The county's Twin Towers Correctional Facility in downtown Los Angeles is a hulking, massive concrete structure. It is also part of the largest municipal jail system in the United States.
On a recent day, four men enter handcuffed with a police escort. The sheriff's deputies assign them cells, and for the duration of their sentences, this is home. The men wear bright blue pants and neon yellow shirts to set them apart from other inmates.
"Here within Twin Towers, we house approximately 3,900 inmates. A majority of those inmates are deemed mentally ill," says Lt. Joseph Badali, a supervisor with the Sheriff's Department.
The United States incarcerates hundreds of thousands of inmates suffering from mental illness, and jails and prisons are struggling to provide for inmates with severe mental health needs.
Los Angeles County is even exploring building a new jail specifically to house and provide treatment for mentally ill inmates. The proposal is estimated to cost more than $1 billion.
Prison Or Hospital?
L.A. County is not unique. In fact, it is far from it. Experts say good numbers are hard to come by, but one estimate calculates there are about 2.1 million annual bookings of persons with serious mental illnesses into jails. That number swells when you count state and federal prisons.
At one time, huge state hospitals housed the mentally ill. When they closed in the 1970s, community-based care was supposed to step in. Instead, with fewer options, the mentally ill were released to the streets, where they often got into trouble. Jails have to take mentally ill offenders in, but they can't force medication.
Psychiatrist Sara Hough sometimes matches the colors of clothing of the inmates that she calls "clients." She tries to establish a rapport with them.
"It's so important that you take your medication and you comply with treatment, because if you don't, you're going come back here. And we don't want you to come back here," she says to an inmate through glass.
Because of its size, the L.A. County jail system is the country's largest de facto mental institution, and Hough has held a job here for 15 years. She's now the head of clinical psychiatry.
The hospital within the prison opened in 1977, right around the height of de-institutionalization, when mental hospitals were closing. About 30 inmates get treatment on this level, but jail officials say they wish they had many times that number of beds to cope with all the acute cases.
"In many ways, we are a hospital," says Hough, the psychiatrist. "What brought them into the system was an alleged crime, and we certainly at the Department of Mental Health are not here to judge that. But while they are here and they suffer from a mental illness, we will provide care."
The county says it is trying to make the best of a tough situation, but columnist Steve Lopez calls it a crime.
"Yes, for some people maybe it's better than being than on the street," Lopez tells NPR's Jacki Lyden. "But that doesn't mean that a jail is a therapeutic environment, and that doesn't mean that this is good public policy, and that doesn't mean that anyone should find this acceptable."
Lopez, a writer for the Los Angeles Times, has put L.A. county mental health on the radar nationally. A series of his columns about a homeless violinist with mental problems became a film.
Lopez says it's simple: Jail is no place for treatment. According to the Justice Department, people with psychological disorders are much more likely to be sexually victimized by fellow inmates:
"An estimated 3.6 percent of [jail inmates], those identified with serious psychological distress reported inmate-on-inmate sexual victimization, compared to 0.7 percent of inmates with no indication of mental health problems."
The sheer size of this population also makes it a target. There are multiple federal investigations of abuse in the county jail system, including at the Twin Towers and the notorious Men's Central Jail.
In response to the federal investigation, the L.A. County Department of Mental Health told NPR, "We look forward to continuing collaboration in assessing and improving our services."
Life After Incarceration
So what happens to people in need of mental health care when they've done their time and are dismissed? It's a question Lopez has asked a lot.
"The sad news is that the majority of them are turned out onto the streets with no linkage kind of community-based treatment center," Lopez says. "And this is a population that needs regular management."
Lopez says, after release, former inmates can take a short walk from the jail and end up in an outdoor drug market and fall immediately back into the same patterns that got them into jail in the first place.
James Puntar has done just that, many times. The 53-year-old grew up in Southern California. He says he started doing drugs when he was just 9 years old, and his addictions only got worse. "By junior high school, I was eating acid, and by high school, I was smoking PCP," he says.
Puntar is the first person to admit he has made a lot of bad choices with his life. For many years, he was homeless and lived on the streets. He has been arrested for drunken driving and petty theft, and he made money dealing drugs. He's also been in the Twin Towers Correctional Facility.
Puntar also has chronic mental illness and a hodgepodge of diagnoses that he says includes schizophrenia, depression, anxiety and mood swings. "I've seen a lot of doctors," he says.
Inside jail, Puntar says he received medications and therapy. But it can be costly, difficult or all but impossible to stay on a medication schedule unsupervised, once released. Puntar says he soon abused drugs again, but they did not quiet his mind.
There were times when he couldn't find somewhere warm to sleep, or the money to eat. In those moments, he says, he thought about going back to jail, the one place he could always count on.
Puntar says he is now two-years sober. A nonprofit group called the Integrated Recovery Network provides him with housing and mental health services. He's now working toward becoming an addiction counselor. But he says he is taking life one day at a time.
"People my age, they got jobs, they've retired from. They've got houses. They got kids who are grown and married. Me, I've got nothing," he says. "I was married to drugs, and my home that I had built for myself was prison."
Jails Doing What They Can
Linda Teplin has researched incarceration and mental illness for more than three decades. "We have to remember that it is not the jail's choice to take these people," she says.
Teplin, a professor of psychiatry at Northwestern University, suggests that perhaps it is the jails that have come furthest in that time.
"Jails have been very good nationwide now about recognizing the need to screen for severe mental disorders when people come in, and also to provide treatment for people who are in their facility," Teplin tells Lyden.
Teplin says that while this is certainly not a cheaper system, it is easier to get support for new correctional facilities than it is obtain funds to provide mental health care in the community. She also says stigma can play a role in what gets backing, since people with severe mental illnesses on the street are not representative of all people with mental health needs.
"They may engage in bizarre behavior," she says. "Many people are afraid of people with severe mental illnesses. They're not a sympathetic group."
Teplin says it would likely take a major public figure — perhaps with an ill family member — to take leadership in this area for any real policy change to move forward.
"I think that would do a lot to alert the public sensitivity to the plight of people with severe mental illnesses being arrested instead of treated," she says.
There are signs of change, however. Many cities have added training for police, and created mental health courts that divert people from jail. But day centers and community centers around the country often struggle trying to raise funds to improve services and acceptance.