Mental Health and the Criminal Justice System

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Trained mental health professionals are responding to crisis situation alongside law enforcement or in place of them? We'll talk about it with a County Sheriff and a Crisis Counselor on this edition of Iowa Press.

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For decades, Iowa Press has brought you political leaders and newsmakers from across Iowa and beyond. Celebrating 50 years of broadcast excellence on statewide Iowa PBS. Here is Kay Henderson.

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Henderson: A few weeks ago, if you watch this program, you saw two people at this table who had personal experience with Iowa's mental health system and have become advocates for change. Today, we are interviewing two people who come to this issue from a different perspective, from the law enforcement perspective, and how they respond to mental health issues in their communities. Our guests today are, Sheriff Tony Thompson. He is the Black Hawk County Sheriff and Author of the book Anyplace But Here: The Uncomfortable Convergence Between Mental Illness and the Criminal Justice System. Also joining us today is Rich Nesmith. He is the Mental Health Liaison with the Linn County Sheriff's Office and a Counselor with Foundation 2 Crisis Services in Cedar Rapids. Gentlemen, thank you for being here today.

Thank you.

Thanks for having us.

Henderson: Also joining our conversation are Stephen Gruber-Miller of the Des Moines Register and Erin Murphy of the Gazette in Cedar Rapids.

Murphy: So, gentlemen, I wanted to start by just kind of getting an understanding of how and why you both got involved in this particular topic and why it's important to you. Rich, we'll start with you. Why do you do what you do?

Nesmith: Well, I'm retired military and when I retired, I realized really quickly I needed something to do, so I started volunteering to help folks. That kind of gave me an opportunity to work with under advantaged people and I wound up meeting somebody from Foundation 2. I fell in love with the company and what they do and how they interact with people and that led to me becoming a mobile crisis counselor, and that led to me becoming a liaison with the Linn County Sheriff's Office that I am now.

Murphy: And tell us just a little bit about, did you have any background in this?

Nesmith: Yes, in a very unconventional way. I am retired military. I spent 25 years as a military pilot. I did get a master's degree in counseling when I was in the military and that was to help with some of the issues that we were having at the Air Force Academy at the time. And so, it was a requirement. I didn't know I was going to like it. It was a serendipitous thing. And I fell in love with it. So, I am a counselor that came from the military, which is a little bit unusual.

Murphy: And Tony, as Sheriff tell folks how you came to be so active. I've interviewed you over many years on this topic. Why has this been so important to you?

Thompson: I write about it, but had you told me when I first took office in 2009 how pervasive this intersection between mental illness and law enforcement was, I would have laughed about it. But truth be told, the unfortunate reality is at the very bottom of that mental health delivery funnel is law enforcement. We are the catchers of all of those that don't fit anywhere else. And it's unfortunate, it's not where we ought to be, it's not where we want to be. But the frustration spills over and suddenly you're writing a book about it just to let off steam, to let that frustration out. And so, every county jail in the state is brimming with mentally ill.

Murphy: You have, and it's always stuck with me, you have described county jails as --

Thompson: They are the largest mental health care facilities in the state. And it's not, it's not be design, it's not be desire, and it's not even this braggadocios type statement. It's the reality that we face.

Gruber-Miller: So, walk us through. What does the county jail look like? How are you attempting to even treat people who are in that jail right now? What do you do to make sure that these people are able to get the help that they need?

Thompson: Well, unfortunately we all know that a county jail is not designed for mental illness, mental health treatment. That's not what we're meant to do, it's not what Chapter 50 of the Iowa Code tells us we're supposed to be doing. But in my jail specifically, I've got 272 residential beds, about 60% of them are occupied by people that are diagnosed mentally ill. That is a frustration in and of itself. Overall, crime in Iowa, crime in Black Hawk County is dropping. But violent crime is up. So, when you think about the people that we're holding, 60% of them are mentally ill, most of them are in jail for forcible felonies, so their heads stay in our beds for much longer periods of time. So, that requires us to kind of mold our treatment, mold our care plan a little differently than we ever have before. We've got a full-time psychiatric nurse practitioner on staff 40 hours a week. I have now got two master's level social workers that work in our facility, one with the Department of Corrections. I pay her salary but her whole full-time job is to try and divert post-arrest people that don't really belong in that facility back out onto the street, back into community-based placement. The other one, she works group sessions, she works with other coordinated care and community-oriented service organizations to try and provide services to those folks that we can get released out of our facilities so they do recidivate and come back. So, it's a perplexing, when you talk about law enforcement, what a weird position for the sheriff, for a jail, for a correctional facility to have to accommodate because there is this enormous gap that we're trying to fill that really doesn't fit our job description whatsoever.

Gruber-Miller: And Rich, walk us through what you do. You actually dispatch and respond to some of these mental health calls with law enforcement. So, talk us through what kind of work is entailed when you do that and what these calls are like?

Nesmith: That's absolutely true is I dispatch with deputies. The dispatchers that dispatch deputies also control me and when I show up. When I show up on a scene, if I'm first there I don't go up, I wait for a deputy to come with me. Obviously our first goal is to make safe. The second thing that I'm looking to do is to try to de-escalate the situation. And deputies do this as well. So, the third thing I do is I offer services as needed at the time whether those be acute services or long-term services. But I want you to understand that I am a tool for the sheriff. That's what my job is, is to be there for him when he needs me. So, if anything falls into that gray area that is like okay, this person doesn't need to go to the hospital, this person doesn't need to go to jail, there's not a criminal activity taking place, what do we do, that's when I become a very useful tool and I'm thrown into that call.

Gruber-Miller: Okay, so you said a couple of things I want to follow up on. So, the sheriff's deputy is actually the first point of contact with the person, or are you?

Nesmith: Well, on a dispatched call the deputy will always be the first one to make contact with a client. I will go out with clients without a deputy, but they are clients that I've been out on before or they are clients that I am called out from another source other than Linn County Sheriff. For example, if Foundation 2 has me go out with a client or if the county services building has me go out with a client. I also support other organizations in Cedar Rapids that sometimes go out and want a little bit of assistance with de-escalation and I'll go with them.

Gruber-Miller: And you mentioned acute services and long-term services. What kinds of things are you talking about when you use those terms?

Nesmith: When we have acute being a short-term service, if we need to get someone stabilized for a couple of days, med management or somebody to talk to, to work through a crisis like a death of a family member and they don't feel like they can do that alone, we have places like the Access Center in Linn County where we have crisis stabilization beds and we have counselors available for them to talk to. We use Foundation 2 mobile crisis outreach services that provides people to come out to your home and provide 24/7 counseling care that you need. That is a short-term, acute thing. That's something if we're dealing with an acute crisis, we can solve it that way, that's great. Longer-term care is working with other providers in the area and providing referrals to something like substance abuse treatment or in-residence treatment for a longer-term stay for somebody that is suffering from schizophrenia, for example, or something that is going to be with them the rest of their lives.

Henderson: Tony, how many Richs do you have at the Black Hawk County Sheriff's Office?

Thompson: Well, I think it's important to recognize we've really talked about two different models here. We've talked about the post-arrest diversion that happens in my jail. And we've talked about pre-arrest diversion. And obviously we want pre-arrest. That model is any time we can keep them out of jail that is critical. And your question is right on the money. There are 99 counties in the state of Iowa. How many have programs like a Rich? We have a model that is a little bit different in that we've got the Waterloo Police Department has a Rich. We do not. I've got a deputy that is also a social worker that rides with a K-9 that is a de-escalation crisis intervention K-9. So, when we've got somebody that is suicidal, actively looking to cause harm, the dog will go in with my social worker deputy and try to talk them down, convince them to come with us and seek help and hospitalization, those sorts of things. So, we approach the same sort of situation from a slightly different angle. But we have those same resources. But it cautioned me as I was listening to Rich talk about access centers and substance abuse detox centers and things like that. We're talking about a state with 99 counties and most of these counties maybe the best they have is telehealth, telepsych. And it is frustrating when you start talking about pre-arrest diversion, which is the goal, keep them out of the county jail. 60% of my population is mentally ill. And a lot of these counties don't have those kinds of resources available to them.

Henderson: Has there been a sea change among law enforcement and people who work in the law enforcement community like you do about the value of this? Has there been a change in attitudes?

Nesmith: There's no doubt. Any time you're new going into a program and trying to sell a program there's always a little bit of reservation. But when even the most hardened people see the results there, they buy in really quick. There is no doubt that these programs work and there's no doubt that they see the value in it. So, I've had fantastic support from the Linn County Sheriff's Office. And, like I said, they're proven to work. They do work. And we are growing. We have LELs. We call ourselves Law Enforcement Liaisons. We have them in Delaware County. We're putting one in Dubuque County. We have them in Dubuque city. We have them in Cedar Rapids. There's one in Marion. There's one in Hiawatha. It's growing and it's going to get bigger. There's going to be a time when this is a common thing, it's going to be that way.

Thompson: We're even investing it, from the administrative level, we're investing in just crisis intervention training, the tools on how to talk better, how to utilize the verbalization skills, how to relate, how to empathize, how to use those skills. And the first thing you'll hear is, oh that's a hug-a-thug program. And I thought, oh my goodness, it just maddened me when I was hearing cops say that because we build that muscle memory, we rely on we know how to index the gun, we know how to do all those things and so we're resistant to change because those are the things that keep us safe and get us coming home safe every night. So, the paradigm shift is hard. But everybody is seeing the reality, the proof of what Rich is talking about, the proof of how talking better, how utilizing those verbalization skills, all of those tools we're starting to put in the tool bag is creating a better outcome. And so, we're shifting that paradigm much quicker.

Nesmith: Absolutely.

Murphy: Sorry, I don't mean to interrupt, we've got a number of topics we want to get to, just to keep the conversation moving. But really quick before we do move on, I want to ask, so you talk about the paradigm shift and the attitudes, you're in Linn County, you're in Black Hawk County, two of the bigger counties. Is there also a resource question, are smaller counties able to have positions like you all have if they would like?

Nesmith: There's certainly options out there. I would encourage these smaller counties to talk to the representatives in Foundation 2 because they work grants for a lot of this to help out with the getting started. But I also do a lot of training for the smaller departments where we provide CIT training, I teach de-escalation training and we can kind of introduce these programs in a non-invasive way at first for them to see the value in it. And, again, when they see the results, the results are almost instantaneous. It's very quick to see, yes, this is worth it. We are reducing recidivism. There are fewer 911 calls. There are fewer emergency room visits. Yes, this is a cheaper and more effective option than what we're doing now.

Murphy: We're curious and want to get your perspective, and Sheriff Thompson, I'll start with you on this one. The state legislature recently approved a redesign and sort of a combining of the state's mental health and substance abuse delivery systems. They had been independent of each other. This was a proposal from Governor Reynolds. We expect that she'll sign that into law. How much will that be helpful? Does that address some of the issues that you all have been describing?

Thompson: We all hold our breath because I think the devil is in the details of a lot of that. That merger between substance abuse and mental illness, those are both really big bullies in the state. So, when you put those two together, you want to make sure they're both going to get the attention that they deserve. Taking it out of health and putting it in HHS, that makes me nervous. I want to make sure that they are going to get the attention and the funding that they deserve and that they need. I know taking 13 regions down to 7 districts is nerve-racking. We all know that the best ideas come out of Des Moines, right? We were the largest mental health region in the state with 22 counties and just through recognizing that 22 counties was too big, we kind of self-attrited. It was untenable. I think we're at 13 counties now. So, we've already kind of learned a lesson that putting a whole bunch of counties under one region didn't work. My fear is the state may have to learn that the hard way. We may put ourselves back a couple of years and have the state learn the hard lesson that 7 regions may be untenable too. So, there's a little trepidation. We're holding our breath. We want to make sure that the funding is there for both big bullies on the block and that the proper attention is given. So, we're hoping.

Murphy: Rich, do you have any thoughts on the proposed --

Nesmith: Not really on the proposal. But what I will say is that I am thrilled to death that legislators are still looking at mental health and it's still on their plate.

Thompson: Amen.

Nesmith: And so, if they're seeing this and they're doing something I'm a fan.

Gruber-Miller: And the state has got also a system sort of set up or at least a framework for children's mental health. How do you both interact with that system? And how does it work with what you do to maybe keep kids out of jail?

Thompson: So, for me I know that the sooner and the earlier we can detect, the better outcomes we're going to have. So, I just spoke to a group of budding school psychologists at UNI and praised them for getting into that career field, encouraged them, because the more we can encourage earlier detection, earlier engagement, the better off we're going to have, better outcomes we're going to have, the less likely they are going to fall through the cracks, the less likely they are going to go untreated. Now, things like schizophrenia where the onset is a little later in life and harder to detect and more challenging of outcomes, that is always going to be there, that is always going to exist. But any time that we can make that earlier investment and demonstrate both to Iowans with affliction or Iowans with mental illness that the state is aware, we're going to champion that all day long.

Gruber-Miller: Rich?

Nesmith: Sheriff Thompson talks about how the jails have become the de facto mental health providers for adults. Well, the schools have kind of faced a little bit of the same thing for children. And so, Foundation 2 has programs that deal specifically with this where they partnership with like the Grant Wood AEA to where they have counselors that are available in schools. And so, there is this big push and effort to provide these vital services early on so that we do identify these things and we can provide services so that it doesn't become a problem that they wind up being Sheriff Thompson's issue. So, any endeavor that we do to solve these issues before they become real problems is great and that is what Foundation 2 is doing through a lot of these programs and partnerships with other organizations. So, big proponent of it. We have SROs, that are school resource officers, that go out to the schools as well. So, again, this is a sheriff and mental health team. The SRO is trained in mental health stuff and CIT trained and they solve those problems. It's a wonderful setup.

Henderson: A couple of weeks ago we had a couple of guests here involved in mental health issues and they recommended that someone, perhaps in a home, has a family member having a crisis, don't call 911, call 988 and then they will route it correctly. Is that what law enforcement recommends?

Thompson: So, my biggest fear, and quite frankly we've been doing a lot of testing at the Black Hawk County dispatch center with 988, that smooth transition between the two. If we get the call first and it doesn't rise to the level of needing -- somebody is agoraphobic and so it doesn't really require a law enforcement response or whatever the case may be, so transitioning back and forth. Or something escalates to the point where oh, now we do need law enforcement to respond. I'm always cautious because you want to make sure, just like Rich was talking about, if it's a dispatched call, making sure the scene is safe. I really think that that's a judgement call. So, you had Leslie Carpenter on. Big fan of Leslie, love her to death, her and I are on the NAMI Board together for the state. And so, we want to advocate 988, we want people to know that the number exists. And I think if you are in engaged, involved in the situation, you need to kind of vet that out. If it's dangerous, dangerousness means a 911 call. If it's one of those things where you just know you need an advocate, you need somebody that is going to help you out and provide resources and outlets and avenues for, 988 is the solution. Does that make sense?

Henderson: It does.

Murphy: Rich, I'm curious your perspective, there has been a sort of shift in the approach to addressing mental health and where to put people who have mental health needs and a shift away from institutionalization towards community-based care. And we've seen the closure of institutions in this state because of that. But we also still hear on the other side of that there's a need for those people with the most critical needs and beds wherever that may be. How do we thread that needle? And what are your thoughts on how we should be approaching?

Nesmith: We've gotten pretty good at identifying at the point of crisis folks that need help. So, we're pretty good at responding. We're becoming very good with the onset of access centers and care facilities for acute care. Where it kind of drops off a little bit is bed space for long-term residents. There is going to be 20% I believe you said in your book, sir, that need long-term care and the number of beds that we have had available for that has dropped. So, if I need somebody in a long-term substance abuse treatment program, it is much harder to find that than it is something that is acute. So, we've got in really good at identifying really good at that acute care and it falls of a little bit. I would like to add a thing that something is needed is some sort of case management to help people through all of these programs. A lot of the folks that need this care have trouble dealing with the bureaucracies, the paperwork, and even knowing that these things exist I think are the real benefit and the real efficiencies are going to come when we have people that help people manage these folks through this program. So, hopefully that answers your question.

Murphy: Absolutely.

Gruber-Miller: Sheriff Thompson, we just have a couple of minutes left. I want to stray briefly away from mental health to talk about another law enforcement question. The state has a new law making it a state crime for immigrants to illegally re-enter the country. You said to a crowd this week you wouldn't be enforcing that law. Why?

Thompson: Because it's unenforceable. We don't have the resources to be able to enforce that law. We don't have anything that will tell us at face level, I stop you, pull you over, run your name, nothing is going to tell me you've been deported. There is no access to the information that is going to allow me to do that. Now, I saw that Governor Reynolds said, well will write another law, we will work with Stephan Bayens to get access to that. Stephan Bayens doesn't have access to that information. That is where the federal government has access to that information. So, I really think that that was a political law that was made to make the feel good about writing it. Great. And I get it. Being deported, they shouldn't be back here. We would love to enforce it, but it's unenforceable as written.

Henderson: Rich, I want to circle back to the premise of the show. If you had a magic wand, what would be the one thing that you would do, and you have about 45 seconds to answer this, to fix the system?

Nesmith: Ooh, that's a tough one. Well, I'll tell you what it is. Again, the navigation of this system for somebody in a mental health crisis is very daunting. If I had a magic wand and unlimited resources, I would have case managers that were professionals at this, that understood what the resources were, understood how to navigate it, assisting these clients through the initial crisis, acute care, long-term care and re-entry back into society to where they feel like they've got a job, they feel like they've got something. Coming out of the jail, you've got somebody that's there for six months, they've got no place to stay, they've got no money and they're standing on the front steps. You need somebody to catch that person, get them back into society, so they do recidivate, they don't come back to jail.

Henderson: Gentlemen, appreciate you being here today and talking about a very serious issue.

Thompson: Thanks so much for having us.

Nesmith: Thank you for having me.

Henderson: You can watch every episode of Iowa Press at iowapbs.org. For everyone here at Iowa PBS, thanks for watching.

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Funding for Iowa Press was provided by Friends, the Iowa PBS Foundation.

The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure.

Elite Casino Resorts is a family-run business rooted in Iowa. We believe our employees are part of our family and we strive to improve their quality of life and the quality of lives within the communities we serve.

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Across Iowa, hundreds of neighborhood banks strive to serve their communities, provide jobs and help local businesses. Iowa Banks are proud to back the life you build. Learn more at iowabankers.com.