Capt. John Caceci

June 11, 2002

Good morning. My name is John Caceci and I am a captain at the Monroe County Jail in Rochester, New York. Thank you Chairman Leahy and Ranking Member Hatch for inviting me to testify and for looking at the issue of people with mental illness in the criminal justice system. I also want to thank my senator, Chuck Schumer, for his commitment to corrections officers across New York State. I am particularly grateful to our sheriff, Patrick O'Flynn, for allowing me to represent our jail and to tell you about some of the promising programs we have developed under his leadership.

Speaking for corrections officers across the country, I can tell you that identifying inmates with mental illness and treating, managing, and preparing them for release is one of the greatest - if not the single greatest - challenges we face in our overcrowded jails and prisons. For this reason, I want to underscore how grateful I am that you have asked someone on the front lines of our country's corrections facilities to testify.

I also want to acknowledge the value of the Criminal Justice / Mental Health Consensus Project Report. Although I did not participate in the effort, I know that the corrections community was represented extensively, and for that I thank the Association of State Corrections Administrators, the National Association of County Officials, the National Sheriffs Association, and other corrections organizations. The recommendations in that document are exactly on point, and I am eager to see them implemented in my community.

MONROE COUNTY JAIL

In Monroe County (in which Rochester is the biggest city), there are about 750,000 people. On any given day, there are about 1,400 inmates in our jail. Around 400 of these inmates are serving sentences of one year or less; the remaining 1,000 inmates are pretrial detainees. Like any jail, the average of length of stay for inmates in our facility is relatively short; over the course of a year, over 17,000 inmates are booked into our jail. Nationally, 10 million people are booked into US jails each year.
Like every county in the country, our jail has experienced explosive growth over the last two decades. When I started working in the jail in 1984, there were about 325 inmates. The population has grown on average by about 100 inmates a year. In 15 years, the population has grown nearly 500 percent. During this time, our jail has almost always been overcrowded, operating at about 120 percent of capacity.

Our facility also resembles most jails in that it is the county's largest mental health facility. No other institution in Monroe County holds nearly as many people with mental illness as does our county jail. As you may know, Riker's Island, the New York City Jail, is the largest mental health facility in New York State. After the Los Angeles County Jail, it is the largest mental health institution in the United States.

That's just not right. We work in a jail and our job is to incarcerate offenders, not hospitalize sick people. With my testimony today, I would like to review several points. First, I want to give you an idea of the types of people who have mental illness who land in our jail. Second, I will explain the services we attempt to provide these inmates. Third, I will describe the impact the current situation has on the operation of our jail. Fourth, I will suggest some ways in which we could improve the response to people with mental illness in our facility. Finally, I would like to recommend some steps that this Committee could take to help corrections administrators and line staff address this overwhelming problem.

WHO IS IN OUR JAIL?

Between 15 and 20 percent of the inmates in our jail have a mental illness, which is consistent with most jails in the country. I want to be clear that we incarcerate many offenders who have committed serious, violent crimes, and some of those people have a mental illness. They need to be punished and locked up. There are no two ways about that.

But the majority of people we see with mental illness in our jail aren't murderers or sex offenders--or even criminals with a history of violence. They are people who have been in and out of our jail on countless occasions, charged with (or convicted of) committing low level offenses, like trespassing, harassment, and vehicle and traffic violations. They can't make bond, and, when they're sentenced, it's for time served.

We don't blame police officers for taking these people to our jail. They often don't have any other option. Take, for example, the young man whom police recently brought to us. He had a history of mental illness, and he had recently been giving his mother a hard time. He'd threatened her, and one evening he was particularly menacing. The mother was frightened, so she called 911. The police arrived and they knew the son wasn't so sick that the psychiatric ward would accept him, and there wasn't another mental health center in the community that would accept him, no questions asked. They have to do something, though, and they are justifiably concerned about liability if they just walk away, so they brought the kid to us. Now we have him in a single cell on 24-hour suicide watch.

Another recent example is of a 19-year old girl who is seriously mentally ill and was receiving services at a center for mental health services in Rochester. She was a behavioral problem there. One day, she pulled the fire alarm--a false alarm, which is a crime. She was brought to the jail and we had to place her on "constant observation" watch. Because she was hearing impaired, we had to bring interpreters from the community mental health center to the jail. They came three or four times a day. The staff from the community mental health center told us that she was not getting better in the jail, and that they wished they had reacted differently when she pulled the fire alarm. What she really needed was intensive mental health services and supportive housing in the community. But there aren't enough of those kinds of supports in Rochester.

MENTAL HEALTH SERVICES WE PROVIDE

Screening

It is hard to compare the percentage of inmates with mental illness in each facility, because each jail uses a different process (if they have one at all) to identify inmates with mental illness admitted to the institution. New York State is unique in that each jail uses the same screening process and the same definitions of mental illness.

At our jail, we screen everyone who is admitted to the jail for mental illness. The state Office of Mental Health developed one form in particular which is nationally recognized, the suicide prevention screening guideline form. In addition, in our jail, we use two additional forms for medical and mental health screening by booking officers. Security command officers have a regularly scheduled daily meeting with medical and mental health to discuss inmates with serious mental health issues or who are at risk of committing suicide. This screening process used in our jail and other jails in New York State has caused suicides to drop by 70 percent over the last decade. Although I am proud that the rate of suicide in our jail is low, we lost one inmate last year to suicide, and that is still one too many.

Information that community-based providers submit to us regarding people with mental illness whom they have served is extremely helpful. At some point, we hope to establish a system in which the mental health community can inform us when someone with mental illness whom they have served is in our jail.

Release Planning

We try to prepare inmates for their return to the community by developing a discharge plan that includes appointments with community-based treatment providers, a short supply of medications, and some type of health coverage. We have better success meeting these objectives with our sentenced population because we know in advance the date of their release. We have very limited success with non-sentenced pretrial detainees because we don't know when they will be released.

Often, we have little more than a couple of hours advance notice before the inmate's release. In these instances, it is nearly impossible to connect the inmate to treatment, housing, and benefits before they leave the jail.

As I mentioned earlier, one of our biggest frustrations is seeing the same offenders over and over again. When we release people with mental illness without a community-based treatment plan and linkage to a community-based provider, we know the odds are good that he or she will be back soon. Without health coverage, it is nearly impossible for most of these people to receive care or obtain medications. Although many are eligible for Medicaid, few are actually enrolled in the benefits program. It would be an improvement to the system in general if Medicaid benefits were suspended rather than terminated to ensure that the inmate has health coverage is reinstated when he or she is back on the streets. The absence of safe and adequate housing in the community also reduces the likelihood of an inmate's successful return to the community.

IMPACT OF THE SITUATION ON LIVES, FACILTY OPERATIONS

It's important to explain the impact that the incarceration of the type of people I just described has on their lives and the operation of our facility.

Inmates with mental illness sometimes act out and violate rules, which means we have to reassign them to segregation or high security cells, which we typically reserve for really dangerous inmates. Inmates with mental illness are also vulnerable to predatory inmates, so we often have to protect them in cells we typically reserve for inmates who are in protective custody.

Other times inmates with mental illness refuse medication or become manipulative. We try to discourage our staff from using the restraint chair, but sometimes it can't be avoided. Still, I always have in the back of my mind the stories I hear from my colleagues in other facilities: as staff try to restrain the inmate, a violent struggle ensues, and staff get injured. I also worry about things getting out of control as the officers try to subdue the inmate, inadvertently asphyxiating him or her.
Extensive training is essential to avoid such scenarios, and we are fortunate that Sheriff O'Flynn commits extensive time and resources to our training academy for basic and annual in-service training. Officers receive training regarding suicide prevention, understanding mental illness and responding to emotionally disturbed persons, interpersonal transaction skills, cell extractions.

The biggest portion of a correctional facility's operational budget is, by far, personnel. Every day, one of our lieutenants or I meet with mental health staff to review the status of those inmates who have mental illness and we are watching closely because we are concerned they may attempt suicide. On a given day, there are about 30 such inmates in our jail.

That may not sound like much, but making sure someone is always watching these inmates 24 hours a day, 7 days a week in a high security area is extremely staff-intensive and therefore expensive. Nevertheless, this degree of supervision is necessary to ensure a safe environment.

IMPROVING THE DELIVERY OF CARE

We can and should improve the availability of mental health treatment in our jail. For example, mental health professionals are on site in our facility only on weekdays during business hours; we need 24-hour coverage.

Currently, when an inmate needs acute care at night or on the weekends, which is a relatively common occurrence, I need to assign one or two escort officers to take the inmate to a local psychiatric emergency room or some other facility where a doctor may be available to see the inmate.

I am very reluctant, however, to advocate for extensive mental health services in our jail. As it is, we receive too many people with mental illness. I have no doubt that a first-rate psychiatric unit in our jail would simply draw more people with mental illness into our facility and discourage building and facilitating better mental health treatment options in our communities.

For this reason, I would prefer to see the community's capacity to support people with mental illness improved. We would welcome community mental health providers into our facility. In fact, we are eager to facilitate their access to the institution to help us. They know the inmates' treatment history in the community prior to their incarceration, and they are the ones who will need to care for them after their release.

In Monroe County we have the benefit of Project Link, an innovative program that takes referrals from the police, the jail, the court, and emergency rooms. They provide intensive treatment, case management, and support, and they report impressive results. In fact, the American Psychiatric Association recently awarded the program the "gold achievement award" for 1999.

RECOMMENDATIONS FOR THE COMMITTEE

We can develop many programs at the local level, and in partnership with our state, but, in the end, if we are going to make meaningful change around this issue, we will need the leadership of this committee and the federal government. To that end, I have several recommendations.
First, as you continue to consider mental health and substance abuse issues among offenders, keep in mind that corrections facilities represent one of the largest health care delivery systems in the country. We should be included in any federal effort or grant program designed to target offenders. Research that the federal government sponsors to evaluate new programs should be expanded to include jail and prison-based initiatives.

Second, the federal government is in a unique position to promote collaborative efforts between corrections and the mental health community. As I mentioned earlier, I believe that building a comprehensive mental health care delivery system behind the walls of our jail will exacerbate the current problem. Instead, we want the mental health community to see us a partner whom they can help. County and state budgets are strapped. Federal funding will help us to initiate--or strengthen--these relationships.

Third, the importance of training correctional staff on mental health issues cannot be overstated. The National Institute of Corrections is an invaluable resource for us in corrections; I urge you to increase its capacity to train corrections staff around mental health issues.

CONCLUSION

Our job is to detain people who commit crimes and watch them once they are in the jail. Local jails should not be in the business of running hospital emergency rooms for people with mental illness. When it comes to people with mental illness, we in corrections have been handed an incredibly complex problem. And sometimes it feels like we're only making the situation worse because we are the only viable alternative for local law enforcement officers.

In sum, many of you may assume that as long as there is space for each inmate in our corrections facilities, the problem regarding people with mental illness in our jails is a problem that is not particularly pressing. Nothing could be further from the truth. We're returning people with mental illness to the community many times in no better shape than when we received them. We're doing everything we can to make sure these people don't hurt themselves and that their health doesn't deteriorate further. This makes it difficult for us to focus on protecting staff and inmates and the community. That is supposed to be our primary mission. Please help us fulfill it. Thank you.