Episode 10: Crisis Management
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.