidal thoughts. I am aware of multiple jail suicides in which individuals denied suicidal ideation during intake and had no overt warning signs.

Suicide occurs approximately four times more often in jails than in the community. Staff should be cautious and risk-averse, but it is also important to recognize that not all suicides are preventable.

Social History and Discharge Planning

Whenever possible, intake evaluations should gather information about housing status and emergency contacts. This information supports both data analysis and discharge planning. If someone is homeless at intake, that fact is immediately relevant. Shelter availability is limited in many communities, and early involvement of reentry services improves outcomes.

Extreme weather makes this especially important. Releasing someone without housing in winter can place them in immediate danger and contribute to a cycle of re-arrest. Jails increasingly function not only as psychiatric facilities, but also as de facto homeless shelters.

When Intake Cannot Be Completed

Sometimes an inmate is too intoxicated, psychotic, or disruptive to complete intake. In these cases, coordination between medical, mental health, and custody staff is essential. Consider an inmate who is actively psychotic, refusing medical procedures, and threatening staff. Medical may want observation, mental health may want specialized housing, and custody may push for segregation.

Psychotic inmates should not be placed in segregation. The decision between medical or mental health housing must be made on a case-by-case basis, with safety as the priority.

Managing Intake Volume

Finally, facilities should attempt to manage the flow of admissions whenever possible.

Warrant sweeps can result in large numbers of inmates arriving simultaneously. If intake evaluations take thirty minutes and only one nurse is available, even a small surge in bookings can create delays lasting many hours.

Extended holding times are dangerous. Inmates awaiting intake may develop withdrawal symptoms, experience medical complications, or suffer unnoticed injuries. These situations create risks for inmates and liability for facilities. Adequate staffing and coordination with law enforcement can reduce these bottlenecks.

Closing Thoughts

The medical intake process is brief, but its consequences are enormous. Decisions made during these first minutes determine safety, treatment, and outcomes for the rest of an inmate’s stay.

In the next episode, we will focus on suicide prevention in more detail.

In the previous article, we covered the basic mechanics of how jails operate. This article does the same thing for the mental health side. The goal here is to explain what mental illness is, how treatment normally works, and why treatment inside a jail looks very different from treatment in the community.

What We Mean by “Mental Illness”

Mental illness is a broad term. In clinical settings, it usually refers to a diagnosable condition that affects emotions, thought processes, or behavior in a way that interferes with a person’s ability to function.

It is important to distinguish clinical disorders from normal human experiences. Feeling sad, anxious, angry, or overwhelmed is not the same thing as having a mental illness. Those emotions are part of being human. They become a clinical disorder only when they are persistent, severe, and significantly impair functioning over time. Diagnosis is more nuanced than this simplified definition, but this is generally what clinicians are looking for.

This distinction matters because incarceration itself causes distress. Being in jail can make people sad, anxious, angry, or hopeless. In fact, it would be surprising if it did not. As a result, jail can make mentally healthy people appear mentally ill, and it can significantly worsen symptoms for people who already have a diagnosed condition.

Mental Illness vs. Serious Mental Illness

Mental illness and Serious Mental Illness (SMI) are not the same thing.

SMI is a technical term commonly used in research and clinical settings to indicate severity. People with mental illness have symptoms that interfere with their lives. People with serious mental illness have symptoms that, if untreated, make independent functioning impossible. Individuals with SMI often pose a risk of harm to themselves or others if left untreated in the community.

One important feature of serious mental illness is anosognosia. Approximately 50% of people with SMI lack awareness that they are ill. This is not denial in a psychological sense; it is a neurological symptom. Anosognosia becomes critically important when discussing involuntary medication and civil commitment, which are topics we will return to later.

Conditions That Are Not Mental Illness, but Still Matter

Some conditions are not mental illnesses but still require special consideration in jails. These include:

• Autism spectrum disorders

• Intellectual disabilities

• Traumatic brain injuries (TBIs)

People with these conditions may not need psychiatric treatment, but they often do not function well in general population. A major concern is exploitation. I have seen inmates with these conditions have food stolen, phone accounts drained, or otherwise be taken advantage of by more savvy inmates.

In these cases, mental health staff may become involved not because treatment is needed, but because housing and classification decisions require clinical input.

Substance Use Disorders

Substance use disorders are extremely common in jails. National estimates suggest that 40–60% of jail detainees meet criteria for a substance use disorder. Based on my own data, this estimate is accurate.

All jails have protocols for acute intoxication and withdrawal. Medical staff identify the issue at booking and place the inmate on a detox protocol when needed. This usually involves monitoring and, in some cases, medication to manage withdrawal symptoms.

There are three important things to understand about substance use disorders in jails.

Diagnostic Complications

Intoxication and long-term substance use can mimic psychiatric disorders. Depression, anxiety, psychosis, and mania can all be caused or worsened by substances. For this reason, clinicians often delay making a psychiatric diagnosis until the person has been in custody for a week or more.

Inmates Lie About Substance Use

People frequently minimize or deny substance use during intake. They often believe the information will be used against them, especially if their arrest involved drugs or alcohol. In practice, complete denial is usually inaccurate, and reported use is typically an underestimate. This matters most for alcohol, which presents unique risks. Severe alcohol withdrawal can appear days after booking and can be fatal. If someone who was recently booked becomes confused, hallucinates, or has seizures, medical staff should be alerted immediately to the possibility of alcohol withdrawal.

Treatment Is Difficult in Jail

Substance use disorders are very difficult to treat in jails due to:

• High inmate turnover

• Frequent housing changes

• Limited treatment staff

• Limited inmate motivation for treatment

Some jails have dedicated treatment units, but they are uncommon. Most jails focus on post-release treatment linkage, because the period immediately after release is especially dangerous. People are stressed, fully detoxed, and may return to prior levels of use without their previous level of tolerance, increasing overdose risk.

Personality Disorders

Personality disorders involve rigid, pervasive patterns of thinking and behavior that are highly resistant to change. Common examples include Antisocial, Narcissistic, and Borderline Personality Disorders. These occupy a clinical gray area. They are not typically disabling in the same way as mood or psychotic disorders, but they severely impair relationships.

They are not classified as mental illnesses largely because they are difficult to treat. Insight is limited, motivation is low, therapy is often sabotaged by the patient, and medication does not treat the underlying disorder.

Despite this, personality disorders matter in jails because these inmates often consume a disproportionate amount of mental health resources. They may exaggerate symptoms, act out, or repeatedly generate crises.

A former professor once suggested using one’s own frustration as a diagnostic indicator: the angrier a patient makes you feel, the more likely a personality disorder is involved. This heuristic is imperfect, but often accurate. We will revisit this topic when discussing malingering.

Levels of Mental Health Care

Mental health treatment should match symptom severity:

• Outpatient treatment for mild to moderate conditions

• Intensive outpatient or partial hospitalization for more severe cases

• Inpatient psychiatric hospitalization for acute danger (typically 3–10 days)

• State psychiatric hospitals for chronic or treatment-resistant illness (30–90 days or longer)

Jails contain people who fall into every one of these categories. In my jail, roughly one-third of inmates likely need outpatient treatment for a diagnosed mental illness, excluding substance use disorders. Approximately 4% have a serious mental illness that would be more appropriately treated in a psychiatric hospital. That rate is two to four times higher than in the community.

Jails also receive patients who are too disruptive or dangerous for psychiatric hospitals, including individuals who assault hospital staff or other patients.

In short, jails house some of the most difficult psychiatric cases in the system.

Who Provides Mental Health Care in Jails

Most jails contract with large correctional healthcare companies. Others partner with hospitals, universities, or counseling centers. Some run in-house programs staffed by county or city employees. My jail uses the in-house model, which I recommend, though each approach has tradeoffs.

Providers generally fall into two groups: therapy-focused and medication-focused staff.

Therapy-Focused Providers

• Mental health technicians or specialists handle crisis intervention, groups, and suicide watch monitoring.

• Counselors and clinical social workers conduct evaluations, suicide risk assessments, and segregation reviews. Therapy is a smaller part of their role.

• Psychologists typically serve supervisory and administrative roles. They oversee staff, review cases, manage policies, audits, and program development. They do not usually conduct competency evaluations for inmates in their own jail due to conflicts of interest.

Medication-Focused Providers

• Medical assistants pass medications, administer injections, and check vitals.

• Nurses conduct intake assessments and can administer as-needed medications under standing orders.

• Nurse practitioners and physician assistants diagnose mental illness and prescribe medication. They are the backbone of jail psychiatric treatment.

• Psychiatrists focus on medication management and supervision. While they sometimes serve as program managers, their time is usually more efficiently spent treating patients directly.

Common Medication Classes in Jails

Medications are typically grouped into four categories:

• Antidepressants – widely prescribed

• Anxiolytics – long-acting agents are preferred; benzodiazepines are usually avoided

• Mood stabilizers – primarily for bipolar disorder

• Antipsychotics – essential for serious mental illness

Benzodiazepines are rarely used outside of detox, due to abuse potential (and high trade value) and overdose risk.

Mood stabilizers reduce extreme mood swings but are often disliked by patients because they blunt positive emotions. They have little trade value in jail.

Antipsychotics are the most effective short-term treatment for psychosis. Long-acting injectable antipsychotics are especially important because many psychotic patients have anosognosia and refuse medication. Injections are safer and require fewer physical interventions. These medications are not without their trade-offs. We will do another article sometime in the future on dopamine-supersensitivity and why antipsychotics sometimes make the problem worse in the long-run.

The cost of these medications is a serious problem and deserves its own discussion. I’ll do an article on this in the future, and we can discuss why the federal medicaid exclusion rule is needlessly extracting money from local governments.

Divided Loyalties in Jail Mental Health

Unlike community clinicians, jail mental health providers have dual responsibilities: patient care and institutional safety. Confidentiality may be breached when safety or security is at risk. Treatment decisions are often driven by risk management rather than ideal clinical practice. This is not ideal, but it is the reality of correctional mental health.

Closing Thoughts

Jail mental health is complex and imperfect. Jails were never designed to serve as psychiatric treatment facilities, yet they have become the primary providers for people with serious mental illness.

Now that we have the basics covered, future articles can focus on more specific issues within this system.

In the previous series, we examined how economic forces have driven rising rates of mental illness—especially among young people. Now we can start digging into the role of jail in all of this. My plan is to explain the nuts and bolts of jails and jail mental health, and after we’ve been through the basics, we can get into some of the more complicated, convoluted, and backwards issues that prevent the mental health system from working.

First, we need to understand what jail actually is. This episode is part one of a two-part crash course on jails and mental health. Here, we will focus on the basics of jails. In the next episode, we will shift to the clinical side and discuss mental illness inside these facilities.

Jail Is Not What Movies Show You

In movies and television, someone is arrested for a serious crime and appears in court almost immediately for a jury trial. In reality, this is wildly inaccurate. In the United States, it often takes a year or more for a felony case—especially something like murder—to go to trial. I have personally seen cases take five years to resolve. During that entire time, the person may be sitting in jail.

Crimes and Sentencing: Three Tiers

• Felonies are the most serious offenses and can carry sentences of one year or more in jail or prison.

• Misdemeanors are less serious and typically carry sentences ranging from 30 days to one year in jail.

• Ordinance violations rarely involve jail time and usually result in a fine.

One important point is that the severity of a charge does not always reflect how dangerous a behavior is. Driving under the influence is extremely dangerous and often classified as a misdemeanor, while possession of marijuana is charged as a felony in some states.

Another important point is that people do not always serve the amount of time suggested by sentencing guidelines. I have seen individuals plead guilty to felonies and receive no jail time, and I have seen people with mental illness fight misdemeanor charges and remain detained—between jail and the state hospital system—for over a year. Technically, no judge sentenced them beyond the statutory limit, but functionally, they were incarcerated longer than the maximum sentence.

Jail vs. Prison

Jails and prisons are often conflated, but they serve very different purposes.

• Jails are short-term facilities. They primarily hold people who have been charged with a crime and are presumed innocent until their case is resolved.

• Prisons are long-term facilities for people who have been convicted of felonies.

The defining feature of jails is rapid turnover. In the jail where I work, the average length of stay is about 48 hours. In a single day, we may book and release 100 people. This rapid turnover is partly due to constitutional requirements. After an arrest, prosecutors must establish probable cause—basic evidence justifying the arrest—within roughly 48 hours. If they fail to do so, the person must be released. This becomes critically important later when we discuss people with severe mental illness who cycle in and out of jail every two days.

From a mental health standpoint, the jail environment is extraordinarily difficult. Jails are noisy, chaotic, confusing, stressful, and sometimes dangerous. Diagnosing and treating mental illness under these conditions is a major challenge, both for patients and for staff.

How Bail Works

Bail functions much like collateral at a pawn shop. A judge assesses how dangerous someone is and how likely they are to return to court. Based on that assessment, the court sets a dollar amount. If the person—or someone on their behalf—pays that amount, they are released. If they fail to appear in court, the money is forfeited. Judges can also deny bail entirely if they believe someone is a serious danger or flight risk.

The implication is: it is easier to get out of jail if you have money.

Many people in jail are indigent or homeless, and even a $500 bail is out of reach. This disproportionately affects people with mental illness, who are far more likely to be poor or unhoused. As a result, they remain incarcerated far longer than others charged with similar offenses.

Why Almost No One Goes to Trial

Television gives the impression that trials are the norm. In reality, they are exceedingly rare. Nationally, only about 2% of criminal cases go to trial. In my jurisdiction, that number is closer to 0.5%. Almost all cases are resolved through plea deals. There are two main reasons for this.

Trials Are Expensive

Trials cost taxpayers tens of thousands of dollars. Judges must clear their schedules, prosecutors and defense attorneys must prepare extensively, and jury trials consume enormous resources—sometimes over minor charges.

From the state’s perspective, trials are risky. Spending large sums only to lose the case is politically damaging for prosecutors.

Jail Is Too Costly for Ordinary People

Most people cannot afford to sit in jail for weeks or months while fighting a charge. Employers will not tolerate extended absences. Rent, car payments, childcare, and caregiving responsibilities do not pause because someone is incarcerated.

Roughly 60% of Americans cannot afford $500 in emergency expenses, which means many people are functionally coerced into plea deals. For some, pleading guilty to a crime they did not commit is the rational choice for survival. This pressure is even greater for people with mental illness.

Probation, Parole, and Holds

• Probation allows someone to remain in the community under supervision instead of serving a jail sentence.

• Parole allows someone to leave prison early under supervision.

• Holds occur when a person is arrested in one jurisdiction for charges pending in another.

If a person has an out-of-state warrant, the jail may detain them while the originating jurisdiction decides whether to extradite. These holds typically last up to 30 days. For minor offenses, extradition is often deemed too expensive, and the person is released. Again, the system runs on money.

Why Jails Have a Mental Health Crisis

Jails were never designed to be mental health treatment facilities. Yet there are ten times more people with serious mental illness in jails and prisons than in all long-term psychiatric hospitals combined.

This happened because mental health services are chronically underfunded at every level. The United States has eliminated approximately 96% of its state psychiatric hospital beds. Community mental health centers are overstretched, and insurance reimbursement rates are so low that many clinicians refuse to take insurance (insisting on cash payments only).

As a result, jails—never intended for this role—have become the largest mental health providers in the country. Police officers and correctional staff are now the most common first responders to psychiatric crises.

In a 50-mile radius of where I work, only two facilities house more mental health patients than my jail. One is a prison. The other is another jail.

Treating Mental Illness in a Jail Environment

Consider the conditions:

• High noise and constant disruption

• Extremely high patient turnover

• More psychiatric patients than a hospital

• Fewer mental health staff than a hospital

• Little to no medical history available for many very sick patients

• Patients often restrained during evaluations

• Housing environments filled with people who are nefarious or psychotic

It is difficult to imagine meaningful recovery under these circumstances. In the next episode, I will explain how jails attempt to provide care despite these constraints.

Two Concepts That Will Matter Later

Recidivism

Recidivism refers to being convicted of a crime, serving a sentence, and later being convicted again. High recidivism rates signal a mismatch between people’s problems and the system’s responses.

Competence to Stand Trial

In the U.S., a person cannot be tried or accept a plea if they are legally incompetent—that is, if they cannot understand their charges, the consequences, or assist in their defense.

Determining competence requires evaluations by independent clinicians. If a person is found incompetent, they must undergo competence restoration, usually at a state psychiatric hospital. This process is slow. From identification to evaluation, hospital waitlists, restoration, and return to jail, the timeline often exceeds seven months, even when everything goes smoothly. In some cases, it takes far longer.

Simply being mentally ill can result in longer incarceration than the sentence for the underlying offense.

What Comes Next

In the next episode, we will shift to discussing basic mental health care. We will examine what mental illness looks like inside a jail, who provides care, and what treatment is realistically possible under the conditions we have discussed.