Episode 6 (Part II): Jail 101
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.