Sociology Mind
2014. Vol.4, No.1, 31-35
Published Online January 2014 in SciRes (
Public Sector Responses to Jail Mental Health: A Review with
Recommendations for Future Research
Ronald He l ms1, Ricky S. Gut ierrez2, Debra Reeves-Gutierrez3
1Western Washington University, Bellingham, Washington, USA
2California State University, Sacramento, Sacramento, California, USA
3Alliant International University, San Francisco, California, USA
Received October 9th, 2013; revised November 21st, 2013; accepted December 13th, 2013
Copyright © 2014 Ronald Helms et al. This is an open access article distributed under the Creative Co mmons
Attribution License, which pe rmits unrestricted use, distribu tion, and reproduction in any medium, provided the
original work is properly cited. In accordance of the Creative Commons Attribution License all Copyrights ©
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2014 are guarded by law and by SCIRP as a guardian.
The history of public mental health intervention in the US has been uneven and in some instances is cha-
racterized by a strong overtone of neglect. While clinical research in primarily private settings has gener-
ated findings that give a strong sense of “what works” in mental health diagnosis and treatment, this re-
view pays special attention to the distribution of mental illness among jailed populations. Local jail sys-
tems house a substantial number of mentally challenged individuals but receive less attention than is war-
ranted given their numbers. This paper concludes with a plea for research with a focus on the community
determinants of mental health systems in order to enhance delivery of services and increase the likelihood
of reaching those most in need of mental health treatment.
Keywords: Mental Health; Jails; Community Mental Health; Mental Health Research; Society and Mental
What seems to work in the field of mental health tre atment?
Researchers, primarily in the US, have documented through a
substantial number of published studies, a series of answers to
this question. In the research note that follows, we summarize
the field of research with the intent to bring into a single space,
a brief on the history of mental health intervention as well as
findings regarding “what works” from the scholarly literature.
Since so many mentally ill individuals are discovered through
the intake process at county jails throughout the country, and
become subsequently “consumers of services” while incarcera-
ted in local jail facilities, we focus special attention on this cri-
tical aspect of mental health populations and delivery systems.
Doing so will allow for an assessment of questions that are less
clea r cut and help di rect atten tion to where research sh ould fo-
cus in light of austere fiscal conditions and shifting parameters
of privatized support for intervention in the mental health
Review of the Lit erature
The US Experience with Mental Illness
Mental health care at the level of the individual has been the
focus of concern throughout a substantial portion of American
history, and in particular during the past 150 years. The scho-
larly literature features a wide range of studies on mental health
issues, primarily focused on individual-level experiences, di-
agnostic issues, and treatment effects. Although there is docu-
mented evidence of substantial rates of occurrence of mental
illness in the developmental stages of our nation, the first at-
tempt to officially document the extent of mental illness and
mental retardation occurred with the inclusion of the categories
insane and idiotic during the collection of the Census of 1840.
By the late 1800s mental health crusaders such as Dorothy Dix
(1843; 1975) were instrumental in establishing and expanding
the state hospital system for the treatment and care of mentally
ill patients, thereby relieving to some extent, the burden of care
for these populations to the ill-equipped almshouses and local
jails (Torrey, Kennard, Eslinger, Lamb, & Pavle, 2010). Be-
tween 1850 and 1869, 35 new state hospitals were established,
and by 1890 another 59 additional state hospitals were estab-
lished. Those institutions being built after 1870 were substan-
tially larger than those built earlier in order to accommodate
more patients who represented an expanding scope of mental
and physical of conditions (Staples, 1990). The process of esta-
blishing state hospitals for the mentally ill, largely initiated by
Dix, continued to evolve and expand throughout the early
1950s, reaching its zenith by mid-decade.
At the high point, state facilities for involuntary commit-
ments of the mentally ill housed approximately 557,000 people
(Kerle, 2004). After years of controversy and documented
abuse of mental patients confined to such facilities, a federal
court ruling issued in Wyatt v. Stickney (1972) led to the wide-
spread deinstitutionalization of those mentally ill persons invo-
luntarily committed to state institutions and who did not fit
within a narrowly defined description, to wit, the presence of
documented evidence that institutional confinement was re-
quired either for the safety of the person or for the safety of the
community. As a result of this ruling, many states chose to
release large numbers of mentally ill patients into their local
communities prior to the development of adequate community-
based mental health treatment services (e.g., ongoing medica-
tion, periodic counseling, and targeted therapy). The mental
health system in the United States went from being primarily an
institutional service program to becoming principally a com-
munity care operation. Virtually overnight, this system went
from what had been a state- or county-provider system to a vast
array of behavioral health networks that are typically organized
as not-for-profit agencies (Cox, Morschhauser, Banks, and
Stone, 2001). Thus, Dorothea Dix began her campaign for men-
tal health care reform and the decriminalization of mental ill-
ness during the 1840s, public policy concerning the responsibi-
lity for and care of the mentally ill has been a topic of great
ongoing debate and occasional sharp controversy (Torrey et al.
By the turn of the century, the mental hygiene movement was
taking root and gaining significant ground across the country.
Clifford Beers, a researcher and gifted writer, drew public at-
tention to mental illness by shocking readers with a graphic
account of hospital conditions in his famous book, A Mind that
Found Itself (1908). Another historical factor that is noteworthy
is the systematic screening of immigrants at Ellis Island for
signs of mental illness and/or mental retardation. The high in-
cidence of mental disorders among immigrants broadened pub-
lic recognition of mental illness as a national health problem
(Grimes, 1974). It wasn’t until 1930 however, that the US Pub-
lic Health Service (PHS) established the Narcotics Division,
later re-named the Division of Mental Hygiene, bringing toge-
ther research and treatment programs to combat drug addiction
and to study the prevalence of mental/nervous disorders and the
efficiency of interventions developed to treat them.
During the nation’s involvement in World War II severe
shortages of professional mental health personnel translated
into a deficit in treatment providers who were able to interpret
the symptoms of mental illness (Grimes, 1974). One truly un-
fortunate result of the interruption of active research and treat-
ment during this time was that the mental health field lagged
behind other fields of medical science and public health. Even-
tually, a national mental health program was proposed, forming
the foundation of what would become the National Mental
Health Act of 1946. This was a key development in the effort to
have the federal government recognize and respond to mental
health problems in the nation. Subsequent to this legislation the
number of institutionalized mentally ill persons in the US rose
dramatically to over one half million hospitalized individuals
by 1955.
In response to over-burdened state mental institutions, legis-
lation dictated that only those who present a danger to them-
selves or the public would remain institutionalized. Thus, over
the course of subsequent years the number of patients with
mental illness being treated in an institutional setting dropped
dramatically, so that today there only about 57,000 persons held
in state mental health hospitals, sometimes against their own
will, the result of a court ruling permitting involuntary confine-
ment. In terms of committed bed space, Lamb and Weinberger
(2005: p. 529) assert that “by the year 2000, the number of state
hospital beds had dropped from its high in 1955 of 339 per
100,000 to just 22 per 100,000 on any given day.” The unfor-
tunate culmination of events following Wyatt v. Stickne y (1972),
and given the clearly insufficient availability of mental health
treatment services, this resulted in the emergence of the crimi-
nal justice system as a default primary provider of mental
health services in local communities (Perez, Leifman, & Perez,
It is ironic that while it has been over a century and a half
since Dorothea Dix’ observations presented to the Massachu-
setts legislature in 1843 about the inhumanity and inappro-
priateness of incarcerating the insane (Dix, 1843), the incarce-
ration of the mentally ill today remains a widespread occur-
rence in the US. The utilization of jails to house mentally ill
defendants has been documented by academic researchers in
recent years using several alternative measures: data taken at
the point of intake processing indicating a recent [documented]
history or symptoms of a mental health problem that must have
occurred in the 12 months prior to the interview; or, a recent
history of mental health problems [that] included a clinical
diagnosis or treatment by a mental health professional. Sy m p-
toms of a mental disorder have, generally speaking, been based
on criteria specified in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) (James & Glaze,
2006: p. 1). Under this classification, contemporary studies in-
dicate that 21% of arrestees processed in the local jails across
the US reported a recent history of mental health intervention,
and 60% of jail detainees exhibited symptoms that are charac-
teristic of some level of mental disorder (Cornelius, 2008;
James & Glaze, 2006).
According to recent evidence reported by the National Insti-
tute of Mental Health, approximately 26.2 percent of the adult
US population suffers from a diagnosable mental health disord-
er in any given year (National Institute of Mental Health 2009)1.
While many of those who suffer from mental disorders receive
professional care and treatment in their community (services
that are often covered in private health plans), other cases are
newly discovered through the process of arrest for criminal ac-
tivity and the related criminal justice processing that occurs
consequent to arrest. A study conducted by the Bureau of Jus-
tice Statistics (2006) revealed that 64% of persons incarcerated
in jails had a discernible mental health problem. This represent-
ed 479,900 mentally ill individuals housed in jail facilities in
the US. This alarming figure was also reported by Cornelius in
his study of the jail population in 2006; he reported on the basis
of his observations that 64% of jail residents suffered from
some form of diagnosable mental health affliction (Cornelius,
In the United States, the National US Jail Census (United
States Department of Justice, 1999) documents an uneven pat-
tern of mental health problems and institutional responses to the
concentrated populations of mentally ill individuals housed in
local jails. In a study of 25 New York jails conducted by Cox et
al. (2001), it was noted that irrespective of age or gender those
persons who are recipients of mental health services are more
likely than persons in the general population to spend at least
one night in a local jail. As noted by Goslin (2008), there has
evolved a vicious cycle of neglect, abandonment, indignity,
cruel and inhuman treatment, and punishment of persons with
mental illness(p. 906). The prevalence of mental health dis-
orders in the US has been well documented in the scholarly re-
search; however, policies to date authorizing and resourcing
mental health treatment for persons involved in the criminal
1This per centage f igure incl udes all catego ries of di agnosab le mental h ealth
justice continuum have fallen far short of ensuring adequate
and equitable services to the mentally ill jail residents.
Mental health research has focused nearly exclusively on in-
dividual-level determinants and consequences, while leaving
largely unexplored the community-level correlates of mental
health treatment, particularly in the local jail environment. This
is a surprising omission from the literature since the criminal
justice system has become a key repository for the mentally ill
as well as a major component in the delivery of mental health
services (Holcomb & Ahr, 1988; Kalinich, Embert, & Senese,
1988; Steadman, Morrissey, & Robbins, 1985; Hardy, 1984;
Gibbs, Maiello, Kolb, Garofalo, Aidler, & Costello, 1983; Tep-
lin, 1984; Gibbs, 1982). While the numbers of involuntarily
committed patients have dropped steadily in state-run hospitals,
local jails have increasingly become de facto providers of tem-
porary housing and emergency assistance for many me ntally ill
persons. This situation has contributed in diverse ways to evol-
ving security concerns for jail administrators who have a pri-
mary responsibility to maintain security and safety for all those
arrestees under the jail’s custodial care.
The existing scholarly literature examining the prevalence of
mental illness within correctional populations has generally
been established using any one of three methods: 1) face-to-
face clinical assessments of incarcerated persons; 2) self-re-
porting by incarcerated persons; and 3) via a system of match-
ing incarceration records with mental health care records (Cox
et al., 2001). Managing a large population of mentally ill detai-
nees presents serious concerns for jail administrators since
these individuals are, according to Ruddell (2010), often dis-
ruptive to the jail milieu and normally require enhanced super-
vision, direction, and treatment, as well as protection from pre-
datory inmates. Ruddell’s report documented the fact that 9.3%
of jail inmates with mental health problems were physically in-
jured during some type of inmate-to-inmate altercation, and 19%
were charged with institutional infractions. Complicating the
picture, the mentally ill are often caught in a cyclic pattern in-
volving going from living on the streets, to incarceration in
local jails, and then back to the streets again. These observa-
tions about local jail populations and the special troubles pre-
sented to administration associated with the presence of often
undiagnosed and untreated mental illness cases invite additional
scrutiny and analysis. Accordingly, research beckons in the area
of documenting patterns of mental illness and mental health
treatment capacity in county jail systems throughout the United
States, along with identifying the community correlates asso-
ciated with local-level jail capacity for managing mentally ill
For the purposes of this review, we highlight the DSM IV
(1994) definition of mental disorder, namely, a clinically signi-
ficant behavioral or psychological syndrome or pattern that oc-
curs in an individual and that is associa ted with present distress
(e.g., a painful symptom) or disability (i.e., impairment in one
or more important areas of functioning) or with a significantly
increased risk of suffering death, pain, disability, or an impor-
tant loss of freedom. The following section offers a summary of
literature on mental illness and treatment, documenting the re-
lative absence of systematic research on community sources of
jail mental health response.
Academic Research Findings Relating to
Mental Illness
The Bureau of Justice Statistics (Bureau of Justice Statistics
2009) offers descriptive evidence that mental illness among
those incarcerated in local jails constitutes an important prob-
lem in many areas of t he country. As noted in the 2006 Bureau
of Justice Statistics (BJS) report, some degree of mental illness
was documented in 60% of jail inmates, a percentage that is
substantially greater than figures reported for those incarcerated
in federal and state prisons. According to this report, approx-
imately 24% of jail inmates self-reported at least one symptom
associated with a psychotic disorder. Among arrestees, those
exhibiting mental disorders experienced the highest rate of de-
pendence on or abuse of alcohol or drugs (76% v. 53% for in-
mates without mental impairment). Gender has a bearing on the
nexus of mental health services and incarceration as well. In the
Cox et al. (2001) study, it was noted that female recipients of
mental health services across all age groups were at a greater
elevated risk for incarceration compared with the general pop-
ulation than the elevated risk of incarceration for male mental
health recipients. Similarly, the 2006 BJS report documented
that some type of mental disorder was documented in 75% of
female inmates and 63% of male inmates. Unfortunately, ac-
cording to the BJS report, only 1-in-6 jail inmates experiencing
a mental health condition had received treatment since their
confinement. Such summary information provides a foundation
for claims that mental illness and substance abuse are problems
that permeate the contemporary offender population housed in
U.S. jails throughout the country.
Local jail administrators face difficult problems linked to a
high level of co-occurring disorders or dual diagnoses. As noted
by Peters, LeVasseur and Chandler (2004: p. 563), “individuals
with co-occurring disorders frequently cycle through acute care
facilities in the community and are increasingly placed in jails
or prisons.A critical concern in tre ating inmates who a re dual-
ly diagnosed is that service providers are often confronted with
the problem of which symptoms to treat first as one often preci-
pitates the other. As documented by Edens, Peters, and Hills
(1997), this detainee population often has more significant psy-
chosocial problems, more difficulty adjusting to institutional ar-
rangements, and more pronounced cognitive and functional de-
ficits when compared to other jail detainees. Alcohol and drug
detoxification must preclude treating any form or mental dis-
order, and generally is not effectively addressed in a punitive
environment. In many cases, dual diagnosis goes undetected
and results in frequent misdiagnosis, the development of inef-
fective treatment plans, and poor treatment outcomes (Drake,
Alterman, & Rosenberg, 1993; Peters & Steinberg, 2000; Tea-
gue, Schwab, & Drake, 1990). While there has been a great
deal of research on the linkages between drug and alcohol
abuse and the commission of crime, less research has been
undertaken that documents the proximal links between these
factors and mental illness. Unfortunately, for many mentally ill
inmates their mental health status remains undiagnosed until a
chargeable crime is committed. At the time of intake and book-
ing, screening efforts may reveal the presence of mental dis-
orders, but all too often local jail facilities do not possess ade-
quate capacity to address mental illness even if it is diagnosed
accurately during the intake process. Moreover, even when
referred to county mental health services, these agencies may
view incarcerated individuals as bad organizational risks to take
on as clients since behaviors that led the mentally ill into the
criminal justice system are often viewed as not being amenable
to treatment (Kalinich et al., 1988). Further, when compared
with the general population, the risk of incarceration increases
as recipients of mental health services progress in age (Cox et
al., 2001).
The prevalence of a high number of detainees with mental
health symptoms is also reflective of the emerging role being
played by local jails in their respe ctive local c ommunitie s. Jails
are locally operated correctional facilities that receive offenders
after an arrest and hold them for relatively short periods of time
(up to 12 months) while awaiting arraignment and trial, and
hold those who are convicted but not yet sentenced, awaiting
possible conviction and subsequent sentencing, or awaiting
transfer to a state prison (Cox et al., 2001). Among other func-
tions, local jails hold mentally ill persons pending their move-
ment to appropriate mental health facilities. While jails also
hold inmates sentenced to short terms, state and federal prisons
hold offenders who typically are convicted and sentenced to
serve one year or more. In general, because of the longer period
of incarceration, prisons provide greater opportunity for in-
mates to receive a clinical mental health assessment, develop an
appropriate diagnosis, and receive targeted treatment by quali-
fied mental health staff.
Fiscal support for community mental health services remains
a low priority for most state legislators despite the fact that
local jails confine offenders who suffer from a variety of mental
disorders and also commit a variety of non-violent crimes. In
addition, the mandate for county mental health services pro-
vided to persons incarcerated in local jails has not been accom-
panied by additional fiscal or personnel services (Kalinich et al.,
1988). As noted by Clear, Cole and Reisig (2011: p. 148), only
3% of the violent behavior in the US is linked to mental dis-
orders and people with mental illness are more likely to be
victims of crime rather than perpetrators of violence.Ye t once
arrested for a criminal offense and booked into the county jail,
the mentally disordered offender must be cared for and dealt
with by the jail staff. Unfortunately, some jails have large pop-
ulations of detainees with mental disorders, and these facilities
have become the largest and most convenient location for men-
tal health services in the community. If an offender is mentally
ill, the facts that take precedence are that a crime has been
committed, the offender is in custody, and his or her welfare
and safety then becomes the responsibility of the local jail until
the case is adjudicated in the courts. An important factor in this
process that should not be overlooked is the political posture
that sheriffs typically must observe in that their appointments
are governed by voters, and a correlative desire to be viewed by
voters as “crime fighters” rather than managers of mental health
services for inmates (Kalinich et al., 1988). Over the past two
decades there has been an increasing level of concern within the
correctional field about problems arising from the jailing of
large populations of mentally ill offenders (Walsh & Holt, 1999;
Torrey et al., 2010).
While the scholarly literature on jails has continued to ex-
pand, it has yet to address these types of concerns sufficiently.
Moreover, the literature has yet to offer an empirical account of
the effects localized community institutions may have on jail
mental he alth screening and response potential. Given a history
of fiscal austerity combined with resistance to developing com-
prehensive service facilities, jails operations have been severely
limited in the provision of internal mental health services. Un-
fortunately, external (drop in) mental health services provided
within jail settings have not fared much better. This is due in
part to correctional officers’ perceived concern that their au-
thority and discretion in managing inmates may be overridden
by credentialed county mental health professionals (Kalinich et
al., 1988).
With the foregoing summarization of literature in mind, we
note that despite growing awareness of mental health concerns,
virtually no research to date has used an empirical approach to
study community correlates of jail mental health services. Put
differently, we know very little about the environmental con-
texts that are most supportive of mental health services delivery
for mentally ill people in communities throughout the US. And
in particular, we have little insight into conditions that might
improve delivery of mental health services in today’s jail sys-
tems, despite having a well-documented and lengthy history of
ignoring of the needs of the mentally ill, and also a history of
uneven attention and in the worst situations, neglect and even
outright abuse of the mentally ill that is also part of our co llec-
tive history. This is a deplorable situation since local jails are
such prominent features in the management of mental illness in
virtually every community in the US today. We turn now to a
brief discussion and conclusions with the hope of bringing new
attention to this field of academic and clinical research.
The foregoing review demonstrates the need for a practical
approach to intervention in the mental health field. A great deal
is known from a clinical standpoint regarding what seems to
work in stabilizing and otherwise assisting mentally challenged
individuals. What is less well understood are the social circum-
stances that make intervention more or less accessible to those
experiencing disorders, who however lack economic means to
obtain assistance with their mental health condition. This area
of research needs to be the focus of attention given the crisis
facing governments who are often charged with dealing with
the mentally disordered in both public health and criminal jus-
tice contexts. Unfortunately, the research does not at this point
have a strong voice in this aspect of policymaking and fiscal
prioritization. We urge researchers to follow in the footsteps, do
what has been done with regard to a variety of other policy
themes and focus on the structural and institutional contexts
that favor or otherwise discourage mental health resourcing.
We note in this context what has been recently articulated in
another research report (Helms, Gutierrez, & Reeves-Gutierrez,
under review), who note that “despite sociologically oriented
studies documenting a wide range of structural and institutional
correlates of diverse outcomes such as suicide, homicide, police
strength, prison admissions, prison population size, and overall
correctional expenditures, among many additional social and
criminal justice outcomes, contributions to the literature have
thus far not turned their attention to the correlates of mental
health resourcing” (p. 3). Their research into jail delivery sys-
tems for managing care for the mentally ill continues by asking
the following: “How well-prepared are local jails to manage the
full range of mentally ill defendants who are arrested and de-
tained in them? Despite widespread recognition that mental
illness is a serious health concern throughout the US (National
Institute of Mental Health, 2009), and that it is also a condition
experienced by many who are held in local jail facilities (Bu-
reau of Justice Statistics, 2006 & 2009; Cornelius, 2008), very
little empirical research has been conducted to assess the readi-
ness of local jails to address the mental illness concerns with
which they are routinely confronted. This is indeed unfortunate
since the county jail is typically the largest facility in any local
community for housing the mentally ill (Kerl, 2004), and thus
represents one of the key mechanisms available for the public
management of mental illness in communities throughout the
country” (p. 3).
A focused approach in this area of research is critical at this
point since public policy seems oriented to other social con-
cerns while federal and local legislators are now facing an on-
going and quite serious revenue crisis. Even as this has devel-
oped, the private sector continues to operate under perverse
profit incentives that often overlook the most critically affected
and least capable citizens in need of mental health intervention.
In light of this, we strongly encourage social researchers to con-
sider this broader focus on mental health resourcing and the so-
cial correlates of support for a stronger public mental health ap-
proach across communities.
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