Last week, nine people who were too mentally ill to help with their defense were in the Lancaster County jail.
The nine had been locked up for between a few days and more than 90 days, waiting for a bed at the Lincoln Regional Center.
They are among dozens of people who have spent weeks in jail this past year waiting for a bed at the regional center after a judge ruled they were incompetent to stand trial.
But there is no room at the regional center — often for months — so they remain in jail, local officials say.
Many refuse to take their medications, and jail staff can’t make them. They may be paranoid and out of touch with reality. They may be hallucinating and hearing voices. They are sometimes anti-social, anti-authority.
And while in jail they often are a risk to staff and other inmates and sometimes to themselves, said Brad Johnson, director of the jail.
They shouldn’t be in jail, he said.
One man, in his 40s, with a long history of severe mental illness, refused to take his medications, refused to return his meal trays and sometimes threw them at the cell door.
The man, arrested on misdemeanor charges of trespassing and resisting arrest, often yelled at guards and other inmates, threatening to hit them, kill them and sometimes kill and eat them, according to staff reports.
His threats included, "I’m going to kick your a--; I’m going to punch you in the face; I’m going to skin your head when I get out of here; You are a f---ing dead man."
Transporting him to a court hearing or removing him to clean his cell required as many as five people.
When the mental health staff attempted to screen him for mental health issues, he screamed “not applicable” to most of the questions, an answer he also screamed at his attorney.
It is not only very expensive to house people with serious mental illness in jail; it is also the wrong place for them, Johnson said.
These people, found incompetent to stand trial, often don’t understand what they did or how they ended up in jail, he said.
Another inmate, a woman in her 60s in jail for disturbing the peace and attempted robbery, also had a long history of severe mental illness.
She often talked about her intentions to kill herself, so she was placed on suicide watch. While in the infirmary she routinely banged her head against the cell door, the wall, or the floor, and punched the wall. She would climb up on the sink — threatening suicide — so she had to be housed in a cell without a toilet or sink.
She eventually began refusing meals. She often took off her clothes and sat naked in her cell. She smeared her feces on the cell walls and sometimes ate it.
When a mental health professional visited her, she sat in silence, staring blankly.
She was finally moved to the city's crisis center because she was a danger to herself. And then she went into a treatment environment, said Brenda Fisher, the jail’s program director.
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But other inmates — although their behavior may be troublesome — are not deemed to be a danger to themselves or others, and remain in jail.
A jail environment is not designed to deal with these types of inmates on a long-term basis, Johnson said.
In many cases, despite staff doing its best, an inmate's fragile mental health deteriorates even further, he said.
The regional center is a more therapeutic environment and staff has the ability to force patients to take medication, he said.
"Here, I have little choice other than house them in a 9-by-10 cell, and that type of housing tends to exacerbate their mental health issues," increasing their paranoia, hallucinations, hearing voices, he said.
And housing people with serious mental illness in jail is expensive. The jail’s $100-per-day cost is based on dividing the total budget by the average daily population.
But there is a big difference when you compare costs for individual inmates. Someone on work release probably costs $30 a day. Inmates with serious mental illness likely cost more like $250 to $300 a day, said Johnson, providing an educated guess.
“It is just a really sad situation. They need care that is difficult to provide in this environment.”
And he pointed out that in a lot of cases, the crimes they commit are a direct result of their illness, he said.
Though the issue of housing people with competency issues in jail while they await a bed at the regional center is not new, it is a growing problem.
"Most of my career, they went to the regional center that day," said Joe Nigro, Lancaster County public defender. "To have them waiting (in jail) is mind-boggling," he said.
Johnson looked at the 19 people with mental health competency orders who were in county custody at the end of July. Seven were in jail; 12 were at the regional center.
The ones at the regional center had been in jail an average of 68 days before getting a bed at the regional center. Half had been in jail more than 80 days before transferring to the regional center.
The average wait time for the regional center now on a civil commitment is around 70 days, said Kathie Osterman, a spokeswoman for the state Department of Health and Human Services.
The Lincoln Regional Center did free up beds by moving some sex offenders to Norfolk, and plans to open a new unit for civil commitments in early 2018 to help with the wait list, said HHS representatives.
There are discussions about changing state law so some people could use outpatient programs to restore competency. Currently everyone must go to an inpatient regional center program, Nigro said.
Those outpatient community programs would be available primarily to people out on bail who have been judged incompetent to stand trial. Moving those people into an outpatient program, rather than making them go to the regional center, would shorten the wait for those in jail, he said.
Outpatient restoration programs will help, but what will help most is more beds at the regional center and more community programs so people who no longer need inpatient regional center services have a place to go, Nigro said.