Frustrated by defendants languishing in their jails, three sheriffs bring mental health treatment behind bars

By Rachel Crumpler

A handful of men in orange jumpsuits gather around tables in a specialized unit on the second floor of the Mecklenburg County Detention Center.

They turn their attention to a whiteboard with the words “defendant,” “judge,” “defense attorney,” “district attorney,” “jury” and other legal terms written on it.

A mental health clinician is there to lead a group lesson on the roles and responsibilities of court personnel. It’s one of a series of sessions the men will participate in that’s focused on their mental health and on boosting their understanding of the legal system.

The men are there because they have been deemed “incapable of proceeding,” meaning they are so mentally impaired that they can neither understand the court proceedings before them nor rationally work with an attorney to help in their defense. These men’s issues range from having intellectual disabilities that lead them to struggle with retaining information to those with psychotic symptoms, such as active hallucinations and delusional beliefs, that interfere with their capacity to proceed to trial.

For most criminal defendants in North Carolina jails, this designation leads to a monthslong wait for a bed in a state-run psychiatric hospital to become available so they can then begin receiving mental “capacity restoration” services that are intended to help them get well enough to go to court. 

On average, these jail detainees wait 173 days — nearly six months — before being admitted to one of three state-run psychiatric hospitals for treatment, according to statistics from the N.C. Department of Health and Human Services.

But this group of men, instead of waiting for a scarce hospital bed, is receiving those services inside the detention center. They are taking part in the state’s first jail-based capacity restoration program — a partnership between DHHS and the Mecklenburg County Sheriff’s Office. 

The goal? To move people more quickly through the capacity restoration process.

Growing trend

Mecklenburg’s 10-bed unit has served 60 people since the program’s launch in December 2022, said Anna Abate, program administrator for North Carolina’s detention-based RISE (Restoring Individuals Safely and Effectively) capacity restoration programs. 

Early results are promising. Data shows the Mecklenburg jail program has been able to help about 80 percent of participants regain the psychological capacity to stand trial.

The program will expand this month to accommodate up to 25 people, including some criminal defendants from other counties.

Providing capacity restoration in jails is part of the state’s effort to meet the increasing demand for such services. Tackling this problem also has the potential to reduce wait times for everyone in the state by reducing the load at North Carolina’s overburdened state psychiatric hospitals, which have historically been the only setting to provide this care. 

The state’s second detention-based capacity restoration program — in Pitt County — started serving people on Feb. 24. And a third is expected to start in the coming weeks in Wake County.

“Unfortunately, a lot of individuals with mental health end up in the criminal justice setting and will end up in a detention center,” Abate said. “So while they’re here, rather than just kind of waiting for a bed at the hospital, it’s great to have this option that they can go ahead and get this treatment for capacity restoration.”

Toll of long waits

Jails are on the front lines of North Carolina’s capacity restoration challenges. Long waits for treatment take a toll on criminal defendants in jails; they often deteriorate during the limbo period. They also take a toll on jail staff who are not adequately trained for the long-term management of people with serious mental health issues.

As of the end of January, 157 people in jail were on the waitlist for a spot in a state hospital for capacity restoration services, according to data shared with NC Health News. 

Mecklenburg County Sheriff Garry McFadden told NC Health News that a handful of people in his detention center have been there since he took office in December 2018, stuck in a cycle of mental decompensation — waiting to go to trial. 

“We don’t know all the factors, but for us, it’s a lot of work, because when these people are here — housed here for that long — they get discouraged,” McFadden said. “They don’t care, and then they act out.”

Eddie Caldwell, executive vice president and general counsel at the North Carolina Sheriffs’ Association, said detainees deemed incapable to proceed are some of the most expensive and difficult to manage.

“Jails are not meant to be prisons — they’re not for holding folks for a long period of time,” Caldwell said. “They’re designed to get them in, get their court case heard and get them out.

“[These inmates] occupy a bed in jail at considerable expense to the county for a reason that could be solved otherwise,” he continued. “It’s difficult to deal with inmates who have mental health issues when you don’t have adequate mental health professionals to both deal with them and try to help them. The problems fall on the sheriffs when these defendants can’t get the help that they need.”

Untreated mental illness often results in disruptive behavioral issues, such as violent outbursts or throwing feces that jail staff have to confront, McFadden said. Ultimately, that can prompt jail staff to place defendants ruled incapable of proceeding to trial into solitary confinement to protect themselves and others around them. But research shows that this isolation often further exacerbates mental health issues.

“As they await their day in court, it only further contributes to the decay of their mental well-being,” Pitt County Sheriff Paula Dance said. “It’s just a snowball effect. It only goes downhill when we are not addressing the root cause, which is the mental health of these inmates and their inability to be able to help themselves or their attorneys to resolve their cases.” 

She said she has five detainees who have been deemed incapable to proceed in her detention center — one who has already waited seven months for a hospital bed.

Jails are up-front about not having adequate resources to care for the high volume of mentally ill people who cycle through their doors. Nine in 10 jails in the Southeast routinely have no psychiatrist on site, a 2023 study by UNC researchers found. 

Trying something different

Managing detainees ruled incapable to proceed has always been challenging for jails, but they’ve been increasingly strained in recent years as the number of those detainees has swelled.

In 2024, more than 2,600 criminal defendants had their capacity evaluated — marking a 33 percent increase in evaluations over the past five years. About 60 percent of those individuals — more than 1,500 people — were deemed incapable of proceeding to trial and needed capacity restoration services.

The result is that a growing share of the limited bed space in North Carolina’s state psychiatric hospitals is occupied by people involved in the criminal justice system. 

These same beds are needed by hundreds of people in crisis in the community who wait weeks or even months in emergency rooms for an opening in a state facility.

State officials have long known that many people don’t necessarily need the level of care offered in a hospital. According to the DHHS, hospitalization is also the most expensive way to provide capacity restoration, costing about $1,200 a day, compared to $400 in jail.

Providing capacity restoration in jail has been a goal since at least 2018 when DHHS sent a series of recommendations for improving the incapacity to proceed system to several committees at the state legislature. 

However, Robert Cochrane, DHHS’s statewide director of forensic services, said pilot programs in this setting only recently got off the ground. The money came as part of state lawmakers’ allocation of $835 million for behavioral health in 2023 — $7.2 million of which is being used to support the three detention-based capacity restoration programs.

Jail-based restoration programs are becoming increasingly common as an alternative to inpatient hospitalization restoration as states across the country grapple with insufficient resources to meet the growing need for services. At least 13 states have turned to providing these services in jails.

Caldwell said that the North Carolina Sheriffs’ Association supports standing up jail-based capacity restoration programs as long as sheriffs’ can choose whether to implement such a program. 

“It seems like a much more cost-efficient, much more expeditious solution to the problem that benefits all involved,” Caldwell said.

From jails to communities

However, some critics say jail-based units are not the solution — that they cannot provide a therapeutic environment for restoration.

Susan Pollitt from Disability Rights NC thinks that, when possible, defendants should be released to their communities to receive capacity restoration as an outpatient.

That’s increasingly possible; North Carolina has also launched three such community-based programs.

“Our goal is for community-based restoration services and a system that would be responsive to people who are in mental health crises and mental health struggles so that they don’t come in contact with the criminal justice system and end up in jail with their capacity questioned,” Pollitt said.

How detention-based restoration works

Sheriff McFadden, frustrated by detainees in his jail languishing for months waiting for a bed at a state psychiatric hospital, was easily convinced to be the first jail to offer capacity restoration on site. 

North Carolina’s three jail-based RISE programs are a collaboration of the jails, DHHS and the correctional health care contractor Wellpath Recovery Solutions. 

Recovery Solutions has run jail-based capacity restoration programs in other states — including Colorado, California and Georgia — for several years. They all follow the same RISE program model.

Abate, program administrator for North Carolina’s jail-based programs, said capacity restoration in jails follows a similar structure to support provided in a hospital setting. 

Program participants attend daily group sessions focused on educating them about the legal system and their mental health, as well as individual sessions tailored to their specific needs. She said each participant also has a weekly check-in with the treatment team to assess their progress.

Participation in jail-based capacity restoration is voluntary. Not everyone is a right fit for treatment in a jail setting, she said. Those who have been living peacefully in jail and taking their medications have the option; however, detainees who are extremely ill or dangerous still need to wait for a hospital bed.

McFadden recalled one man who had spent at least five years in custody because he lacked the mental capacity to proceed. Once his mental health issues were addressed through the RISE program, McFadden said he was finally able to move forward, and his case was eventually dismissed.

The time it typically takes for someone to have their capacity restored in the Mecklenburg program is about 48 days — four times faster than when a person receives services in a state hospital. And if someone can’t be restored in jail, they can still go to a state psychiatric hospital. 

It’s a benefit of having a tiered care system, Abate said.

“We’ve had individuals who were not appropriate or refused the RISE services and so they went to Broughton [Hospital] and they got stabilized and started their treatment,” Abate explained. “Some didn’t like the hospital setting and didn’t want to stay in the hospital, and so agreed to move back down to the jail to finish up their capacity restoration with RISE. 

“It’s a great resource to have so that individuals can move through depending upon their needs, and so that we’re not wasting any time and getting people in treatment as quickly as possible for capacity restoration.”

Combating decompensation

The jail-based programs are also working to combat one of sheriffs’ biggest frustrations with this population: a cycle of mental decompensation that can entangle someone in detention for years.

Over the years, Dance said she’s seen detainees get their capacity restored in a state hospital and then return to jail where they sit waiting for their court date to be scheduled. During that time, she said a person will often decompensate and can again be declared in need of capacity restoration services.

Dance said she’s had some detainees caught in this cycle for over two years — even those charged with low-level offenses. 

That’s why Dance said she brought all the stakeholders — the District Attorney’s Office, Public Defender’s Office and judges — together before launching Pitt’s jail-based capacity restoration program. The different groups were able to work out an agreement where court dates for program participants can start being scheduled in anticipation of program completion to reduce the possibility for decompensation. 

“This program is about providing an individual high-level care that makes them whole again,” Dance said. “The goal is to allow these people to participate in their own case and make knowing decisions that will deeply impact them for the rest of their lives. When that happens, it kind of brings the temperature down and allows both the defendant and our staff to coexist in a safer and functional environment.”

However, sheriffs, mental health advocates and state health officials say more has to be done upstream in the community — before people’s mental health deteriorates — to reduce the number of people entering the criminal justice system with mental illness in the first place.

“Not having enough mental health support in our communities really lays the foundation for them drifting into the criminal justice system,” DHHS’ Cochrane said. “Sadly, for decades, we’ve not been adequately funded for our community health needs in North Carolina — like a lot of states — and it’s no surprise then that we’ve gotten to this place where we’re having to deal with it in the criminal justice system more and more, and have limited resources to do that.”

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