Mental health care and L.A. County jails

Are there resources to rejoin society?

On a quiet property in an average neighborhood of El Monte, Calif., Viviane Lafebre picks up four plastic bowls and sets of utensils. The metal utensils return to a locked cabinet. The employees must keep any sharp objects out of reach.

"Looks like nobody ate this morning," Lafebre chuckles. "They don't usually eat Saturday mornings. Oh, but for lunch, they're having sushi."

Lafebre is a transitional rehabilitation specialist and mental health worker at Braswell Rehabilitation Institute for Development of Growth and Educational Services, or BRIDGES, an 18-month dual-diagnosis rehabilitation inpatient center.

Each "client" has a mental illness and recovering from substance or alcohol addiction – a dual-diagnosis. Not all of BRIDGES' clients come directly from incarceration but those that do can be very successful at here.

"They keep their place clean. They're on time for their chores, on time for class, on time for group. They're all great. Most of the time they come here because they want to better themselves."

This is one resource for those who need mental health care at the point of reentry after incarceration. Advocacy coalitions and groups like the Los Angeles Regional Reentry Partnership (LARRP) or National Alliance on Mental Illness' Los Angeles County Council (NAMI LACC) work in the community and with law enforcement to establish practices and affect public policy.

Mental health advocates sit on LARRP's Steering Committee, which is like a board of directors. The organization consists of four committees for each initiative, including housing, health care, employment and supportive community services. NAMI is a national, state and local organization with mental health lobbyists from Washington D.C. to grassroots organizers throughout L.A. County. Los Angeles' 12 affiliates hold support groups, awareness events and law enforcement training.

Advocacy organizations like NAMI and LARRP can connect those leaving the criminal justice system to programs for their specific mental health needs or other support resources other than inpatient programs too.

Programs like Project180 and Homeboy Industries are more likely to meet those immediately leaving incarceration. Project180's mission is to turn around lives and prevent recidivism with comprehensive reentry programs, tailored to each person's behavioral health and other support needed. Homeboy Industries, famous for their bakery staffed by former gang members, has a host of programs that include mental health services for their trainees. The 18-month gang rehabilitation program partners with L.A. County parole division, Sheriff's Department and board of supervisors, to name a few.

All three programs aim to reduce recidivism. For example, within three years of release, adult felons in the state of California have a 61% recidivism rate. Los Angeles County has a 50% rate of returning to prison within three years, according to the last report published on the California department of corrections and rehabilitation website in 2014.

Mental health care is going through a transformation within the County of Los Angeles. The Los Angeles County District Attorney's Office conducted a sequential intercept mapping (SIM) workshop in 2014 to identify resources and gaps in the L.A. County Sheriff's Department's mental health care. Stakeholders in the process included those from law enforcement to health care groups.

District Attorney Jackie Lacey made recommendations for a five-step model.

The Sheriff's Department is to expand response teams, increase diversion opportunities in screening and post-arraignment, strengthen reentry programs and provide training to reduce recidivism.

"My efforts have always been trying to have the system divert as many people with mental illness out of incarceration and into treatment," Mark Gale, the criminal justice chair for NAMI LACC, says. "If there's a goal, it's to see to it that people who are ill are not being punished for being ill, and that people receive treatment regardless of what setting they're in. Everybody deserves and should get appropriate treatment."

Gale was one of the 46 people present at the SIM workshop. He shared the SIM report.

"You can't just throw people back into the community; you've got to give them the services and support that they need. And we're starting to do that. We have a long way to go – and there's not enough money, not enough resources, not enough doctors, not enough clinicians, we need all those things – but were making big, big strides in a very short period of time," Gale says.

The practice of this five-step model is just getting started but he is confident.

"We're very excited about [the reforms]. There's so much wrong in the criminal justice system and so much wrong in the mental health system that I've got to hand it to Los Angeles County. They've really stepped up and take it seriously, including our board of supervisors. It is not just on the radar, it's front and center," Gale says.

Much of the focus on the law enforcement side is to educate officers and deputies to engage appropriately with those who have mental illnesses.

As the law enforcement chair, Gale has immediate knowledge of the law enforcement trainings from NAMI.

"They've got to have the de-escalation training. Law enforcement officers are trained secure the site and make sure everybody's safe," Gale says. "Law enforcement officers look you in the eye to let you know they're serious. When somebody's in a psychotic episode that's probably the worst thing you can do."

If you've got two scared people – scared of each other – it's just fight or flight. I think everyone chooses to fight.
- Andrew Zaragoza, transitional rehabilitation specialist and mental health worker

The BRIDGES staff has seen how negative encounters with law enforcement can affect people.

"This population, they're very afraid of law enforcement. I see a lot of them that come through deathly afraid of the police. And that's sad because they're afraid to report things. When they encounter a police officer it's probably when they are not on their meds," Lafebre says. "They get scared. What are you going to do when you get scared? Protect yourself."

Andrew Zaragoza, a transitional rehabilitation specialist and mental health worker at BRIDGES, thinks there is not enough understanding and empathy when encountering someone with a mental illness.

"If you've got two scared people – scared of each other – it's just fight or flight. I think everyone chooses to fight," he says.

"I think they've been trying to do more in the last couple of years. I don't know what training they get, but I think they need a little bit more or for a longer time," Lafebre says.

"Having de-escalations skills, being familiar with what some of the diagnoses are, what to look for, because there are interventions that can be used to help deal with people with different types of mental illnesses," Miriam Aviles, assistant director of Project180, says. "Sometimes it's just a matter of connecting someone to a hospital or a shelter, or providing someone with some type of resource. They don't have to go back to jail because they just really need some help."

The debate of if law enforcement is properly trained is evolving with the five-step model reforms.

"It's critical. [Officers] are often the first point of contact for a lot of people. So, the training and understanding of the mental health population and when they come in contact and how they engage become extremely important," Troy Vaughn, founder and executive director of LARRP, says. "We see a culture change and understanding of how we interact with the population and with law enforcement and so I think if we continue we'll have a more diverse understanding within law enforcement."

The deputies who have direct contact with inmates need to be able to put the education and training into practice.

A deputy sheriff who works in a Los Angeles County jail facility spoke under the condition of anonymity because he was not authorized to speak about inmate cases.

"In the academy, we learn about dealing with mentally ill inmates where we run scenarios. And after the academy we went through more – jail ops training – that's before you go into a custody facility to help teach you about working custody and the inmates," the deputy says. "That's where we also learned about the mentally ill and went through scenarios of how to solve situations or talk to them and how to determine if someone is mentally ill. We get training now too."

Deputies receive training and go to seminars for various new policies and recertification, including mental health care issues. For those that work in the jail, or custody, it is observing inmate behavior that can be the difference between the person getting help or not.

"Usually someone that's mentally ill goes through classifications, and medical screenings, psychologist and then they're usually housed at Twin Towers Correctional Facility," the deputy says. But some fall through the cracks and into Men's Central Jail or another facility.

"By using different skill sets, they are taught, 'use your words instead of force.' It saves lives. Too many people are being hurt by too many untrained law enforcement officers. If you don't provide them with training there's a management problem by the county whose job is to insure public safety," Gale says of NAMI's courses.

All we're trying to do is help them get to the right place. We know they're not supposed to be in Men's Central Jail so we just try to get them out.
- Deputy sheriff, Men's Central Jail

This deputy sheriff uses this skill set.

"We talk to them. I just start a regular conversation. Ask they where they're from, how old they are, what's their name, what they did for a living, if they're on any kind of medication and what kind if they don't want to tell me. And I'll say, 'Hey I called someone to come talk to you, they're going to talk to you and try to help you out, I'm just trying to help you.'" And the deputy will fill out a behavioral observation paper for the mental evaluation team.

"Sometimes the inmates go suicidal. I've cut someone down from trying to hang themselves. I saw he had tied a blanket to his cell you could hear him struggling to breathe. I had to cut off the blanket off his neck."

In the end, the deputy says, "All we're trying to do is help them get to the right place. We know they're not supposed to be in Men's Central Jail so we just try to get them out. These guys can cause issues that can be avoidable if they're placed in the right housing location. The last thing we want is for them to assault one of us or have to control the individual."

"We risk people going back to prison if we don't offer reentry services. Often times the trainees, especially if they spend a lot of time in prison, are just trying to get acclimated to what life is like," Fajima Bedran, MFT, director of mental health services at Homeboy Industries, says. "They don't plan to go back to what they used to do. [They should be] offered therapeutic services where they can deal with their past in however way they need to deal with everyday living. Learning coping skills or learning social skills can all be done in therapy. They risk going back to their prior lives because that's all they know. And they go back to neighborhoods and situations."

"I think that people that are incarcerated suffer from a lot of trauma in their lives so upon returning into the community, some of them have a difficult time making that transition," Vaughn says.

Access to high level mental services while incarcerated and in transition is critical to the process of helping them reintegrate.

"BRIDGES is a long-term residential program. We continue their mental health treatment here," Lindsey Griffo, intake coordinator at BRIDGES, says. "They are required to attend groups daily, and we do integrate them into the community where they can get a part time job or go to school part time to help them learn independent living skills, and hopefully transition to an environment where they can live independently or back into the care of family and a more of functioning with society."

Residential programs like BRIDGES or support programs like Project180 and Homeboy Indusrties some one of the many pieces that LARRP wants to support and expand.

"Returning citizens need a landing space and safe spaces that allow them to transition and reintegrate back into society," Vaughn says. "It's also important because we need to create balance and transparency in the process of what reintegration looks like as far as our communities, particularly looking at policy challenges and helping to impact those challenges."

It does not have to be long-term programs though. Support services can be faith-based organizations, mental health support groups or peer guidance. The important thing is that those who are coming out of incarceration can access whatever resources they need to be successful.

"Treatment is beneficial for those who are incarcerated by helping with long-term placement and helping them to get stabilized, rather than just releasing them into the community and having it be a cycle of the same events that may be recurring due to mental health illness," Griffo says.

"This population is able to be productive members of society with the appropriate support and resources when they are out. They need to be connected. Because if not, they're going to struggle and they're not going to be successful," Aviles says.

"I'm very proud of what our county is doing. If I had to sit and write a road map of different ways we could be helping people get out of incarceration and return to the community, we're doing it. I think we'll end up being a national model," Gale says.

In El Monte, the optimism comes with a healthy dose of encouragement.

"We've gotten so much better just about talking about mental health in 2017, which is great, but to integrate it into the systems would be better, especially in law enforcement," Zaragoza says. "Maybe it's monthly training, or a guest experience or just making it personal to each officer so they think when they see someone who clearly can't communicate with them in a way that can be understood."

Zaragoza is called outside by a client to the tables between the community garden and a mural-coated wall.

"It's 10 o'clock and no one's up for their meds," Lafebre says.

She walks to a series of locked cabinets in the office. Just like the utensils, the employees must keep the medicines out of reach. Soon the residents will be out, and take them by themselves.

Deinstitutionalization points to jails' mental health crisis

Deinstitutionalization in the U.S. through 1995

The first governmental move that affected those with mental illness was when colonial Virginia's governor sent "those deprived of reason" to jail. This was the catalyst for a public mental health hospital, but the role of the criminal justice system – a kind of holding cell for the mentally ill – has come full circle.

The United States used to have many public mental health hospitals. Between 1950 and 1960, with the highest numbers of patients in these facilities around 560,000, a push for deinstitutionalization targeted psychiatric institutions.

By the mid-1990s, hundreds of thousands of patients were back in the community, with numbers around 70,000 in psychiatric facilities.

Now, the criminal justice system is going through a series of reforms to address the growing population with mental illnesses who are incarcerated.

It is a common belief that deinstitutionalization is linked to homelessness and the skyrocketing numbers of mentally ill inmates in the criminal justice system.

The push to close public mental health facilities sent many patients back into the community. People that would have gone into institutional settings and inpatient programs do not have as many options now.

Currently, those with mental illnesses in jail or prison might return to the community. Programs and advocates focus on the reentry point to help reduce recidivism.

Check out the timeline below for a few events in the journey of caring for those with mental health needs.

It's worth noting many things factored in the process of deinstitutionalization, not just the prospect of community-based treatment for patients.