NH faces overlap of crime, mental illness: Jail super says 'they don't belong in concrete'
New Hampshire's county jails might be the best place to observe the uneasy overlap of two expensive, high-profile systems — criminal justice and mental health.
One day last month, the booking area of the Rockingham County jail had three mentally ill people in its six cells.
A corrections officer was posted full-time outside the glass wall of one inmate's cell. The bearded inmate was suicidal (he had tried to sever a blood vessel with a peeled fingernail). He was on a hunger strike and in his third week waiting for a spot at the state Secure Psychiatric Unit, reserved for the most dangerous of mentally ill people.
In another cell, an inmate slept against a concrete wall that he smeared with his feces. He recently had been discharged from the New Hampshire State Hospital, which treats patients with psychiatric illnesses.
Mental health problems — suicidal ideation, depression, drug withdrawal, a risk of harm to others, psychotic episodes — have spiked in the past two years, said Jason Henry, the jail's superintendent.
“It’s almost like a mental health ward in our processing area,” Henry said. “Our heart bleeds for these people. They shouldn’t be here in concrete and steel.”
Yet they are. Meanwhile, jails aren’t the only place that the separation between mental illness and crime is blurring.
This is the sixth story in a year-long collaboration on mental health between Seacoast Media Group, New Hampshire Union Leader and Dartmouth Health.
Police are being trained to recognize mental illness and use the proper techniques to handle mentally ill people. Increasingly, prosecutions turn on psychiatric evaluations of defendants rather than guilt or innocence.
Such dangers played out last month in a Manchester courtroom, when a woman tearfully testified about being raped in a city cemetery last year.
Just days before the rape, her assailant had been released from the Hillsborough County jail after being found mentally incompetent to stand trial. Prosecutors are now feverishly trying to commit him as a sexually violent predator. If they fail, he will be free.
“My charge is to protect the public at all costs. How do I do that when the system is not supportive?” said John Bryfonski, the police chief of neighboring Bedford and first vice president of the New Hampshire Police Chiefs Association.
The treatment of mentally ill people can be a challenge by itself. But experts say several factors open the door to crime for them:
The use of powerful street drugs, including fentanyl and methamphetamine;.
Labor shortages in the mental health treatment field, which hamper and delay treatment.
The expense and unavailability of housing for many, which amplify the stressors of poverty and homelessness.
New Hampshire's patchwork of services: Mental health courts are available in only six of 10 counties, and rural areas tend to lack comprehensive treatment, with patients drawn to cities for care.
More problems than resources
Advocates for the mentally ill say it shouldn’t be this way. They point to some disturbing facts.
More than half of the inmates at prisons in New Hampshire have a mental health diagnosis. The number is even higher among women inmates: 67% were prescribed psychiatric medication in 2021.
Those figures don't include hundreds in county jails across the state.
In Rockingham County, for example, 51% of the 170-inmate population require an active treatment plan or have a significant mental health diagnosis. Some should be at the state psychiatric hospital, Superintendent Henry said.
But only 144 beds are available at the New Hampshire State Hospital, and earlier this month 50 were unfilled because of a lack of nursing staff.
“Deinstitutionalization didn’t really happen,” said Susan Stearns, the executive director of the National Alliance on Mental Illness — New Hampshire, referring to the emptying of mental health institutions across the country in the 1960s. “They just changed the institution.”
Most people with mental illness are not criminals, and they are more likely to be victims of crime than to commit crime, according to NAMI. Yet the public is quick to attribute heinous, high-profile crimes to mental illness, Stearns said.
“It gives us a rational explanation," she said.
Only a small percentage of the criminals that Strafford County prosecutes are inherently bad people who should be locked away, said County Attorney Tom Velardi. The remainder suffer from drug or mental health problems, sometimes both. Once the problems are addressed, the person should be allowed to re-enter society, he said.
“In my 23 years as a prosecutor, I can’t tell you how many victims said, ‘Please, get this person the help they need,' " Velardi said.
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Tell that to Christie Gilbert.
On Aug. 4, 2021, David Lent shot and killed their 12-year-old son, Trent, at the Hinsdale home of Lent's mother. Lent then told his mother that he and the boy were going to hell, put a pistol in his mouth and killed himself.
Lent, who had a criminal record and diagnoses of depression and bipolar disorder, had been arrested the previous December for assaulting his girlfriend and barricading her, her daughter and himself in a bedroom. He punched police who responded to the situation.
He was charged with misdemeanors and jailed for eight weeks. Lent blamed the incident on a mental health crisis sparked by a lack of access to his meds, Gilbert said
A judge eventually released him under conditions that he participate in treatment at the mental health center in Keene, refrain from drugs and not own any guns.
A subsequent overdose didn't get him in trouble, Gilbert said. And apparently no one visited the house of Lent's mother, where several loaded pistols were lying about.
So many people were willing to cut Lent a break — judges, prosecutors, people involved in his care — she said.
“Everything’s just about helping people. They don’t think about the consequences,” Gilbert said.
New Hampshire homicide prosecutors refused to discuss the case, which they say is open and ongoing 14 months after the murder-suicide. Police reports provided to Gilbert redact any mention of Lent's mental health issues and treatment.
What is the relationship between crime and mental illness?
We asked 13 people at the intersection of crime and mental health problems about the connection between the two, from their perspective. You will find their answers throughout the end of this piece.
Mental health court efforts
Amanda Grady Sexton, director of public affairs for the New Hampshire Coalition Against Domestic and Sexual Violence, said domestic violence, the leading cause of homicide in the state, is a choice.
While mental illness can exacerbate violence issues, it does not cause violence, and the abusers still have control over their actions, Sexton said.
In theory, New Hampshire has systems designed to sort out those nuances of mental illness and criminal activity. For misdemeanors, mental health courts are available.
If a defendant pleads guilty, any jail sentence or fine is suspended while they engage in treatment and are under court supervision. The process involves incentives and sanctions, with the goal being stability, treatment and good behavior.
Rochester District Court has one of the longest running mental health courts in the state.
"Some might say, 'It’s this person’s mental illness, that’s why they did this act.’ There’s not a clear nexus there," said Circuit Court Judge Susan Ashley, who sits on the mental health court in Rochester.
Ashley elaborated: If a person is hearing voices, walks by a house, believes another is captive and breaks a window to free him, his mental illness had a direct role in the crime.
On the other hand, if the person was stable, went out drinking with friends and broke the window out of rowdiness, the mental illness wasn't responsible.
Mental health court doesn't work for everyone.
From 2007 to 2022, 154 people participated in mental health court in Rochester. The completion rate was 65%.
Ashley said many factors are responsible for the low participation. If a person is using drugs, drug court would likely be the first option. A crime has to be serious enough to involve the threat of jail time; otherwise, a defendant likely will plead guilty and pay a fine.
Also, treatment providers are in short supply. Defendants sometimes must wait for a provider before enrollment in mental health court. Setbacks occur when a provider takes another job and exits a defendant's treatment midstream.
The five rural counties of Belknap, Carroll, Coos, Cheshire and Sullivan have no mental health courts to address misdemeanor charges. The state has only two mental health courts for felony crimes — in Keene and Manchester.
Mental health courts operate inconsistently. No state funds are appropriated for mental health courts, so everything is left to local organizations and courts. No state or national standards exist for the operation of mental health courts.
“It’s completely grassroots organizing,” the judge said. State funding would mean standardization.
Competency a conundrum
When mental health issues emerge in the most serious of crimes, defense attorneys have two options.
The insanity defense is available for defendants, but it usually is invoked in only the most serious of crimes, such as murder. More frequently, lawyers file papers claiming their client is so mentally incompetent that he cannot assist in his defense.
All states have such systems. But New Hampshire’s differs in two ways.
New Hampshire makes no statewide effort to restore a person to competency. Often, a defendant can be stabilized at a psychiatric facility and then released into the community, but they still can't participate in their defense and their crimes are never prosecuted.
Meanwhile, New Hampshire is the only state that requires prosecutors to prove a defendant is mentally competent to stand trial, according to Associate Attorney General Jeffery Strelzin, who oversees public protection at the state Department of Justice.
Other states require defense attorneys to prove incompetency.
“Whichever side has the burden of proof, it’s obviously much more difficult,” Strelzin said.
A judge who rules on competency also determines whether a defendant is dangerous. If so, the case moves behind closed doors to Probate Court, where another judge can order committal to the state hospital.
A treatment stay at the state hospital usually takes months but can last for years, said Dr. Jeffrey Fetter, a Dartmouth Health psychiatrist and the chief medical officer at the State Hospital.
“Our goals are to treat our patients. Our responsibility is to treat the mental illness and the dangerousness.”
He said adverse childhood experiences — everything from abuse to poverty — play a factor in a plurality of the cases at the hospital.
A patient's legal status never drives treatment, and it never should, he said. But it will play a role in their exit plan — where they end up, the time frame for their discharge, whom they must avoid after release.
The hospital often releases patients conditionally, with requirements they remain on meds and keep appointments with their community mental health center.
Fetter said the hospital doesn’t keep statistics on violations of conditional discharge. Anecdotally, the biggest factors seem to be going off medication and simple case management issues such as access to food.
Other factors include a history of problems with the police, co-occurring intellectual challenges, and abuse of illegal drugs and alcohol.
Few places to go
In jails, the availability of treatment varies from facility to facility, often based on the willingness of a county to invest in treatment plans.
David Campbell, a homeless Manchester man with a criminal history of theft and diagnoses that include schizophrenia, said he gets a lot of consideration at the Hillsborough County-run Valley Street jail because of his diagnosis.
He said he has a standing prescription, so his medications continue when he's in jail. But he's also been in jail without his meds; he had to wait weeks for a doctor to see him.
"It comes down to sitting in line," he said.
Rockingham County employs five people involved in either mental health or drug abuse counseling. The jail also contracts with a health care provider who provides an on-call psychiatric nurse practitioner and a master’s-level drug abuse counselor.
Superintendent Henry and his staff reject the notion that jail would be an ideal place to treat a mental illness, which is based on the fact that inmates are under observation, behavior can be controlled and drugs are not an issue.
Most stays are short-term, they said, and addressing drug use is often the priority. The setting may be too perfect.
“We can give them all the treatment they want, but you have to remember, we’re in a vacuum. They don’t have the guardrails (on the outside),” said Jon Banville, the assistant jail superintendent.
Henry believes housing is key to any plan to reduce unnecessary incarceration. That’s especially true in Rockingham County, an affluent county that has few opportunities for affordable housing and transportation.
A 2021 survey of mental health and criminal justice professionals in Rockingham County identified housing as the No. 1 priority for diverting mentally ill people from the justice system. Transportation access was third, higher than more clinical-oriented priorities such as state hospital beds or treatment access.
“It basically comes down to brick and mortar. Where do you send people to live?” Henry said.
Pushed back to the brink
At the state hospital, social workers struggle to find places for patients to live once they are ready for discharge, Fetter said.
In early October, half of State Hospital patients were stable but remained at the hospital because they had nowhere to go, he said.
Housing is especially challenging when crime is part of the mix. Many public housing agencies deny benefits to those with criminal records.
Some are discharged to homeless shelters. But a homeless shelter lacks the stability essential for mental health.
“It shortens your time horizon,” Fetter said. Released patients are worried about where they will get their next meal and how they can protect their possessions from theft. No one is thinking about the next medical appointment, employment or establishing a healthy relationship, Fetter said.
“It all gets pushed down when you’re trying to survive the night,” Fetter said.
That means, they will likely become, as the latest terminology describes it, "justice-involved."
Police departments are being trained to recognize symptoms of mental illness and de-escalate situations.
“A lot of times when the police are involved, it’s a mental health crisis. They’re already not coping with life events. That’s why we’re encountering them," said Sgt. John Goodridge, who is supervisor of the crisis intervention team with Nashua police.
Most often, mentally ill people are charged with minor crimes: criminal trespass, disorderly conduct, drug possession.
A mental illness doesn't negate the person's need to follow the law, Goodridge said. But what happens after the arrest - mental health court or a state hospital committal - can lead to an improvement.
He said the biggest trigger to a crisis is stress.
In Bedford, Chief Bryfonski said seven of his 37 officers are trained in crisis intervention. If they can't respond during the crisis, they try to follow up and let the person know how to get help, he said.
Mental illness can be used to beat a charge, he said. For minor property crimes, that's not much of a concern, he said. But it also happens in cases of violent crime.
“The question becomes, what happens when that subject is deemed incompetent and then they’re released?” Bryfonski said. “They obviously showed some culpability to do crime, is this going to happen again to another person. How do we prevent that?”
By the numbers
2,500
Approximate number of beds at New Hampshire State Hospital in the 1950s
222
Current number of “designated receiving beds” in New Hampshire State Hospital and privately operated psychiatric facilities
1,044
Number of inmates at state Department of Corrections prisons with a mental health diagnosis in early October
1,869
Total New Hampshire prison population
$417,577
Most recent annual bill for psychotropic medications, New Hampshire Department of Corrections
$477,691
Most recent annual bill for medically assisted treatment of drug/alcohol addictions, New Hampshire Department of Corrections
48
Number of mental health professionals employed by the state prison system
1,066
Number of inmates at Rockingham County jail inmates on suicide watch in 2020
1,135
Number on suicide watch in 2021
777
Number on suicide watch in first nine months of 2022
36
Average monthly number of orders for competency evaluations filed with the state Office of Forensic Examiner in 2015
66
Average monthly number in 2019
45
Number of criminal defendants over a recent 12-month period deemed incompetent to stand trial, not restorable and not dangerous, making them basically unable to be tried or jailed.
60
Number of stabilized patients at New Hampshire State Hospital waiting 15 days or more for discharge to a less restrictive setting.
38
Average number of people waiting, mostly in hospital emergency rooms, for admission to a designated receiving facility in fall 2022 (not including those waiting in jail)
$75.25 million
Total amount of federal grants to New Hampshire to address mental health and substance abuse in 2021
Read the rest of the series
This article originally appeared on Portsmouth Herald: New Hampshire grapples with the overlap of crime, mental illness
