Mental health problems in the jail can range from severe emotional turmoil due to being arrested, PTSD which can be triggered in jail, up to schizophrenia and bipolar disorder, Alkhawaga said. Though Dr. A is able to help many people, that mental health care comes at the price of a criminal record, one that some patients shouldn’t have.
“You end up with many mentally ill patients in the communities and you don’t have enough money resources, programs, (or) housing to accommodate them,” Alkhawaga said. “When you are already on the streets, you don’t have enough psycho-social support, you’ll end up doing illegal acts, disrupting the community, and end up being in jail. This is instead of finding a dignified place for these people to live, get treatment, and spend enough time until they recover.”
Jails have become the de facto place for mental health and substance abuse treatment. People with mental health disorders are overrepresented in the criminal justice system, the Montgomery County Behavioral Task Force found last year.
For many patients, the door to the jail is a revolving one. People with bipolar disorder are at the greatest risk of multiple incarcerations — 3.3 times more likely — per the American Journal of Psychiatry.
“The advantage that Dr. Alkhawaga and I have is that there’s so much recidivism that we mostly know the people who come in,” said Larry Stephens, a therapist that works in the Greene County Jail.
Once they get out of jail, the lack of support on the other side can set patients up for failure. Lack of housing, jobs and even behavioral health resources can hamstring their recovery and success upon release, according to the task force report.
In Dr. A’s own practice, he recommends to his patients that they stay on probation for a little longer than they absolutely need to.
In some cases, it saves their lives.
“We have seen patients, on the last day of probation — who did well, especially during the opiate epidemic — they overdose and die the next day,” he said.
How did we get here?
Between 1960 and 1980, state mental health institutions across the country shuttered by the hundreds, as public awareness about the overcrowding, understaffing and inhumane treatment at some state hospitals pushed lawmakers to abolish them.
At the same time, rapid developments in psychiatric medicine, including effective psychoactive drugs, promised a “cure” for serious persistent mental illness.
In October 1963, President John F. Kennedy, signed the Community Mental Health Act, which was meant to free thousands of Americans with mental illnesses from life in institutions, and envisioned building 1,500 outpatient mental health centers to offer them community-based care instead.
Kennedy was assassinated three weeks later. The state hospitals shut down, but only a fraction of the community mental health centers meant to replace them were ever built.
In 2009, a study in the American Journal of Psychiatry found that the deinstitutionalization movement of the 60s and 70s left many severely mentally ill people with nowhere to go. Those people became homeless, and thus, much more likely to end up incarcerated.
The field of psychiatry has advanced exponentially in the 50 years since the deinstitutionalization movement. The primitive psychoactive drugs of the 1960s have been supplanted by modern medicines, and the community mental health system we have today has done well for many people.
But for individuals with severe, persistent psychosis, cracks in the system remain.
“We have either hospitals or homelessness. There’s nothing in between,” Alkhawaga said.
Mental health crisis calls to law enforcement have been on the rise. Since 2019, hospitals in Montgomery County have seen a 26% increase in patient encounters for behavioral health needs in area emergency departments, with an additional 8.6% increase in patient encounters for substance use disorder.
Greene County has experienced similar trends, Greene County Sheriff Scott Anger said. Anger recently stepped down from the Mental Health Recovery Board for Greene, Clark and Madison Counties, after serving for the last 12 years, though continues to teach crisis intervention training through the organization.
“Today, there’s more crisis calls than we’ve ever had. And some of the crisis is involving even younger people than we ever would have imagined,” he said.
Police officers will commonly write “pink slips” — or notices that involuntarily send someone for an assessment that could have them committed to the hospital for 72 hours — or if the person has committed a crime, that person will be taken to jail, Anger said. Once that person is in jail, mental health staff are able to triage and evaluate the person.
“Even though if it comes from law enforcement, intervention is intervention,” Anger said.
Mental health treatment in jail
Any inmate can receive counseling for any reason. However, the most severe cases of mental illness will be seen first, Stephens said.
“They can fall into any range of categories. It could just be severely anxious and depressed because of their arrest. They may have the second category of severe PTSD, which is triggered in jail. And then the third would be some stress induced psychosis,” he said.
No addictive medications are allowed in the jail, but other than that, if there is a type of medication that has worked for patients in the past, that is taken into account, Alkhawaga said.
“When I come here, my level of respect to the inmates is 10 times higher,” Alkhawaga said. “When you feel neglected and rejected, you’ll give up. When I treat them with respect, extreme respect, they are likely not expecting it. You give them hope.”
“I’ve adopted Dr. Alkhawaga’s approach that… anytime you can make any more of their reality better where they’re happy and they feel good about life, for even a minute, then you’re being successful,” Stephens said.
Dr. A’s work sometimes involves sparring with insurance companies, other doctors, or the healthcare system in general to get people the treatment they need.
“You admit somebody into the hospital with mania. After five days, insurance says they don’t meet the criteria for inpatient (care), so you discharge them ‘half-manic,’” Alkhawaga said. “They leave the hospital, and then a week later, I see them in the Greene County Jail.
“If they had stayed in hospital longer, so the mania is completely in remission, you would not see the jail situation,” he said.
People who have had frequent contact with both police and doctors for mental health issues know the ins and outs of the system, they know how to answer questions in order to get what they want. In some cases, the only person on Earth who can force someone else to get mental health treatment is the judge.
“I saw a patient yesterday with his mother, and I told her the only way you get him treated is to press charges against him. As harsh as that can be, the only way you can get treatment and save his life is through the legal system,” Alkhawaga said.
There is evidence that both court-ordered drug rehabilitation and court-ordered mental health treatment are just as effective as voluntary treatment, though treatment is shown to be most successful when the individual has a strong motivation to change — law enforcement induced or not, according to the National Institute of Health.
“I tell my patients that your prefrontal cortex, which inhibits you and makes you have the insight and ability to make the right decisions, is not functioning well. And we need to train it back,” Alkhawaga said.” So you need an outside force that keep you straight for a while. And the longer you do that, the better your brain will adapt to this new life. And the legal system is a good system for that.”
Adaptations in criminal justice
Jails have adapted to this new role, and mental health treatment is embedded in correctional facilities around the Dayton region.
TCN has started building their own network of residential care, including a new project in Fairborn. Housing is one of the most common barriers to success after incarceration, particularly for those with substance abuse disorder.
Greene County is in the middle of constructing a new jail off of Greene Way Boulevard, which will have additional space for programming, including mental health treatment. One of those programs is the Stepping Up Initiative, Anger said, a nationwide effort to more effectively plan for and treat individuals with mental health problems, both while they are in jail, and after they leave.
“Every discipline has things they can do to help,” Anger said. “It’s so important to build relationships between law enforcement and other agencies and the private sector that can help fill those gaps. I think there’s more focus on trying to do that than ever, but there’s also more cases than ever.”
The Mental Health & Recovery Board of Clark, Greene & Madison Counties teaches crisis intervention training for first responders annually, Anger said. Some officers will even accompany TCN case managers on calls to be able to differentiate firsthand between mania, withdrawal, deception or noncompliance.
In Montgomery County, the creation of a behavioral health portal aims to help healthcare providers coordinate care for patients coming into emergency departments and other facilities, including the Montgomery County Jail.
Montgomery County has also dedicated millions in opioid settlement dollars to a renovation of the jail, which will include the removal of more than 200 regular beds and the addition of 100 medical beds. Work is expected to begin this year and will also include creating new spaces for detox and other medical needs.
If there was one thing Alkhawaga wants individual people and families to know about treating anyone with mental illness, it’s early detection. Waiting until someone has a manic episode, or is suicidal or homicidal, before treating their mental illness is like waiting until someone’s cancer is in Stage 4 before treating it.
“The problem is people are (diagnosed) late, or people are neglected, or are misdiagnosed or misperceived,” he said. “We will deny the addiction, don’t want to deal with it ...but really early detection of signs and symptoms of mental illness and addiction is key, and knowing what resources are available.”
Staff writer Sydney Dawes contributed to this report.
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