Mental Health in Nevada and its Detrimental Impact on Criminal Justice
Maciej Borys Jezierski[*]
This paper will explore the troubled history of mental health services in Nevada and the reasons why there is an ongoing mental health crises in Nevada with particular attention paid to Southern Nevada. Most importantly, the marginalization of mental health services in this state and its direct impact on the criminal justice system; the use of correction facilities to house and stabilize the mentally ill as a band aid solution by the state and local government at a great cost to the taxpayers, policing, corrections, regular medical service providers and those in need of real mental health services.
Working on the Line
Working at the Clark County Detention Center (CCDC) offers a front row seat and a behind the scenes look at a cross section of our eclectic and transient population. There is an overall consensus of frustration within law enforcement regarding the failings of our criminal justice system towards the suspects and especially to the many victims of crimes whom are left feeling powerless rather than empowered by their contact with the law enforcement.
We work within the confines of the legal fabric to merely keep up with the volume of subjects arrested on the streets and to expediently process them through central booking, provide them with a court date and for vast majority, to speed them on their way out of custody. This expedition of processing is meant to keep the costs of housing at the jail to a minimum (which is around $140 a day) while decreasing our jail population which has always been above our maximum capacity and shows no sign of dwindling regardless what measures have been taken. CCDC has steadily been overpopulated by approximately 800 inmates over its maximum capacity. This number remains undeterred by the varying expedition of processing and administrative release by court services, attempts for police officers to have greater discretion to cite and release rather than to arrest, attempts by the courts to expedite case reviews, judges to utilize outpatient programs and community services, contract housing within other facilities in Nevada, housing of low level offenders in a newly built North Valley Complex in North Las Vegas, and even a short lived Saturday court to ease the jail overcrowding.
Even with these programs and initiatives to reduce overcrowding, the root cause of the problem remains and with it a mission that no jail was ever designed to undertake. With all other state mental health resources dwindling and having their programs cut, CCDC has a double duty of being the largest jail in Southern Nevada and also the largest mental hospital in the state. Subjects that should be served by a comprehensive, long term, mental care system are now stuck within a cycle of incarceration. We are required to house and stabilize mentally ill inmates who through the nature of their condition, lack of psychological and medical care services by the state are dumped onto the criminal justice system to be cared for. This is not a secret, mental health officials have been fighting a bitter, losing, uphill battle over resources, facilities and budget with the state for years. Mental health officials know the system’s woes begin with the mentally ill population that doesn’t have health insurance or family support. These people end up homeless and get arrested for petty crimes such as trespassing, jaywalking, and pedestrians on a highway; anything to justify their temporary removal as they are considered a public nuisance. “They’re taken to the jail, the state psychiatric hospital, the emergency room or a combination of the three, and taxpayers ultimately pick up the tab. They are then released, and often the cycle starts again when they stop taking their medications. Over the years, the state’s mental health system has reflected the same cycle endured by mental health patients themselves, oscillating between making progress and receding into crisis” (Doughman, 2013).
Conceptual model guiding research of mentally ill within the American justice system is encompassed within the criminalization perspective model. The criminalization model explains that the mental health care system systematically failed to provide sufficient community-based treatment solutions increasingly resulting in the criminal justice system “caring” for the mentally ill population and increased police involvement in traditional mental health circumstances. According to Fisher, Silver and Wolf (2006) criminalization refers to a process by which behaviors once legal become illegal, and are now subject to punishment by the criminal justice system. Mentally ill individuals who prior to 1970s were managed by involuntary transport and hospitalization in mental health institutions are now primarily managed by the criminal justice system due to stringent restrictions placed on civil commitment across the United States. The criminal justice system has been forced to take over the main responsibility of managing the mentally ill population since the mental health system failed to provide adequate control and treatment.
Criminalization of Mental Health
Mentally ill have always been a part of the population and their treatment by society and law enforcement agents has varied throughout the history. It has been the policy of mental health services in the United States prior to 1970s to manage the mentally ill population through state institutions by the way of institutionalization and medication. However due to gross abuses and neglect by the mental health system, laws pertaining to involuntary hospitalization nationwide were scrutinized and narrowed to protect the constitutional right of due process of the mentally ill. These reforms made commitment more difficult and release from mental health hospitals less difficult, affectively turning people with severe mental illness to the criminal justice system as the only avenue left for social control in the absence of adequate mental health services. Fisher, Silver and Wolff cite a perfect articulation for the criminalization argument from a statement in a 1996 Research Brief issued by the Soros Foundation which is as valid today as it was eighteen years ago:
Mentally ill offenders are often arrested because jails lack adequate procedures to divert them into community-based treatment programs…Mentally ill offenders are often jailed because community-based treatment programs are either nonexistent, filled to capacity, or inconveniently located. Police report that they often arrest the mentally ill when treatment alternatives are unavailable (1996, p. 2, quoted in Fished et al., 2006).
A 2002 report by the Department of Justice on mental health of inmates in local jails (defined as those receiving a clinical diagnosis or treatment by a mental health professional) shown that about two thirds (64.2 percent) of jail inmates satisfy the criteria for a mental health problem currently or in the previous year. A 2004 Department of Justice survey of state and federal prisons had shown a lower rate of diagnosed mental health problems of 56.2 percent for state prisons and 44.8 percent for federal prisons as compared to the highest rates in local jails. The same surveys also indicated that fewer than half of inmates who have a mental health problem have ever received treatment for their condition while less than a third received treatment after being incarcerated (NIMH Inmate, 2002).
Mental Health Worldwide and National Impact
Mental illness refers to a wide variety of disorders ranging from minimal to extreme degrees of illness. According to the Nevada Department of Health and Human Services, a mental illness “must cause distress and result in a reduced ability to function psychologically, socially, occupationally or interpersonally”. Problems posed by people with mental illness, and their impact on criminal justice have been debated by local, state, national and international agencies for years. This is not a uniquely American problem as each country faces questions as how to best care for their mentally ill population. The World Health Organization estimates that worldwide there are over 450 million people suffering from mental disorders and that 25 percent of individuals will develop one or more mental or behavioral disorders at some stage in life, in both developed and developing counties. Suicide causes more death each year than both homicides and war, and depression is responsible for 90 percent of all suicides. The economic cost of mental disorders globally over the next 20 years is estimated at $16,000 billion!
The costs associated with mental health in the United States are no less monumental. The National Institute of Mental Health estimated in a 2002 report that serious mental illness impacts around six percent of the US population, with direct costs (expenditures for mental health services and treatment) and indirect costs (expenditures and losses related to the disability caused by these disorders) totaling in excess of $300 billion per year. America has a very pronounced mental health crises and the question of how exactly to approach the mentally ill has been hotly debated for over thirty years by mental health and criminal justice professionals (Human Rights Watch, 2003; Lamb & Weinberger, 1998).
Nevada’s Population Boom
Nevada’s economy was and continues to be almost entirely dependent on hospitality industry, tourism, gaming, retail and construction. In the prosperous years prior to the recession of 2007, Nevada’s economy was one of the strongest in the nation with job growth averaging 3.1 percent versus only 0.5 percent across the nation (MHDS, 2012, p. 8). Therefore, jobs were plentiful, average salary was high in comparison to the low cost of living, and higher education was not a necessity to make a decent living in many of Nevada’s service sectors. This also sparked a population exodus to Nevada, helping make it the fastest growing state in 18 years.
The rapid growth during the 1990’s and early 2000’s did not translate to state’s social programs and infrastructure. Nevada was not prepared for the consequences of such quick rise in population and strain on its resources. With the stream of people arriving to Nevada’s two largest urban centers, the Las Vegas Valley and Reno, came needs for more services which the state did not make adequate preparations for. Nevada struggled to keep pace with population growth. The escalating demand for mental health services and the necessities required for mental health patients outpaced the capacity of the facilities and programs more rapidly than anticipated. Other changes in Nevada’s communities could be seen in the wealth disparity exacerbated by the shift in Nevada’s changing climate. Between 1980 and 1996 the gap between richest and poorest families with children grew by 10 percent (Wagner et al., 2012, p. 18). A substantial amount of strain to the criminal justice system is from insufficient social welfare resources, lack in mental health facilities, and a decrease of community response in urban neighborhoods. These may also be contributing factors to the influx of crime rates. Nevada’s crime rates are higher than the national average crime rates because of these lacking systems and through the sudden, rapid growth that the two major urban centers received (Landreth et al., 2006, p. 8). According to the US Census Bureau comparison of Nevada and National violent crime in 2008, Nevada’s violent crime rates per 100,000 was nearly double the national average at 728, while the national average was 454.5 (Wagner et al., 2012, p. 2).
The Recession of 2007-2008
In December of 2007 the recession hit Nevada with a devastating blow, and almost overnight all of Nevada’s positive economic indicators plummeted. Due to the state’s reliance on undiversified economy, Nevada continues struggling to recover from the recession, as the industries that Nevada relies on so heavily are struggling themselves. As of 2011, 17 percent of Nevadan’s live in poverty and income per capita has fallen to 20th in the nation. Nevada continues to have the nation’s highest unemployment rate at 12.5 percent and leads the nation in the highest number of home foreclosure rates. The need and reliance on public assistance programs such as Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Programs (SNAP) has increased yearly straining the available resources and dwindling state budgets (MHDS, 2012, p. 8-9).
Nevada’s social problems have elevated as the economy plummeted. Nevada residents found their lives in disarray as they struggled to keep their homes, jobs and make ends meet in general. According to America’s Health Rankings 2012 data, Nevada is 38th in the nation, when it comes to overall health and well-being based on 45 indicators such as high school graduation rates, unemployment, lack of health insurance, etc. Nevada has fallen further behind in public expenditures for health care (49th), primary care physicians (47th), immunization coverage (40th) and lack of health insurance (49th).
Nevada’s Division of Mental Health and Developmental Services (MHDS) in their 2012 review provided further meager indicators in Nevada’s health ratings. Since 2011, Nevada’s education system is 49th in the nation, with 2009 graduation rates only near 47 percent (Wagner et al., 2012, p. 19). Nevada continues to lead in teenage suicide rates and is fourth in suicide rates per 100,000. Nevada leads the nation in domestic violence incidents, and ranks fourth highest in teen pregnancy rates. With so much social upheaval and stressors, it is no wonder that Nevada ranks among the ten most criminal and delinquent states in the United Stated for both violent and property crime (Wagner et al., 2012, p. 8).
Crime and Delinquency in Nevada
As the rankings and indicators show, Nevadans are struggling to maintain a standard of living that contributed to Nevada’s success in the years prior to the recession. With high unemployment, and dwindling potential for legitimate career advancement, many have turned to crime. Coupled with the transient mobility within Nevada’s population, the 24/7 entertainment lifestyle, ready access to alcohol and illicit drugs, little to none social capital within the community Nevada residents reside in; the two largest urban centers of Las Vegas and Reno became dangerous places to live and work.
In 2008, Nevada ranked second in the nation for violent crime and motor vehicle theft, third for robbery, and ninth for forcible rape and aggravated assault (Wagner et al., 2012, p. 1). A first of its kind crime victimization survey in Nevada in 2008 found that one percent of Nevadans experienced crime victimization within the past 12 months, 23 percent of respondents experienced violent crime and 25 percent reported experiencing property crime. Comparison of the state data victimization survey compared to the national data of victimization found that Nevada’s rates far exceeded the national rates, and that crime was much less reported in Nevada than elsewhere (Hart et al., 2009).
These high figures may be due to or associated with: high population growth, high unemployment, disruption in family structure, weakening of family institutional controls (as the number of single parent households increases), economic pressure, strain on Nevada’s social programs to keep up their services, and high population turnover in urban neighborhoods. “Among the negative consequences are a lack of mutual trust, unwillingness to supervise youth, and the failure to organize the neighborhood efforts to maintain social order. When residential stability is low, collective efficacy diminishes, as it becomes more difficult to form interpersonal relationships, mobilize local communities, and maintain informal social control over juveniles and defend neighbors’ property” (Wagner et al., 2012, p. 17).
Nevada’s Mental Health and Law Enforcement
Nevada has many scathing indicators which are believed to exacerbate and cause high rates of mental illness. Some of these strongly correlate with the increase in mental health rates, many which are endemic to the Las Vegas Valley and Reno areas: occupational stressors (i.e. 24/7 work cycle with scattered shifts, inadvertent exposure to alcohol, cigarette smoke, tourist service sector, hyper-inflated sense of materialism with increased rate of risk taking), social isolation, single status, poverty, homelessness, migration, rapid social change, and higher than average incidence use of tobacco, alcohol and marijuana (Landreth et al., 2006).
Nevada has one of the highest rates of mental illness in the country. In a 2009 report the National Research Institute reported that the number of people over 18 with a serious mental illness is around 5.4 percent of the population in the state of Nevada. In addition, Nevadans reported suffering from frequent mental distress (14 or more mentally unhealthy days per month). This was more than the national average with Nevada at 13 percent versus the national average of 11 percent. “By 2010, United Health Foundation and America’s Health Ratings reported that the average number of mentally unhealthy days per month for Nevadans again exceeded the national average at 4.0 compared to 3.5” (MHDS, 2012, p. 10).
The mentally ill tend to have run-ins with law enforcement at a substantially greater rate than the average citizen. This may be due to not being able to receiving the treatment they require or long term care, self-medicating with alcohol and or drugs, and not taking their medication as needed. The mentally ill, if left untreated, pose a hazard to the community, law enforcement and themselves. Mental Health History and Structure in Nevada
The history of mental health care in the state of Nevada, in comparison to its present state, has a long and proud tradition ever since its inception in 1868. In fact four years after achieving statehood, the State of Nevada contracted with the State of California to accept and care for their insane inmates. In 1882, Nevada’s first state asylum was completed in Northern Nevada (Reno) and begun accepting the mentally insane for treatment. As changes and improvements were made over the years this state hospital became the backbone of what is now the Northern Nevada Adult Mental Health Services. Southern Nevada meanwhile did not open its first mental health outpatient clinic until mid 1960’s and its first public psychiatric hospital until 1975.
This important geographical demarcation between Northern Nevadan and Southern Nevada continues to this day. While Northern Nevada mental health care evolved from a hospital based institution, Southern Nevada’s evolved from community based programs. Northern Nevada had the time to establish a much greater infrastructure for mental health services and a higher level of service capacity compared to that of the South.
Other historical factors have also contributed to where the Nevada’s mental health care is now. The state is the sole provider and primary source of delivery of statewide funding to public agencies delivering mental health services. Therefore, mental health services are vulnerable to the state political climate and among the first to feel the sting of the legislature when the state is in economic trouble. Historically, mental health advocates have been among the weakest and least successful lobbies in Carson City. The answer to why that is quite simple. There is little protest from the vulnerable beneficiaries of the mental health program; the mentally ill. They simply do not have a voice to address the decisions made on their behalf (Landreth et al., 2006).
The more direct deterioration of the Nevada mental health services is traced to 1983. Faced with financial hardship, Nevada legislature began to cut the funding for mental health. Governor Bob Miller cut the budget again in 1992. Once adjusted for inflation and population growth, the total cuts amounted to a 40 percent drop in available budget. The Mental Health Legislative Task Force, a group of Nevada advocates and professionals noted these repercussions because of the budget cuts in the 1990’s:
Closings included four mental health clinics in Clark County, one clinic, a halfway house and the geriatrics unit in Washoe County, and seven out of 15 rural clinics. Case management was cut, hundreds of staff positions were discontinued and residential rehabilitation programs were closed. With one stroke of the pen, Nevada's mental health system lost over a decade of progress (Mental-Health-Budget, 1997).
The Legislature added $177.5 million to mental health services in 1997 to stop the mental health budgetary crisis then, a 48 percent increase (Mental-Health-Budget, 1997). There was a hope by mental health professionals that the state had renewed its interest in public programs such as mental health, but their jubilation was short lived. While budget allocations had fluctuated higher in some years, Nevada’s mental health services had never fully recovered from the budget cuts of the early 1990’s. In order to adequately provide care for the fastest growing urban population in the United States and their mental health needs, a consistent budget that kept up with inflation and rising population was required (Landreth et al., 2006). In 2010, per capita mental health spending in Nevada was 57 percent of the national average. Even with the increasing need of mental health facilities, the State of Nevada was forced to cut approximately 80 million from mental health since the beginning of the recession in 2007 (Coolican, 2013).
2013 Nevada Mental Health: The Final Straw
The strain and multitude of problems stemming from the inability of the Nevada Department of Health and Human Services (NDHHS) to provide even the basic services for thousands of mentally ill people in Nevada could not go on indefinitely. As best summed up by the NDHHS Director Mike Willden in front of a legislative committee regarding Nevada’s mental health care this year; “That piece of our system is broken” (Doughman, 2013). This year has seen Nevada’s mental health department facing lawsuits, state reviews, oversight and accreditation problems. The major issues which plague NDHHS were described in a September 9, 2013 article in the Las Vegas Sun written by Andrew Doughman:
• Rawson-Neal has lost its independent accreditation from the Joint Commission, a nonprofit quality control agency, and could lose federal funding for not meeting minimum care standards.
• The Dini-Townsend psychiatric hospital in Northern Nevada also could lose certification, and two other state psychiatric hospitals in Nevada — Lake’s Crossing in Reno and the Desert Willow Treatment Center in Las Vegas — already lack certification, according to documents provided by the state health department.
• The ACLU of Nevada is representing Brown in a class-action suit against the state for "severe and extreme physical, emotional and psychological harm" suffered when Brown and others were improperly bused out of state after being discharged from Rawson-Neal.
• The city of San Francisco is threatening to sue the state for instances like Brown’s in which Nevada improperly bused mental health patients to San Francisco, forcing taxpayers there to pay for their care.
• The Clark County Public Defender’s office is again suing Nevada for long wait times at the Lake’s Crossing facility for the criminally mentally ill. A similar suit ended in a settlement that should have addressed wait times. Since then, however, the public defender’s office claims the problem has continued with some clients waiting months for services.
• Lake’s Crossing, a facility in Reno, is the state’s only psychiatric facility for the criminally mentally ill, meaning law enforcement in Southern Nevada must fly the criminally insane to Reno to receive evaluations and services.
• Health department officials have told legislators they’re struggling to hire doctors because medical professionals know that they can earn as much as $50,000 more with comparable benefits packages by working at places like the federal Veterans’ Administration.
• Southern Nevada’s emergency rooms are again seeing unusually high numbers of mentally ill patients, a situation that prompted Clark County to declare a public health emergency when something similar happened a decade ago.
For its defense, Nevada still continues to suffer from the highest revenue gap as a percentage of its general fund in the nation with 37.4 percent for 2013 (MHDS, 2012, p. 6). Given the severe revenue shortfall, funding has been decreasing continuously since 2007, now totaling approximately $80 million (Myers, 2013a). The budget for the fiscal year 2011 through 2013 was reduced by 12.5 percent, resulting in a loss of 150 positions across the state impacting the level of services provided and the proper level of care for patients (MHDS, 2012, p.46). Nevada has three adult psychiatric hospitals equaling 1,170 hospital beds, however due to budget cuts not all of these beds are facilitated. Rawson-Neal in Las Vegas is licensed for 289 beds, but due to state funding is only able to utilize 190 beds, 30 of which are observation units. Dini-Townsend in Sparks, another psychiatric hospital is licensed for 70 beds, but only budgeted to run 50; 10 of which are observations units. The third psychiatric hospital, Lakes Crossing in Sparks is a maximum security facility that evaluates competency of inmates to stand trial, is budged for is the only facility that uses all (66) of its beds (Myers, 2013a).
Nevada’s Incarcerated Mentally Ill
A recent Review Journal article estimated that about 20 percent of the Clark County Detention Centers inmate population has mental problems severe enough to require psychotropic medication. According to the article it costs around $140 per day, plus the cost of medication, to jail a mentally ill person compared to a cost of around $850 per day per patient to place them in Rawson-Neal mental institution for treatment (Myers, 2013b). With dwindling resources in state mental institutions, inmates are often stabilized at the jail, and if well enough so they do not pose a danger to themselves or others, released back to the community only to repeat the cycle at a later time. CCDC does not have the resources and the mandate to provide long term care and post incarceration care for the mentally ill as a proper mental facility should. This catch and release strategy does not solve the problems of the mentally ill in Nevada. But, like so many other strategies, it is a band aid solution to a much larger problem which law enforcement and the criminal justice system cannot face alone.
In their 2009 report, The National Alliance on Mental Illness graded Nevada’s mental health care system with a letter grade of D. It is interesting to note that they also graded the United States mental health care system in its entirety with the same failing grade (MHDS, 2012, p. 10). Even though the condition of mental healthcare is alarming, it is still not a priority nationally, particularly in Nevada. “In a state with high rates of severe depression and other serious mental illnesses — as well as suicides — a strong commitment is needed to restore and expand the mental health safety net,” the 2009 report said. “Without one, Nevada will find its emergency rooms and criminal justice system overwhelmed — and costs being shifted to other sectors of state and local government” (Myers, 2013a). This prediction has come to pass. Our emergency rooms are constantly overcrowded. On average 50 mentally ill people crowd the emergency room across Nevada waiting to receive services. At times these individuals are accompanied by a law enforcement officer waiting for the person to be medically screened and accepted as a Legal 2000 which places the mentally ill person on a mandated 72 hour psychiatric observation.
According to the Department of Health and Human Services between 70 to 90 percent of individuals can have a significant reduction of symptoms and improvement in quality of life through a combination of pharmacological, psychosocial treatment and support. However, with the funding limited and decreasing yearly, the current wait for an outpatient bed is a minimum of 30 days, even with a court order (Coolican, 2013).
Crises Management, Patches, and Solutions
Funding impacts the number and quality of staff (counseling and case workers), newer medication, training, programs that have shown to work, more outpatient clinics, programs providing special needs such as shelters for homeless mentally ill. More clinical resources for long-term care funded by the state instead of merely short term and crisis intervention which Medicare covers.
Solutions that work are well known, but they all require a solid budgetary support system and resources. It seems that finally, from embarrassing failures and public outcry, the state and local leaders have taken serious steps to prove that they are serious about fixing the broken mental health system in Nevada. Having ignored and marginalized the state’s social services for so long and still recovering from an economic tsunami, the legislative solution is to come up with the resources to implement programs which thus far have been held back due to economic recession and budgetary constraints. Positive and frantic steps already taken this year saw opening of closed facilities and attempt to hire back of some of the 364 mental health employees laid off since 2008. A second psychiatric facility in Las Vegas was reopened. Funding for a previously cut program that provides home health services to severely mentally ill was restored. The Legislature added $30.4 million to the state’s mental health system budget and approved new programs such as home visitation and transitional housing for mental health clients who have substance abuse problems who are returning from correctional facilities.
There are plans to implement a program in Clark County which exists in Northern Nevada, where crises intervention team members ride-along with law enforcement. In so doing, they are able to divert mentally ill patients to get them the services they need, rather than have them arrested or transported by ambulance to a regular emergency room for evaluation. Work is also in progress on a 24/7 facility in Southern Nevada required to stabilize and provide in-patient treatment, which would be prepared to house people in mental health distress and provide its resources to law enforcement personnel (Doughman, 2013).
There is no doubt that Nevadans should have access to proper social health care facilities and professionals, which includes mental health services. The last few years have proven especially trying, and reading through the many indicators and studies pertaining to Nevada and its residents welfare, it is difficult to stay positive about daily life here. This state has failed to support its residents well being, and that failure when viewed through the totality of the evidence shown here, materializes in the increased crime rates, jail incarceration rates, decreased social indicators and overall quality of life. As history has shown, Nevada has a pattern of support and neglect of its mental health services. Shamefully, it has taken a complete collapse, scandals and public outcry of the mental health this year for the state to act. While the steps taken so far are positive and provide some glimmer of reprieve, only time will tell if Nevada legislature will have the political will and motivation to provide steady yearly funding that surpasses inflation and population growth.
Fixing this massively complex problem requires a solution which will encompass the many entities that mentally ill come in contact with, including the police, jails, courts, probation and parole, social workers and health workers. Mental health needs are long term and chronic, requiring more than just a band aid approach. If handled correctly through appropriate clinical resources and trained professionals they correlate to decreased homelessness, drug use, chronic offenders and increased employable workforce as special needs people having their health needs taken care of settle into the society (Mental-Health-Budget, 1997).
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[*] Maciej Borys Jezierski is a graduate student in the Department of Criminal Justice, UNLV.