Dr. Jones Tapia Takes On Mental Health in Prisons

Clinical Psychologist Heads Cook County Jail

Posted Jun 11, 2015

Nneka Jones Tapia, used with permission
Source: Nneka Jones Tapia, used with permission

“I like challenges,” said Dr. Nneka Jones Tapia. 

She had better, because Jones Tapia has taken on one of the toughest and important issues facing our society today; namely, how to address the mental health needs of prisoners in order to reduce recidivism and promote healthy re-entry into society.

In a historic move, after years of working as a psychologist in the prison system, she has been promoted to executive director of the Cook County Jail in Chicago, one of the biggest prisons in the country. And her promotion is part of an ongoing revolution in this country, whereby people want to see reduced incarceration and improved mental health outcomes of those who are in the prison system.

Many consider prisons to be the new “asylums,” wherein there are more people with mental illness in prisons than in hospitals. Despite the fact that there are several efficacious forms of medication and psychotherapy that can be helpful in treating mental illness, large percentages of individuals in prison do not receive appropriate mental health treatment. For example, a 2006 Bureau of Justice Statistics report found that over 50 percent of individuals in prison had mental illness, but only one-third of these individuals were receiving mental health treatment. A recent report by the Government Accountability Office suggests that as many as 51,000 prisoners are on a wait list for drug-addiction treatment that could improve their mental health and reduce their sentences.

In many ways, Jones Tapia’s promotion is not surprising, given her personal history and professional development. “I had never worked in a correctional facility, but actually believed that my steps were ordered in the sense of different life experiences that attracted me to that,” she explained. “And I just started studying more and more psychology, and received my master’s degree and my doctorate degree. Then, in my doctoral program, I decided that I wanted to intern at a correctional facility. Had never been to Chicago before, but felt inclined to work at a large facility.”

“And so I moved my country self to Chicago; didn’t know a soul. And I’ve been here for most of the time since then. I completed my internship here, and then went on to complete my post doctoral training here for the year. They hired me as a staff psychologist for a year. So I worked in the field for a year before going back to the South, and I was the chief psychologist of the privately owned federal prison for a year. And again, I was going to go back to my roots and stay, but after a year, Cook County called me back. And I came back as chief psychologist for the medical provider that was here. And did that for three years, and thought I had done all I can do and then the sheriff pulled me over to this side thankfully, and I’ve worked for the sheriff’s office now since October 2013. In my former role with the sheriff’s office, I oversaw all of the mental health initiatives, and now in this current role, here I am,” she said.

Jones Tapia has found that each day presents its own challenges. “No two days are alike. Any time you work in a correctional facility, I don’t really think we can plan our day. But I’ve tried to do that to the best of my ability,” she said. “So usually starting off, we start with a brief staff meeting with just myself and the chief of staff and the bureau chief, just to give an idea of some of the incidents that have occurred at the jail since we left the night previous. And thinking about higher-level ways of how to manage those issues. Then we try to get out to talk to the staff, engage with the inmates, just so that we’re not missing an important part of managing this large operation. Then we just come back to the table and just be as flexible as possible with coming up with ideas to assist the staff as well as the inmates.”

Part of the challenge is being familiar with and ready for every conceivable mental illness diagnosis.  “Since I have been here at Cook County, I believe I have seen every mental health diagnosis in the [Diagnostic and Statistical Manual of Mental Disorders] come through these doors. Now, we’re seeing quite a few individuals coming in with mood disorders. A lot of individuals coming in with more severe bipolar disorder,” Jones Tapia said. “The impulse-control issues are definitely prevalent. But most concerning is that we’re seeing more people coming in with severe and moderate psychosis. And they require a lengthy stabilization period. You may have heard that at our Cook County jail, our overall population is going down. But our mental health population is going up, and they’re coming in much sicker.”

But through her experience working in the correctional system,  Jones Tapia has already identified different factors that can be helpful or harmful to the mental health of individuals in prison. Her first suggestion is the presence of diversion programs, or programs where individuals are taken to mental health facilities and assessed prior to being incarcerated. There is evidence that pre-booking and court-based diversion programs reduce time of incarceration for mentally ill individuals in prison. However, current programs do not appear to reduce recidivism. Jones Tapia feels we can do better.

“It starts with true diversion. And I do not believe we have seen true diversion at this point. And what I mean by diversion is, having a mental health assessment center where our community law enforcement agencies can take individuals to for an assessment,” she explained. “And I’m talking about those that are engaging in more nuisance behaviors that really shouldn’t be brought into the jail. But the unfortunate circumstance of our local law enforcement is either that they’re going to bring them to jail and be done with it in 15 to 20 minutes or sit with them at a local emergency room for hours. And that’s just not a wise use of their time. And so to have the establishment of mental health triage centers throughout the community where they can take individuals for a quick assessment and treatment plan and then have some level of community supervision, that would be true diversion.”

Jones Tapia recognizes further that many of the stressors, such as poverty and family conflict, that are related to relapse in mental illness are actually made worse, not better, by incarceration. And as a result, these diversion programs need to address these potential stressors as well in order for diversion programs to be truly effective.

“And I should say when I’m speaking of discharge planning, it does not end at the jail. You really have to start in the jail, but continue beyond our doors. So we have the community treatment providers come into the jail and introduce themselves to the detainees and so that they are more likely to follow up with those individuals post-release, when they’ve already been engaged with them,” she explained.

Jones Tapia has been encouraged by what she has seen at the Cook County Jail. “And then with respect to discharge planning, we here at the jail, under the direction of Sheriff [Thomas] Dart, have come up with a number of discharge-planning initiatives. He just opened up a mental health transition center in August of last year, where we offer individuals mental health treatment in the form of group therapy, education, job-readiness skills,” she said. “And we really try to give them as many resources as possible so that when they leave us, they have the tools that they need to truly be successful. And with that program, we’ve had about 40 individuals that have been released from custody. And all of them are continuing their mental health treatment. And most of them are either employed or in school, which speaks to the successes of this proper discharge planning.”

The federal Department of Health and Human Services says that one important way of improving diversion programs and is to make sure that these programs use state-of-the-art treatment.  Jones Tapia describes how cognitive-behavioral therapy appears to be particularly efficacious among individuals in prison. “Because in a jail we never know how long an individual is going to be in our custody, we really want to make the greatest impact in a short amount of time. And as such, we’ve seen that when we try to focus on solution-focused therapies, cognitive-behavioral therapy, the detainees respond pretty well to the cognitive-behavioral therapy. When you’re giving them tools to help them manage some of their symptoms, they really seem to appreciate that. And again, not knowing when they might be released, it gives clinicians the satisfaction of knowing that they’ve impacted the person positively even if for a moment,” she explained.

Her insights are consistent with research demonstrating the efficacy of cognitive-behavioral therapy (CBT). Research suggests that CBT can be efficacious for a range of clinical disorders, including mood, anxiety and substance-use disorders. Further, this efficacy appears to apply to prison populations. One meta-analysis of 58 studies found that cognitive-behavioral therapy, particularly anger management and interpersonal problem-solving skills training was associated with reductions in recidivism in both youth and juvenile offenders.

But even if diversion programs and empirically supported treatments such as cognitive-behavioral therapy are offered, barriers exist. One of the major barriers is with the individuals who struggle with mental illness suffering from stigma. In 1999, the U.S. surgeon general identified stigma of mental illness as one of the biggest barriers to treatment.

Jones Tapia explains how the issues manifest in prison: “Every night, we process hundreds of individuals coming into our jail. And everyone coming into the jail receives a mental health screen. It’s very difficult in that process to identify someone with mental illness if they do not self-report it, especially if they’re relatively stable. And what we’ve seen is that a number of individuals don’t self-report a history of mental illness possibly because of that stigma. Because they feel like they have an opportunity to be ‘normal.’ And they try to ingrain themselves in the general population areas of the jail, and then as time goes on, because our staff are so well-trained, they begin to see some of these symptoms manifest, and they refer them to appropriate mental health professionals. But that’s one way the stigma impacts us, is that a number of people are able to come in and present very well with that initial screening in hopes of being placed in the non-mental health care unit.”

Another barrier that Jones Tapia thinks may limit the efficacy of treatment for individuals in prison is the ability to give medication to patients who are not volunteering for treatment. This issue has received much debate as issues of efficacious treatment and civil rights may collide.

“One thing that comes to mind is our involuntary medication policies. Right now, at least in the state of Illinois, a person has to reach such a level of severity before we can involuntarily treat them,” she explained. “And that, I’ve heard time and time again from families, is the most heart-wrenching. Because they know their loved one needs treatment, and we know that a lot of individuals don’t want to accept treatment. What is a family member to do other than to watch their loved one steadily decline and then get to the point where they can forcibly treat them? So I’d really like for us to take a look at the involuntary-medication policy.”

Jones Tapia recognizes that this is an issue of substantial debate. Many civil rights activists would argue that the involuntary medication of individuals in prison goes too far. From her perspective, the key is to open up the issue for discussion and bring the relevant stakeholders in to work together to treat mentally ill inmates while preserving human dignity. And ultimately, her thoughts on involuntary treatment revolve more around having a range of options.

“I’m saying that there doesn’t have to be any one side of the pendulum. We really need a nice balance. We need to have safeguards in place so that we don’t treat individuals against their will who don’t require it. But we know when we have information that someone who does not accept treatment is more likely to deteriorate and has a history of deteriorating, we have a responsibility to act,” she said. “And what I would say to anyone is that it will take all of us to come to the table and really agree on what’s going to work best. Because what we’re doing now is not working. When we have individuals who are becoming sicker and sicker, family members have no recourse, then loved ones end up committing some crime. And a lot of times, that’s as simple as trespassing, and they come to jail.”

“I would ask some of our naysayers to consider what that is doing to the civil liberties of individuals,” she added. “I just don’t want to seem like I’m saying we should forcibly medicate everyone because I’ll be the first one to say that we all have our rights and our responsibilities. But what I do see is that we have to offer more options for mentally ill individuals, as well as their families. Continuing along the lines of forced medication, we have individuals in our custody now that have presented with such a level of violence — not because they are violent individuals by nature, but because their symptoms have become so exacerbated that that’s the way they respond to others. And once we have acquired a court order, which is very difficult to obtain for forced medication, involuntary medication, you see the human side come out.”

One of the reasons that getting proper treatment might be important is not only to reduce suffering of inmates, but also to allow them the possibility to gain the benefits of social interactions while incarcerated. For example, some research suggests that social isolation, such as that among those in solitary confinement, is damaging to physical and emotional well-being. Moreover, inmates who are well enough to receive education may be able to increase prospects of employment upon release and reduce recidivism.  

Jones Tapia offered an example: “I’m thinking of one gentleman that was so violent that we had difficulty having him out with other individuals. So he would have to come out of his cell alone and just be around the officers. And you want to increase social interaction as much as possible, but we have to keep other people safe. And once the gentleman was placed on psychiatric medication, because he really didn’t understand at that point what he was giving up, that he was declining treatment. But once he was placed on the medications, I’ve seen him in school. He’s an active participant in group therapies. He helps officers out on the tier. And that is more of the human side that I’ve seen through treatment.”

Her ascension to her new role is part of a broader picture of people recognizing that the criminal-justice system is not as effective as anyone would want in managing mental illness. And there is a movement from all sides of the political spectrum to reduce people with mental illness being put in the criminal-justice system. Most notably, many people feel that a mental illness such as substance use and dependence should not be treated as harshly in the criminal-justice system. For example, Sens. Rand Paul (R-Ky.) and Cory Booker (D-N.J.) have proposed the Redeem Act, proposing reforms such as expunging the records of nonviolent offenders such as those convicted of drug possession by the age of 15 so that these individuals have a better chance of securing employment.

Jones Tapia reflects on the bigger picture of reform. “The issues that we’re seeing here at Cook County are, I’m sure, much the same in smaller counties, as well as larger counties. And Sheriff Dart has done a great job with being a visionary and a spokesperson for the issue. But we need more people to engage our local lawmakers to make sure they truly understand the issue that we’re facing and make more fiscally responsible decisions when it comes to not cutting treatment services in our community; Because we’ve done that before, and we’ve seen the results. We’re experiencing the result when we see 2,000 [or] 3,000 mentally ill people in Cook County Jail.”

“So we really have to make a greater impact to enforce change and understand that we all have a stake in this. It could be our family member. It could be our neighbor. And when it hits close to home, that’s when we tend to respond,” she says.

“Well, let’s respond now, because this problem’s not going away, it’s getting bigger.”

Michael Friedman, Ph.D., is a clinical psychologist in Manhattan and a member of EHE International’s Medical Advisory Board. Follow Dr. Friedman onTwitter @DrMikeFriedman and EHE @EHEintl.