With nothing but a bus pass in her hand, Sarah Jackson stood outside Jackson County’s jail again.
How many times had she been locked in that cage just in the past year? Ten times?
At least 10.
Here she was again, back on the outside with nothing to calm her mental illness.
Nothing to get her back on medication. Nothing to clean her cravings for alcohol or heroin.
At 45, Jackson embodied the difficulties and failings suffered in jails and prisons, now the nation’s largest psychiatric wards — a mental health crisis that has only been getting worse.
Not that therapists in the county jail in downtown Kansas City didn’t try all those times Jackson ended up in “the hole” — the solitary, segregated cells of concrete floors and hard bunks in which Jackson inevitably found herself.
That’s what happens when you fight with the guards, mouth off.
Four out of every 10 inmates in the jail spiral into a similar cycle, say mental health workers in the jail. Those affected get arrested, released and rearrested, over and over — most of them prodded to some degree by mental illness.
And a national survey released this month by the Arlington, Va.-based Treatment Advocacy Center shows that most jails are seeing far more inmates with serious mental illnesses than five or 10 years ago.
“Jails are the de facto mental health hospitals,” said Brian Johnson, the Jackson County Department of Corrections’ health services and compliance manager.
Missouri and Kansas, like many states, are struggling to recover from recession-era cuts to mental health services.
“As community resources for mental health services have declined in recent years, the responsibility for providing mental health services has increased at local jails,” Johnson said.
Helping inmates in Jackson’s condition is particularly difficult. She didn’t heed the therapists’ entreaties. She didn’t follow any of their plans for her — that is, if they even had time to make a plan.
She didn’t yield even to her younger daughter, Rogia Hunt, who would drive into the neighborhood along Prospect Avenue at 35th Street when she knew her mom was on the loose again, asking familiar faces on street corners whether they’d seen her.
Get in the car, Hunt pleaded in tears whenever she found her. There was a wonderful mother she remembered, if she could get her back. Come home.
No, her mother told her over and over. Sometimes she returned her 24-year-old daughter’s tears, but Jackson wouldn’t go, even though she knew she’d probably end up here again outside the jail — angry, another bus pass in hand, staring at a bleak horizon, unwilling to confide in anyone.
“I was hurting,” Jackson says now. The way things were headed, “I was going to die.”
At its extreme, mental health counseling in jail comes down to peering through the veiled hood on a restrained inmate and asking, “Are you thinking of suicide?”
“It takes being face to face and not being scared,” said Robin Reneau, a supervisor with Truman Behavioral Health, which contracts to serve Jackson County inmates.
“They may be flailing about and spitting,” she said. “When someone has a hood over their face, it can be hard to connect.”
“They are vulnerable,” said Elaina Miller, a therapist in the jail who tried many times to counsel Jackson when she was in crisis. “They’re told when to shower. They’re told what to eat.”
The mental health workers walk through halls where everyone is trying to get their attention, said Jena Fouraker, a recovery coach who kept trying to shape plans to push Jackson toward a safer community and away from her corner on Prospect.
“They’re yelling, ‘Who are you?’ ‘What can you do for me?’ ” Fouraker said. Some who know them shout out, “Hey, Truman!” or “Hey, Behavioral Health!”
Some rebel by smearing their feces on the wall. Others wail or bang on walls.
There are no sound-softening surfaces. The clamor echoes. In that noise, Fouraker said, “it’s hard to be therapeutic.”
But the need for therapy is overwhelming. Nearly two-thirds of the inmates in jails nationwide have mental health problems, according to the Bureau of Justice Statistics. One in five suffers serious mental illness.
Yet few inmates in national surveys who suffer mental health problems reported receiving any treatment during their incarceration.
Many, jailed for minor crimes, are dispatched before help comes. Services are lacking for many, or inmates resist and refuse aid.
When the number of inmates with mental illness in jails is added to those in prison systems, the number of incarcerated individuals with mental illness nationwide totals some 356,000, according to estimates by the Treatment Advocacy Center.
That number is 10 times as great as the 35,000 people being treated in the nation’s shrinking supply of state hospital beds, the center reported.
“That’s a travesty,” said Betsy Johnson, a legislative and policy adviser for the Treatment Advocacy Center. “We should be ashamed of ourselves.”
Most of the nation — 36 states, including Missouri and Kansas — began boosting their investment in mental health services in 2013 after broad cuts during the recession, reported the National Alliance on Mental Illness. States were spurred widely by reactions to the Sandy Hook shooting of December 2012, when a man with a mental illness shot 20 schoolchildren and six adults in Newtown, Conn.
But in 2015, the report found, only 24 states increased funds for mental health. Kansas was one of 11 states that saw decreases as state legislators wrestled with budget shortfalls and disputes over taxes. Missouri kept funding stable.
Missouri is making some notable efforts, mental health advocates say, including dedicating an additional $10 million to pay for community mental health liaisons that work with police and hospitals to help divert people to community services who might otherwise end up in jail or in emergency rooms.
“This followed many years of cuts to mental health budgets,” said Cindi Keele, executive director of NAMI Missouri. “Missouri still lacks a solid mental health safety net.”
But Jackson had one saving grace. While the jail’s mental health team was trying to help her, Jackson’s two daughters and her mother weren’t giving up either.
So many jail inmates in mental health crises have lost their families, said Nae-Na Oliver, who kept trying to get Jackson to join a class — Thinking for a Change — that Oliver teaches in the jail with Kansas City’s Ad Hoc Group Against Crime.
When Oliver circulates through the jail enrolling inmates for her class, her form includes a line asking for an emergency contact.
“Nine out of 10 times they leave it blank,” she said.
It hurts her most, Oliver said, “to see individuals who are severely mentally ill in ‘the hole.’ No family to support them … and the jail is not helping them.
“They are in this rat circle, this maze in the judicial system.”
In a spiral
The surface of Sarah Jackson can turn as hard as granite.
Underneath is the daughter of a minister, who died when she was 17, and a gospel-singing mother. Jackson — herself a singer — held on to music as a last thread as illness and anger overtook her.
But the strong-boned face that glistens around her wide brown eyes and warm smile could become a chiseled snarl — especially when vagabond living turned her gaunt.
Mental illness was expressing itself in her 30s, when altercations, including an assault and a temporary standoff with police, meant stays at Western Missouri Mental Health Center and Two Rivers Behavioral Health System. She also spent 2 1/2 years in prison in Chillicothe. She was released on parole in May 2012.
Early on she was diagnosed with intermittent explosive disorder and prescribed a mood stabilization medication.
Here’s what police and prosecutors couldn’t see when Jackson’s hardened shell began confronting them repeatedly after January 2015.
The oldest of her three children, her 27-year-old son, had died of a seizure Jan. 16 in the Lee’s Summit home he shared with Jackson and her oldest daughter.
Jackson left that home after his death, unable to stay there, and fell in among friends around Prospect Avenue, picking up alcohol and drugs rather than medication.
“I was destructive with my anger,” Jackson said. “I was walking around with this rage.”
The rap sheet that followed unfurled multiple arrests for disorderly conduct, trespassing and resisting arrest.
Soon the municipal court judge began ordering Jackson to stay off Prospect. Police officers increasingly familiar with her would see her and U-turn onto the curb to confront her anew.
A hamstrung justice system and the domino effect of diminishing psychiatric beds chewed Jackson up.
The people who run the Kansas City Rescue Mission see the fallout every day.
“This is the reality,” said Joe Colaizzi, director of the mission’s homeless shelter. “Most of the people here are from prison, or have drug and alcohol addictions, or mental illness, or are in depression funk and in a spiral.”
Many come with mental illness medications in grocery sacks, he said. The shelter holds the medications for the residents and administers them, but many people disappear back into the street and leave their medications behind.
Time was, into the early 1960s, that state hospitals warehoused people with mental illness, peaking at 558,922 nationwide in 1955, according to the Treatment Advocacy Center. But reforms in the later 20th century aimed for more compassionate, inclusive care in community settings.
Missouri, which once had 12,500 state psychiatric beds, now has 1,250. Kansas, which had 5,500, now has 291, though 50 of those are unavailable as Osawatomie State Hospital completes federally mandated improvements.
The fact that so many people with mental illness crowd jails and prisons today shows how poorly states and communities developed and funded their mental health safety nets, said KiDeuk Kim, a senior research associate for the Urban Institute.
The stigma and criminalization of mental illness persists. Well-intended community mental health networks are starved for resources.
What alarms Kim most in the institute’s research is that the criminal justice system, bearing the brunt of it, is still at a loss for what to do.
“We don’t know a whole lot about how to treat them,” Kim said. “Each state has its own system. There is no common understanding of what mental illness is and no agreed treatment.”
Stopping the cycle
Each time Jackson was booked into the Jackson County Detention Center, if it were a typical day for the jail, she was one of about 80 inmates joining an overall population of some 960.
From that first day, the jail staff begins working on an inmate’s plan for exiting, Brian Johnson said.
“We don’t know if they’re going to be here two hours or two months,” he said.
In 2015, more than 700 Jackson County inmates received mental health services, said Lance Foster, Truman’s behavioral health team leader in the jail. And that’s only a portion of those who likely need help, based on the national trends.
The number was an increase from some 640 receiving services in 2014. The number of inmates whose needs were severe enough to see a psychiatrist increased from 185 in 2014 to 261 last year.
The burden weighs heavily on jails, Johnson said.
“We’re not funded to be mental health hospitals,” he said. “We have to pick it up. We have to try to address it.”
On a recent typical day, mental health professionals saw four inmates for individual therapy, helped nine with links to community support, put six through an anti-drug program, had four in a group session, saw 19 inmates in crisis and sent eight to see the staff psychiatrist.
When an inmate is in an acute crisis, the inmate can be involuntarily admitted to a mental hospital for 96 hours. With a court hearing, days can be added. Still, many former inmates will return to jail.
The staff watches the real-time log of entering inmates, looking for familiar names — like Jackson’s — and another chance to try to stop the constant returns to jail.
“But you have to want to change,” Jackson said.
She and the people trying to help her — Miller and Fouraker — recalled episodes of Jackson tossing medications back at the nurse, or simply waving away an invitation to talk, or slumping in the chair in Fouraker’s office when they tried to explore housing options.
“I didn’t need housing,” Jackson said, repeating the conversations with Fouraker. “I had places to stay. Here or there.”
“That’s homeless,” Fouraker said.
Jackson’s family at one point was arranging for her to go into ReDiscover’s mental health services in Lee’s Summit, said her oldest daughter, Sanisha Bennett, 26.
But she wouldn’t go.
Providing mental health services in jail, Fouraker said, means accepting rejection and still pressing on when that familiar inmate returns.
“We want them to know we haven’t given up,” she said.
Jackson’s family didn’t give up either. Her mother, watching from her apartment near Jackson’s troublesome corner at Prospect, kept praying, Bennett said.
And every time Jackson rejected her plea to get off the street, Hunt, the younger daughter, was prepared to come back the next day and the next — on and on — until that day last fall when Jackson finally said, “I’m coming.”
‘Live or die?’
One day in June, Jackson, now 46, took one more spin down Prospect behind the wheel of her younger daughter’s SUV.
She has no business here anymore. This was a tour to show where she hit bottom.
Gospel music filled the cabin and both mother and daughter, in choir-trained voices, sang along here and there.
Jackson’s health was back. Her summer glow.
“I used to hang back there with all those people,” she said, pointing to an alley behind a small market. That place over there — she pointed out a nearby business — is completely off-limits to her, ordered by the court. Confrontations at other shops and businesses also brought bans.
And then she pulled the SUV over at the corner where a concrete stump sat near a payphone outside a convenience store — her spot where she was last September when she finally agreed to go with her daughter, both of them in tears.
“Enough was enough,” she said, recalling the depths she’d reached. “Do you want to live or die?”
She wasn’t done with jail at that point. She had failed one more drug test. She had to make another court appearance that would land her that last trip behind bars.
But this time she joined Oliver’s class in the jail. This time she stayed on her medication. This time she worked with Miller and talked about her grief over her son.
She created therapeutic art with Miller, filling a clear vase with sand and smooth stones on which she painted words: Forgive. Trust again. Pain is gain.
Release serenity inside.
This time she worked with Fouraker to set up a housing option, taking refuge in the Kansas City Rescue Mission’s Women’s Center.
She’s going to Metropolitan Community College-Penn Valley, where she is studying social work and planning to join in the outreach to others who suffer.
She stood here at her old corner, knowing both how jails so often fail as mental hospitals and how people there also save lives.
“Uh-oh, Mama,” Hunt said, hugging Jackson but watching warily. Jackson is still well known here. Old friends were calling out to her. Some were coming by.
It’s time to go.
But some here know how her life has changed. One man shouted boisterously from across the street.
“From this point on, Sarah,” he boomed, “it’s up!”
Jackson raised her thumb in the air, pumping her fist.