Death watch

It’s there when you’re first ushered into the bowels of Sacramento County’s main jail downtown. “Do you need to see a psychiatrist?” the sign stenciled on the wall reads. “Tell a deputy.” The stencils reappear in every cell in the booking area, a thinly veiled acknowledgment that the stress you’re experiencing at this moment may be beyond your capacity to handle, that you may require professional help.

It’s under the yellow fluorescent lights during the initial interview with an intake nurse, that the incarcerated get a first suicide evaluation. Say you are suicidal and you’ll go straight to the jail’s psychiatric inpatient unit, or a psychiatrist will come to booking to evaluate you. Deny that you are suicidal but mention to the nurse that you have a history of mental illness, and you’ll get flagged for a follow-up evaluation with Jail Psychiatric Services within two days of being booked.

It’s not namby-pamby sentiment that created the signage and extra care aimed at singling out those who may have thoughts of killing themselves. Everyone knows jail is stressful, and this jail has a tough reputation in some circles. But in 2002, seven inmates killed themselves in separate incidents, an abysmal record officials still are trying to live down. It later was deemed necessary that greater access to jail psychiatric staff had to be made available to all inmates and—this is key—everyone on staff had to see themselves as potential conduits to that connection.

“Two-thousand-two was a real eye-opener for us,” recalls Sheriff’s Capt. Scott Jones, now jail commander. Jones has a forthright handshake and the physique of a ballplayer. His normally friendly face turns cloudy when talking about the year of the suicides.

“You know, we’d just been plodding along, doing our thing, doing what we thought were best practices at the time, and had had some suicides but nothing to cause great alarm. Regardless of the cause [of the spike], it caused us to look at what we were doing and what we could do better.”

Turns out, quite a lot.

Sheriff Sgt. Brendon Hom doesn’t come off as the stereotypical “jailer” and certainly not the “dirty screw” of prison-movie lore. Leading an informal tour, he often stops and chats comfortably, naturally, with the inmate-workers along the way. These talks can be long or short, but they’re always respectful and light in tone.

“Part of our training teaches us to be aware that sometimes all [someone] needs is someone to talk to,” says Hom, a 14-year veteran of the department. “And I believe that if they’re able to interact with another human being, it goes a long way.”

Additional training of deputies was recommended by the Suicide Prevention Task Force, which was commissioned by the sheriff’s department in the wake of the jailhouse suicide spree. The panel, which was headed by nationally recognized suicide-prevention expert Lindsay M. Hayes, inspected the cultural, clinical and physical makeup of the jail to decide what changes needed to be made.

To better understand the enormity of the task, know that at any given time about 19 percent of the jail’s population has an open case with JPS, and the majority of those inmates are taking some form of psychotropic medication. Today, that equates to roughly 450 inmates out of 2,400 held in the two-towered, eight-storied complex on I Street across from the federal building downtown. JPS also serves the 2,000 inmates at Rio Cosumnes Correctional Center, the county branch jail in Elk Grove where about 400 psychiatric-care cases are currently open.

Despite dealing with two in 10 inmates receiving psychiatric care, deputies back in 2002 received only two hours of suicide-prevention training at their law-enforcement academy and 15 minutes of refresher material quarterly—woefully insufficient preparation in an environment where they were expected to be the first line of defense against inmate suicides. One of the first things the task force did in 2003 was bump up the training hours to eight at the academy, with 30-minute refreshers each quarter.

Line deputies, including deputy Christine Patterson, say they feel more support now than they did five years ago, bolstered by better information and two-way communication with jail psychiatric staff.

“Five years ago when all those incidents were happening, it just seemed like it was going on and on and on and no one knew why,” says Patterson, who’s been with the jail more than six years. “Now, we get updated all the time. I have a better feel overall for prevention. The more you know, the better.”

Having a JPS clinician now assigned to specific floors helps deputies, as well, Patterson says, explaining that deputies and clinicians develop a rapport that makes the job easier. “Before, it seemed we were just another voice,” she said. “You’d call something in and refer it and then you just never knew what happened with it. Now, you get follow-up and you know.”

It’s a two-way street for psychiatric nurse Jeanne Templeman, who says she depends “quite heavily” on her officers. “[They] like it when we see an inmate, get back to them and present our findings and compare it with what they’re seeing.”

Custodial officers now carry with them a pocket-sized laminated card—another task-force recommendation. On one side is a list of JPS referral numbers, both for the main and branch jails. On the other side is a list of suicide risk factors and suicide observational factors. Deputies should be aware, for example, if this is the inmate’s first incarceration, or if the inmate has been put into single-cell housing, as both are potential risk factors for suicide. Likewise, a visit or phone contact bringing bad news or an inmate coming back from a court appearance with a poor outcome warrant special attention.

Observationally, deputies should be looking for changes in eating or sleeping habits, deteriorating personal hygiene, “saying goodbye” behavior, isolation, crying, or depressed mood, among other signs.

“This used to be a cop’s jail,” Jones says, explaining the way custodial officers once viewed their role. “We had to secure these inmates, provide basic services and so forth, but everything else was just ancillary. Like education and psychiatric services. It was like, ‘We have to do this, but we don’t like it.’

“I think now staff sees a bigger picture. Sure, we have to provide security and those basic things, but it’s better for our jobs, better for society, if we can administer these other services, as well.”

As with others in law enforcement, Jones reiterates the often-repeated fact that county jails have become de facto mental-health treatment centers because too few resources exist in the community.

As a result, Jones explains, “a person’s mental-health issues will often manifest themselves in ways in the community that lands them here. Anything from drug abuse to acting out to violence. But the root cause is mental health. So if they come here and we only treat the drug abuse, we’re only treating half the problem and not the root cause. I think there’s a greater awareness now by custodial staff and a greater thrust to treat those underlying mental-health issues.”

It’s hard to imagine not being depressed sitting in one of the two-man cells. The cramped, 10-foot-by-8-foot container is utilitarian by design: A stainless-steel combination sink/toilet unit sits in one corner, and a 3-foot-by-3-foot table extending from the wall is the only place to house personal effects. The institutional beige paint is chipping in places. Each bunk has a 2-inch-thick vinyl foam mattress, which does little to disguise the bunk’s hardness. The windows, three 70-inch-by-5-inch slats, let in enough light during the day to remind inmates there’s a world out there in which they’re no longer a part. Etched into a bottom bunk is the word “pray.”

If there was a “big-ticket” item among all the reforms that have taken place, it would be the task force’s focus on how people were killing themselves—and what could be done with the physical materials at the jail to eliminate those means.

While prison lore may be filled with inmates using bedsheets to escape custody, inmates here were using them to escape permanently. But hanging oneself in the jail wasn’t accomplished as one might imagine—from the ceiling. Instead, inmates would wrap and knot a sheet around a space between the back of the upper bunk, sit on the lower bunk with the noose around their neck, and then lean forward until they choked themselves to death.

As a result of the 14 bedsheet hangings between 2001 and April 2005 alone—and 27 total since the jail opened in 1989—both custody and JPS staff agreed it made sense to get rid of bedsheets altogether, using a harder-to-tear, harder-to-knot blanket for a mattress cover instead.

Jones recalls it not having been an easy one-for-one swap. There was paperwork and red tape. Permission had to be sought from the Corrections and Standards Authority because the request touched on Title 15 of the California Code of Regulations and inmates’ rights to mattress covers. The switch was granted in May 2005—but not before another inmate hanged himself on May 18, 2005. By July 2005, all bedsheets had been replaced with blankets, at a cost of $49,157.

The task force also ordered the bunk spaces welded shut, along with the nickel-sized hole in the middle of the upper bunk originally there to allow water to drain when the bunk was hosed down. The hole also had provided a perfect location through which to thread and knot a bedsheet or other devise. The entire retrofitting project cost $45,000 and was finished in May 2006.

Paying for counter-suicide measures has been money well spent, according to many jail watchers.

“When there’s a suicide, it’s very distressing, disheartening and sad for everyone,” says supervising clinician Mark Sussman. “My experience is that over the last four years, we’ve really made it safer.”

He comes across as a guy not easily ruffled, earnest, with a “can-do” attitude. Working from tight quarters on the jail’s third floor, he supervises the JPS outpatient unit and a staff of eight clinicians, whose job it is to oversee more than 400 open cases a month—or about 55 cases per clinician.

Arriving at the jail in 2004, Sussman oversaw the modernization of the office, moving from paper charts to electronically updating patient records so anyone with access to the jail’s database could see where the inmate was in the system and when JPS had last seen them. Additionally, enacting a task-force recommendation, JPS switched from a generic two-page assessment form to an electronically generated, in-depth four-page triage evaluation form.

“We had to get better, more comprehensive information, and in a more timely way,” Sussman says. “The idea there was that if we could be more efficient, we could see more patients, and that’s borne out.”

Assigning clinicians to specific floors brought a level of consistency to patient care, as well as strengthening the working bond between deputies and clinicians, helping to keep inmates safer, Sussman asserts.

“We have a really important responsibility to keep these people safe so they can have their day in court,” he says. “And it’s JPS’ responsibility to make sure they get their mental-health care while they’re in here.”

“You can’t have the kind of changes we’ve had without a ‘buy in’ from custody, and we’ve had that,” Dr. Gregory Sokolov says as he leans forward in his chair in his small, second-floor office. Sokolov, a serious-minded man in his late 30s, was engaged as the JPS medical director in December 2003. Along with newly hired clinical director Paul Hendricks, Sokolov has gone on to provide the foundational support and leadership for JPS’ end of the mental-health reforms.

“When I came on board, we felt custody leadership was ready and eager to work with us on issues such as suicide assessment and prevention, wait-lists for [inpatient admission], and especially the ongoing review of the jail at that time,” Sokolov says.

His arrival practically coincided with the release of Sacramento County grand jury recommendations, mirroring the ones issued by prevention expert Hayes calling for more thorough inmate psychiatric assessment at the time of intake/booking, more frequent monitoring of inmates once they get to general population, and better and more open communication between correctional and court staff to monitor inmates’ moods following court proceedings. All recommendations have been in place for the past three years.

Sokolov now oversees a staff of 55 psychiatrists, nurses, licensed clinical social workers, other clinicians and support workers who are employed by the UC Davis Department of Psychiatry, which contracts with the sheriff’s department to provide psychiatric services at both county jails. Emboldened by the task-force and grand-jury recommendations, Sokolov and his staff have created a functioning mental-health clinic—complete with an 18-bed inpatient unit, and outpatient services including intake, triage, diagnosis, treatment, psychiatric case management, therapy groups and discharge planning—all within the confines of the jail.

It is perhaps the physician in him that makes Sokolov draw the distinction between the two types of inmates/patients treated in the jail when he’s trying to help you understand how psychiatric services are delivered here. He is very precise with his description.

In the first group are those who qualify as chronically mentally ill offenders—i.e., inmates who have diagnosable mental illnesses, such as schizophrenia or bipolar disorder, and who have had multiple contacts with JPS and community mental-health agencies. In the second are those whose first contact with mental-health practitioners came with their first contact with JPS staff; some may not have a severe mental illness but still require ongoing care. Suicide is of equal concern among those in either group, Sokolov says, because of the various risk factors common in the correctional environment—including being locked up, closely monitored and amid suspected criminals all day.

“In the community setting, a prior history of severe mental illness can be a significant risk factor for suicide,” Sokolov says. “But in the correctional setting, it’s just an additional risk factor. The way that can be qualified is that many of the suicides in here were done by people who did not have a prior history of mental illness. That’s why we screen everyone coming through the door—not just those who say they have a mental illness.”

Whichever group they fall into, they make Sokolov’s a busy practice. Outpatient contacts—i.e., inmates not in the inpatient unit—jumped from 20,000 in 2003-04 to 25,000 in 2005-06, the last year for which figures are available. The inpatient unit has its own pressures. From September 2004 through August 2005, there were 847 admissions, with 73 percent of those inmates reporting having had prior psychiatric hospitalization. The average stay on the inpatient unit is five to seven days. In the same time period, the number of inmates on medication for a psychiatric disorder in an average month climbed to 589 in 2006—up from 511 in 2004 and 284 in 2000.

Mentally ill offenders cost Sacramento County millions each year in jail, probation, law enforcement and court expenses. A 1999 report to the California Board of Corrections estimated the county spends about $53 million on such costs, though officials think that estimate is low now.

Also in 1999, the last year for which figures are available, local arrest data revealed 13.5 percent of all those arrested previously had received services from county mental health. That means roughly 9,700 offenders arrested every year have mental-health issues.

That data supports “the belief that mentally ill offenders cycle in and out of jail in higher-than-average proportions,” reported the study, which added that in a two-month cycle of evaluation, 103 mentally ill offenders were arrested more than one time in one month, and 84 were arrested in both months.

This is a population with a high co-morbidity of drug and alcohol problems—about 90 percent of inmates with mental-health issues have co-occurring substance-abuse problems. Staying sober after leaving the structured environment of the jail is a big challenge for many, Sokolov explains, while for others it’s a matter of securing stable housing, staying on medication and following up with after-care that means the difference between success and failure.

To that end, JPS has hired two discharge planners who work with inmates to connect them with various programs in the community before they leave jail. (See “Re-entering the real world,” page 19.)

“This is a very difficult population to treat and manage, and the most difficult thing is keeping people from coming back to jail,” Sokolov says, shaking his head.

It’s a Monday morning in June and Sussman, the supervising clinician, pulls the file of John Pratt, who’s been referred to JPS by booking the previous night because he told the intake nurse he has bipolar disorder. Sussman will conduct a triage interview to determine what services, including medication, Pratt might need.

Pratt fits the profile of a chronically mentally ill offender: He’s been in jail 27 times since 1995, and in the Sacramento County Mental Health Treatment Center 10 times during the same period. His alleged crime—auto theft—was committed while off his medication and under the influence of crack cocaine. His record is filled with other crimes such as shoplifting for food and failing to stop for police.

Pratt, who allowed SN&R to use his name, is tall and lanky and looks down at the floor during most of the interview. He’s pleasant, if somewhat matter-of-fact, when answering questions, and as the conversation continues, his frustration with his situation becomes apparent: His mood is depressed.

“If you want the truth, I would just as soon stay in here until everyone is done talking about what should happen and I can leave here and just go back east where my family and friends are,” he says. “There are too many people telling me what I can and can’t do with my life.”

Sussman notes, as with many people he sees inside these walls with bipolar disorder, that once Pratt stopped taking his medications but continued to self-medicate with street drugs, his living situation became dysfunctional—something Pratt himself admits. Pratt claims the auto-theft charge against him is false, saying he and his girlfriend purchased the old Ford Tempo in question for $130 from his girlfriend’s friend. After turning over the keys and the paperwork, however, the friend reported the car stolen, Pratt alleges, leading to his arrest. During Sussman’s interview, however, it is apparent Pratt is resigned to take whatever sentence the judge will dole out, not believing it’s worth participating in his own defense.

“His tolerance level for frustration is extremely low,” Sussman says, shaking his head. “He’s very depressed right now. It’s not unusual.”

Pratt says he and his girlfriend talk about quitting all the time, but addiction is a tough nut to crack.

“Rehab is cool. It works when you’re in that protective environment,” Pratt says. “But then you’re sent back to that old environment with no follow-up. It didn’t work that well for me.”

The pattern seen in Pratt’s chart is well-represented throughout the jail in people with bipolar disorder and schizophrenia, Sussman says. “People have a history of drug use that coincides with the history of going in and out of jail for crimes they often wouldn’t do if they weren’t using the drugs or alcohol and were on their meds.”

As a result of the evaluation, Sussman will call the Sacramento County Primary Care Center and the mental-health-treatment center—the last two places providing medication for Pratt—to verify his recent prescription history before restarting Pratt on medication taken previously. Pratt says he’s appreciative the meds will be restarted, believing they will help him think clearer and sleep better.

Sussman also tells Pratt he’ll be referred to discharge planning to receive follow-up services in the community after leaving the jail, which seems to provide some measure of hope.

“My biggest thing is I just want to be left alone by people who don’t have anything to do with wanting me to get better,” Pratt says, solemnly, his sadness palpable.

So is the county jail, as Sussman asserted, safer?

The numbers say yes.

According to Bureau of Justice statistics, the suicide rate in county jails in the United States is 54 deaths per 100,000 inmates, which would be equal to 2.7 inmate suicides per year for jails the size of Sacramento County’s.

On March 31, 2006, another inmate hanged himself. He used a pair of torn, jail-issued calf-high socks. The ankle-high socks you now see on the feet of the inmates as they pass you in the hallways are a direct result of that suicide.

But that was also the last hanging, and the only suicide in 2006. Since that time, 16 months as of July 31, there have been no suicides at the Sacramento County main jail. Further, since January 2007, when Jones took over as jail commander, officials report custodial officers having thwarted seven suicide attempts.

“Whether they were intent on killing themselves I don’t know, but those seven had the capacity to do it,” Jones says. “So it’s not like people aren’t trying, but we’re continuing to become better adept at seeing the warning signs or intervening when signs are present and at an earlier stage.

“There’s been a fundamental acceptance/internalization by staff of the threat of suicide and the need and desire to prevent it in a way that’s part of the reality of officers unlike it ever was in the past.”

About half of the seven interventions were opportunistic, according to Jones, meaning deputies doing cell checks noticed something amiss. In one case, it was as overt as an inmate holding an actual noose. In others, officers noticed inmates “not acting right” and after further inquiry called jail psychiatric staff.

Mark Iwasa, chief deputy of investigations who served as jail commander when most of the changes took place, says Sokolov and his team deserve a lion’s share of the credit when it comes to the overall improvement of jail psychiatric conditions.

“I think there is little doubt the elimination of the bedsheets has been a major contributor to the drop in suicides,” says Iwasa. “But equally important is a multidisciplinary approach that includes staff training on recognition and intervention, improved clinical identification and programs, as well as improvements in areas such as jail classification and inmate programs and recreation.”

Also encouraging are the words of praise from outside agencies, not always considered “corrections-friendly.”

“From our perspective, it’s improved quite a bit,” said Steve Lewis, chief assistant with the Sacramento County Public Defender’s Office. “We have direct communication with Greg [Sokolov] by e-mail when any of our attorneys sense a problem with any of our clients.”

As encouraging, Lewis said, is JPS’ involvement in Sacramento County’s new mental-health court, just in its nascent stage, diverting mentally ill offenders away from jail and into treatment. Sokolov’s staff is making the initial referrals to the court, which is now a pilot project. “The goal is to take that person who is in and out of custody all the time and get them treatment,” Lewis said. “So their JPS team is actively working to do that.”

And Jones and Sokolov? They’re cautiously optimistic and crossing their fingers.

“Whether it’s a statistical anomaly or not, we haven’t had a suicide in over a year,” Jones says, noting the 2.7 per year average. “I hesitate to throw out those stats in any sort of celebratory way because the reality is that as long as you have correctional facilities, you will have suicides. So all these things haven’t eliminated suicides, but we have achieved a measure of success based on these proactive practices we’ve taken.”

Additionally, according to JPS figures, inmate grievances against psychiatric services have dropped from three to four per week to two to three per month.

The positive results haven’t surprised Sokolov.

“Overall … we knew with continued changes and improvements to our program, suicides would decrease and the amount of inmate grievances against JPS would decrease, which they dramatically have,” he said.

You might say that Jones’ and Sokolov’s commitment is stenciled on the walls of the jail.