Second of two parts

PEORIA — The questions are standard today.

Do you take any medications?

Do you feel like hurting yourself or someone else?

Have you ever been diagnosed with a mental illness?

Staff at the Peoria County Jail asks every detainee about health, both physical and mental, during the same booking process that includes mug shots and fingerprints.

Mental health histories, as well as intentions for self-harm, form part of an intake survey that provides correctional officers with a rudimentary picture of an inmate's overall well-being. The tabulation also constitutes the first step in a protocol that aims to treat mental illness behind bars and beyond the barbed-wire fence once inmates are released.

The process may seem simple, but the implementation of those questions and even the primary duties of the employees who ask them took decades to reach the current state. Along the way, they were shaped by forces that affected every jail in the nation, as well as state policies that inadvertently pushed more mentally-ill people toward incarceration.

"This jail has become the largest mental health institution in the area," said Peoria County Sheriff Brian Asbell. "Today, I'm happy to say we have a mental health professional here every day, because treatable mental illness is one of the major causations of crime in our community."

Constitutional right

The local approach to inmates' mental health treatment can be traced to three milestones dating as far back as 1976, when a landmark U.S. Supreme Court decision directly addressed the way correctional facilities handled healthcare for every person behind bars.

In Estelle vs. Gamble, the justices actually ruled against a Texas inmate who claimed the treatment he received after a massive bale of cotton fell on him while working in a prison textile mill in 1973 amounted to unconstitutional cruel or unusual punishment, according to the National Law Review.

The court's opinion, however, did equate indifference to a prisoner's medical needs with an unnecessary and wanton infliction of pain — in essence qualifying healthcare, and thus mental healthcare, as a constitutional right for all inmates.

The effect on the correctional system was immediate.

"It's one of the most expensive things we do," Asbell said, noting that inmate health care costs today account for 9 to 14 percent of the Peoria County Sheriff's Office annual budget.

Zeller closure

The next milestone forming the Peoria County Jail's approach to mental illness again involved a major shift at a level of government beyond local grasp.

Around the turn of the century, changing treatment preferences gained enough acceptance among the upper echelon of Illinois policy makers to precipitate the closure of the state's main facilities, or zone centers, in favor of community-oriented treatment options. In 2002, Peoria's zone center, the Zeller Mental Health Center, closed its doors.

A limited number of former residents from the facility ended up in different living situations that resulted in more contact with law enforcement and the criminal justice system, Asbell said.

More significantly, police and emergency responders lost the most effective and efficient resource to deal with mentally ill citizens encountered while responding to calls for help. Emergency rooms and hospital psychiatric units remained viable options, but those outlets could not handle the breadth or volume of individuals detained by authorities.

"Throughout the state, all the sheriffs and jails ran into the same problem," Asbell said. "Jails became de facto mental health centers because there were no other options."

According to current figures compiled by the Peoria County Jail, as much as 80 percent of inmates suffer from mental illness. Some situational symptoms, such as depression, are expected during imprisonment, but rates of more serious mental illnesses such as personality disorders or schizophrenia range as high as 10 to 15 percent.

Those figures correspond with national numbers and illustrate how jails and prisons have become "the new asylums," according to the Treatment Advocacy Center. The group issued a report in September 2016 that found each jail in the three largest cities in the United States — New York, Los Angeles and Chicago — housed more mentally ill inmates than any remaining psychiatric hospital in the country. Based on the total national inmate population in 2014, individuals with severe psychiatric disease behind bars outnumbered patients in state hospitals nearly 10 to one.

Compared to the incidence of mental illness in the overall population, the prevalence among Peoria County prisoners is staggeringly high.

In 2015 and 2016, only 15.73 percent of Illinois residents 18 and older reported suffering from any mental illness in the past year, according to the National Survey on Drug Use and Health. In a more narrow category of the survey — serious mental illness in the previous year — only 3.74 percent claimed symptoms.

The increased prevalence of inmates with mental illness after Zeller's closure contributed to circumstances where courts once again marked a milestone for change at the Peoria County Jail.

Accreditation

The third and most recent marker did not result from a single court decision. The jail's medical and mental healthcare lacked consistency, Asbell said, and was the source of the most litigation involving the facility. The lawsuits highlighted the need for an inmate healthcare system that adhered to independently established and professionally accepted standards.

In 2010, the Peoria County Jail sought accreditation through the National Commission of Correctional Health Care (NCCHC), a process that included contracting with the Human Service Center for mental health screening and treatment.

They achieved accreditation in 2012 with a protocol that begins at booking and is intended to continue after inmates are released. The continuity of care is meant to reduce crime by treating the mental illnesses that are often at the root of illegal behavior.

"It's pretty simple at this juncture: it's a person eight hours a day who simply provides assessments and brief interventions," said Cindy Gilmer, vice president of clinical services at the Human Service Center. "Then we do our best to try to provide some type of referral, a link, some type of aftercare for that individual when they get released."

The position represents the first mental health professional working full-time inside the facility. Jailers still conduct some initial screenings at the time of booking, but every person staying overnight or longer receives a more in-depth interview from medical or mental health professionals.

"We were depending on security staff to make these clinical decisions on what was going on with a person related to mental illness, and they weren't qualified to do this," Asbell said. "We also found people were very hesitant to provide their medical history to security, so we switched it up."

In addition to the daily presence of a mental health professional, a psychiatrist visits the jail at least four hours per week to manage inmate medications. If needed, detainees are provided a seven-day supply of meds when they are released.

The medication plan has resulted in a 30 to 40 percent increase in pharmaceutical costs per inmate, though the jail has paid less for drugs overall because of a decline in the jail's population, according to figures compiled by the county.

The Human Service Center also provides cognitive behavioral therapy classes once a week for male and female inmates, teaching detainees how to identify what triggers troubling behavior and figure out how to change factors that cause them.

"If we can begin to manage those feelings, then we can begin to manage behavior and how we react," Gilmer said. "That's what is critical, but all that takes time — and the volume is such that the assessment and brief interventions are what takes most of our time."

The greatest challenge of the enhanced focus on mental illness also is the top goal: to continue care after incarceration concludes.

An obvious logistical hurdle to the plan is the uncertain timeline of an inmate's stay. Appointments can't be scheduled if someone doesn't know an exact release date.

Coverage for treatment outside the jail also proves problematic. But because a significant percentage of the inmate population qualifies for Medicaid, the Peoria County Jail partnered with Heartland Healthcare to help detainees enroll and receive benefits.

"A theme for us is continuity of care," Asbell said. "When someone is discharged from the facility, we want them to continue treatment. ... All this goes hand in hand with trying to make these individuals more productive citizens, and hopefully, they don't get back in that cycle and return to the jail."

Matt Buedel can be reached at 686-3154 or mbuedel@pjstar.com. Follow him on Twitter @JournoBuedel.