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Case in Point

Mentally Ill and Languishing in Jail

A Pennsylvania case illustrates a national problem: People with psychiatric illnesses often remain incarcerated while they wait for a hospital bed.

Anne Marcelline thought her daughter’s schizophrenia was under control. Elle, 34, had her own apartment in New York City, a steady job in a law office and was studying for the Law School Admission Test. She seemed stable—so stable that to clear her mind for the test, she stopped taking her medication.

It wasn’t long before she had a psychotic break and ran away, something that had happened at least once before, when she ended up in Georgia, in homeless shelters and a county jail. This time, she turned up in Bucks County, Pennsylvania, nearly 100 miles from her home. Elle was arrested while walking down the street, suspected of stealing cash from the register of a gas station.

This story was produced in collaboration with Frontline (PBS). An audio version of Case in Point is broadcast with The Takeaway, a public radio show from WNYC, Public Radio International, The New York Times and WGBH-Boston Public Radio.

That was nearly two years ago. Elle has been trapped in the Pennsylvania justice system ever since. “If she wasn’t convicted, why the hell is she there? You know she’s ill,” her mother said. (Through her lawyer, Elle declined to comment for this article; her name has been changed to protect her privacy.)

A Pennsylvania judge deemed Elle incompetent to stand trial because of her mental illness. After such a ruling, defendants are usually transferred to a mental health facility in hopes of stabilizing them enough to eventually appear in court.

But Pennsylvania is one of many states that has far too few hospital beds for the mentally ill defendants who need them, leaving people like Elle to languish in jail while they wait for a spot. It has ranked among the worst states when it comes to these wait times, a nationwide problem that experts say may be linked to the downsizing of psychiatric hospitals and inadequate community mental-health resources.

In some cases, people facing minor charges have spent longer in jail waiting to go to a hospital than the time they would have served had they been sentenced. State officials across the country are looking for possible solutions, from building more beds to keeping individuals with mental illness out of the justice system entirely.

In Pennsylvania, the state chapter of the American Civil Liberties Union (ACLU) sued the state Department of Human Services in 2015 over these delays, settled twice and has since filed another motion asking the court to intervene.

Data from the state Department of Human Services obtained by The Marshall Project and Frontline show that defendants are finally getting into hospital beds more quickly. As of April, defendants in Pennsylvania waited an average of 24 days to be admitted for “competency restoration”—the legal term for providing basic mental health care so someone is coherent enough to understand the charges against them and assist in their defense. That’s down from the peak of the crisis in January 2017, when defendants had been waiting an average of eight months to get into a hospital and an average of more than a year for Norristown State Hospital, where Elle was ultimately admitted.

A spokesperson for the state Department of Human Services said in an email that the agency was working to speed up the system even more, after investing over $63 million since 2016, in part to add 175 more hospital beds, and also funding community treatment options. “We are not able to control the number of referrals we receive for competency restoration treatment,” wrote the spokesperson, Ali Fogarty. “We have been and remain committed to reducing the length of time that individuals in the criminal justice system wait for mental health and psychiatric treatment.”

But wait times are still too long, said Vic Walczak, legal director of the Pennsylvania ACLU. And as the statewide legal battle plays on, families like Marcelline's are stuck in the middle. The ACLU is now pushing for a seven-day limit; federal courts have ruled that anything longer is a violation of rights. “Keeping them in jail is illegal. And from a health perspective, some of them could suffer irreparable harm,” Walczak said.

Legal battles have also been waged over wait times in Oregon, Colorado, Alabama, Louisiana, Nevada, Utah and Washington. Many states have struggled to comply with court rulings, some racking up millions of dollars in fines and investing millions to build beds to try to meet the need. Civil rights attorneys have filed numerous lawsuits trying to fix this problem by setting strict time limits. But without enforcement, states are routinely blowing past these deadlines.

Attorneys, forensic psychiatrists and hospital administrators say the real problem is a system that fails to distinguish between who needs to be in the justice system and who could be served in a cheaper community setting.

“I think a lot of people with serious and persistent mental illness are falling through the cracks of our mental health system and … into the arms of law enforcement,” said Neil Gowensmith, a forensic psychologist who the court appointed to oversee competency-related delays in Colorado.

Officials across the country are piloting ways to reduce the backlog. States like Florida handle misdemeanor cases where the defendant is incompetent in an outpatient or community setting. Others have created programs to prepare incompetent defendants for trial while still in jail, when there isn’t a hospital bed readily available. Data from California show such programs save money, though critics say jail is never the right setting for mental health treatment.

Anne Marcelline’s daughter was deemed incompetent to stand trial, after a mental health breakdown landed her in jail. Because of a shortage of hospital beds, she’s been stuck in the system for nearly two years.

Anne Marcelline’s daughter was deemed incompetent to stand trial, after a mental health breakdown landed her in jail. Because of a shortage of hospital beds, she’s been stuck in the system for nearly two years.

Marcelline found out her daughter had been arrested when a family member searched for her name online and pulled up her Bucks County mugshot more than a month after Elle ended up in jail. Marcelline traveled from Harlem to Pennsylvania to pay her daughter’s $2,000 bail and bring her home. But when she got there, Elle, still in the midst of a psychotic episode, refused to leave. “She said, ‘Who are you? You aren’t my mother, my mother is dead. My whole family is dead,’” Marcelline remembers. “She thought she was on a spaceship, she wouldn’t leave the facility. She asked the guard, ‘Can I go back to my room now?’”

Later that night, the jail released Elle after her mother left. She was soon discovered sleeping in a stranger’s car inside their garage, with the glovebox ajar. Elle was arrested again for burglary, criminal trespass and theft from a motor vehicle. (It’s not clear if anything was missing from the car, but the open glove box was enough to bring theft charges.) This time, her bail was set at $50,000.

It took six months for a judge to rule Elle was incompetent to stand trial. Part of the delay was due to her mental state. She had landed in solitary confinement because of her erratic behavior and refused to meet with the psychologist. In their limited interactions with Elle and jail staff, her family gleaned that she wasn’t getting proper medication and was still experiencing delusions. “They are destroying my child,” Marcelline said. “My biggest fear is that she may never recover.”

Mental health experts note that long stints in jail instead of a hospital may actually push defendants further from the mental clarity they need to proceed with their cases. “The symptoms of their mental illness tend to become more and more extreme,” said M. Geron Gadd, the legal director of the Alabama Disabilities Advocacy Program.

The Bucks County Department of Corrections referred questions to the county’s public information officer, who said they could not comment on specific cases. A spokesperson for PrimeCare Medical, the private mental health-care provider for Bucks County, said the company could not comment on an individual’s treatment. CEO Thomas Weber said that mental health staff will see someone waiting for a hospital bed “on at least a daily basis” while that person is still in jail.

After the judge’s decision, Elle was placed on the waitlist for the Norristown State Hospital. Marcelline called frequently to check Elle’s progress; she remained third on the list for nearly three months, according to court transcripts. Months went by with no updates. Her family celebrated her birthday without her for the second time since Elle was locked up.

Elle’s attorneys were unsuccessful in a petition to the court to get her out of jail. The judge offered to release her to her family’s care, if she immediately went to in-patient treatment in New York. But Elle told him that she wanted to live with her husband (who doesn’t exist, according to her family) in Pennsylvania.

Throughout the process, the family has been in a complicated legal limbo. Elle was incompetent to stand trial but still an adult in charge of her own case. She can decide not to sign a release form for her medical records, choose not to put her siblings’ names on her visitation list or refuse to leave the jail.

“I don’t understand how someone can be declared incompetent but still have legal standing to make these kinds of decisions. We literally can’t help her,” said her cousin Pearl Mensah. “The rules don’t make sense. Someone either has their marbles in the eyes of the law or they don’t.”

Elle’s attorney later asked the court to dismiss the charges against her because they had violated the rule that requires a trial to take place within a year of the complaint. But the motion was denied; the rule does not apply to delays because of competency issues. In a November hearing, Elle asked the judge: “I don’t have a release date, and I have been there over a year. Isn’t that like, illegal?” The judge did not directly answer her question.

The next month, Elle was finally sent to the Norristown State Hospital. There she was given medication, therapy sessions and a basic education on how the courts work. Her condition improved—her siblings were able to visit and speak a couple times on the phone. After four months, she was found competent and returned to the Bucks County jail to face the burglary, theft and trespassing charges against her.

Bucks County District Attorney Matthew Weintraub said he would consider dismissing the charges if Elle secured a spot in a mental health treatment facility and was willing to go. His office has tried to find ways to expedite cases, Weintraub said. “Our goal isn’t to try and keep people locked up as long as possible. Our goal is to treat people as individuals [and] get them out of this spin cycle,” Weintraub said. “Those wait times are too long, and I’m just as frustrated as anybody.”

In May, Elle finally appeared in court. The judge threw out the charges of burglary and theft, but the trespassing charge for entering the stranger’s garage and car remained. Her formal arraignment is set for this month, and her trial date is scheduled for October.

“I want her home. I pray every single day,” Marcelline said. “It should be so simple, let me take care of my child. Let my child go. I can’t take it anymore.”

Christie Thompson is a staff writer and Manuel Villa is a data reporting fellow at The Marshall Project.

Leila Miller is a reporter at the Los Angeles Times. Before joining the newspaper in 2018, she was a reporting fellow at PBS's Frontline.