On a recent Friday morning, 13 men dressed in bright yellow jumpsuits sitting across five tables participate in a group sharing exercise.
The prompt: What parts of daily life cause stress, frustration or sadness?
One man raises his hand and says being out of touch with family and friends. Another is upset he didn’t get to go to court that day. They take turns around the room, sharing vulnerable — sometimes emotional — responses. Many of their stressors are the same.
The men are also asked: What can they do to change those experiences?
One says keeping a positive attitude. Another says realizing he can’t change what’s already been done. Others say they turn to coping strategies like meditation.
This is one of many group sessions these men will take part in over the course of an eight-week program in Forsyth County detention center’s Behavioral Health Unit. The men all have a serious mental illness and are currently residing voluntarily in the 20-bed specialized housing unit, which opened in September 2021.
Jails have become de facto holding facilities for people with mental illnesses but they aren’t often equipped to address these needs. Forsyth County is prioritizing addressing these individuals’ needs, said Amber Simpler, chief psychologist at NaphCare. NaphCare is Forsyth detention center’s contracted medical services provider.
In operation for just over a year, jail staff say the behavioral health unit is already making a difference.
The unit has served 117 men who have passed through Forsyth’s detention center to date — a number that will continue to tick up as the need for mental health treatment continues unabated.
“What we’ve done is actually seen people almost come back to life,” Simpler said, adding that it’s the difference between treated and untreated mental illness.
Incarcerating people with mental illness
People with mental illness are overrepresented in U.S. jails and prisons. About 2 in 5 people who are incarcerated have a history of mental illness, according to a Bureau of Justice Statistics report published in 2017.
Jails and prisons were not designed to provide mental health care, and data shows only about 3 in 5 people with a history of mental illness receive mental health treatment while incarcerated in state and federal prisons. Fewer than half of people with a history of mental illness receive mental health treatment while incarcerated in local jails, which often have fewer resources than larger penitentiaries.
“Mental illness is underserved in the detention environment, and that’s across the nation,” said Shela Williams-Stacey, the jail’s mental health director. “There are a lot of people who are incarcerated because of symptoms of their mental health.”
Simpler, who specializes in forensic psychology and has been working with the justice-involved mental health population her entire career, said confining people because of a mental illness is not new. But in recent decades, the practice of housing them in jails and prisons has ballooned, adding new demands on correctional facilities.
It’s a demand that she said Forsyth detention center is trying to meet. The behavioral health unit is providing counseling and mental health services to individuals in the jail who need it — sometimes getting a diagnosis and treatment for the first time in their lives.
Residing on the unit
Forsyth County Sheriff Bobby Kimbrough said establishing a behavioral health unit to address the growing mental health needs in his detention center had been a goal of his since being elected to office in 2018. The unit came together in 2021 after the Forsyth County Board of Commissioners selected NaphCare to be the health care provider at the detention center and included funding for the unit in the contract. County commissioners initially allocated $329,100 in county mental health funds for the unit’s first 10 months.
After NaphCare assumed the jail health care contract on Sept. 1, 2021, Simpler said the behavioral health unit opened later that month. Part of the reason NaphCare was able to move so quickly is because the company had prior experience building a mental health stabilization unit at a jail in Florida and was able to adapt that model based on the needs of the population in Forsyth County.
Forsyth’s behavioral health unit serves individuals with a severe mental illness, such as schizophrenia, bipolar disorder and depression. Every person going to the behavioral health unit must agree to consistently take psychiatric medications as prescribed. People are admitted on a rolling basis into the unit as beds are available.
Simpler designed the eight-week program based on a curriculum from the federal Substance Abuse and Mental Health Services Administration. The program curriculum includes courses on coping, dealing with stress, practicing mindfulness and preparing for life transitions. Simpler said the unit uses a recovery model in which residents of the unit are taught to understand, manage and talk to others about their mental illness.
“What we’re trying to do is empower them to manage their own health,” Simpler said.
There are three group sessions that individuals are required to attend every day, Williams-Stacey said. Though participation isn’t mandatory, she said she’s been blown away that everyone willingly participates and is actively engaged in learning from each other.
Williams-Stacey added that she thinks a big percentage of treatment is actually in the community formed on the unit — learning they are not alone with their mental illness and knowing that they can ask for help and receive support from others.
Jail staff said they’ve seen individuals carry the skills and coping tools they learn forward once they leave the unit.
“The gains and the benefits that they have not only impact them at the individual level,” Simpler said. “They impact this community, and they make for a safer community. They make for stability.”
‘Night and day’ difference
Jail staff said they’ve witnessed a night and day difference in the individuals that have come through the behavioral health unit.
In fact, the improvement has been so drastic for some that staff are having to do a double take.
Williams-Stacey, the jail’s mental health director, said Detention Services Bureau Commander Major Robert Whittaker didn’t initially recognize one inmate in the general population who had graduated from the program. Prior to going to the Behavioral Health Unit, she said he had spent over 300 days in segregation, also known as solitary confinement, where he was volatile and not taking care of his hygiene. He became a different person once he started using coping strategies and taking his medications as prescribed while on the unit, said Williams-Stacey.
Before the unit was created, Detention Administrative Lieutenant Melissa Green said segregation was the only option for some people in the facility, either as a form of restraint or to protect them from other inmates. Research shows individuals with mental health disorders are disproportionately assigned to restrictive housing — often due to behaviors that may be manifestations of their symptoms.
Now, the behavioral health unit offers a needed alternative.
“There’s just so much change in affect and in functioning and in their interactions with people,” Williams-Stacey said. “This is night and day different stuff, and it’s really a joy to be able to watch that transformation happen.”
Not everyone stays the full eight weeks in the unit as they can be released from jail, be released on bond, or be sentenced to prison time at any point during their stay. Due to this, there’s a constant revolving door of people coming into the unit and leaving.
But for those who do complete the eight-week program, there’s a graduation ceremony to celebrate the accomplishment. It’s a joyous occasion with Sheriff Kimbrough in attendance.
Williams-Stacey said graduates receive trucker hats they wear on graduation day and can choose to decorate. There’s a ceremony that involves a procession to the traditional song “Pomp and Circumstance,” video-recorded remarks from peers and loved ones, and the awarding of certificates. There’s even special food and soda — a treat many haven’t had since they were first incarcerated.
One of Williams-Stacey’s favorite parts is that a picture of each graduate is taken and it’s put in their property so they can take it with them and remember the moment and their progress once they leave the jail.
“If you compare it to their booking picture, it is always just night and day,” Williams-Stacey said. “It doesn’t look like the same person.”
Residents of the unit are also noticing their own transformation.
“When I first came to the program I was lost and filled with anger and depression,” said a behavioral health unit resident who was a member of the inaugural graduating class in January 2022. “I was getting DR’s and constantly getting into trouble. With this program I found how to cope with my depression and found out how to do other things such as isolate when I am angry.”
Specialized mental health units as a model
Currently, few jails in North Carolina, or even across the nation, offer specialized housing units for those with a mental illness. NC Health News previously reported that Mecklenburg County Central Detention Center opened a 28-bed voluntary jail psychiatric unit in August 2019. Durham County also opened a mental health pod for detainees too acutely mentally ill for the general population in September 2017.
While these specialized units are not common, recent research from the North Carolina Department of Public Safety and UNC-Chapel Hill examined therapeutic diversion units — treatment-oriented housing units for incarcerated individuals with mental illness — in North Carolina’s prison system. Researchers found that compared to restrictive housing, which isolates inmates from one another, the therapeutic diversion units had positive effects on infractions, mental health and self-harm among people experiencing incarceration.
For example, the number of self-harm incidents in segregation units was more than three times the number of those incidents in the therapeutic units. The number of assaults, substance possession, verbal altercations, property damage and disobedience were all dramatically lower in the therapeutic units than in the solitary units.
Sheriff Kimbrough said he’s been amazed by the results of the behavioral health unit thus far.
“It’s obvious that it’s working,” he said. “It’s obvious that it’s needed. And it’s obvious that it’s something that we’re going to maintain and sustain.”
The unit originally started as a 10-month pilot program but the administration wanted to keep it around. County commissioners allocated $406,900 to fund the unit in fiscal year 2023 and $419,000 is anticipated in fiscal year 2024.
“What is happening here in Forsyth County is certainly making a local impact,” Simpler said. “But what you don’t necessarily recognize day to day is that when we show what we’re doing here in Forsyth County to the greater community, to the nation, then they go, ‘Huh, I want that too.’ So you’re not only being a model for your community, but you’re being a model for this nation.”
Kimbrough wants to go beyond the behavioral health unit serving males with a mental illness at the detention center and offer the services to the female population as well.
The jail has fewer women so a specialized housing unit is not feasible, he said, but NaphCare is developing women’s programming that can hopefully be implemented soon.
“There are various camps about whether or not this level of mental health care should occur in a corrections environment and the reality is whether it should or shouldn’t, there’s a need,” Simpler said. “And we have to fill that need.”
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.