Treatment limited for jail inmates struggling with mental health, but they have access to a therapist, telehealth

Outagamie County Jail, like the other 73 jails in Wisconsin, has limitations to mental health treatment it can provide to inmates before they are convicted and sentenced.
Outagamie County Jail, like the other 73 jails in Wisconsin, has limitations to mental health treatment it can provide to inmates before they are convicted and sentenced.

APPLETON – James Cooper has been in Outagamie County Jail for over a year and he says his mental health is deteriorating.

"I'm not getting the help that I need here. Nor is anybody else that is here with mental health issues," Cooper said in a phone call from the jail in February.

Since his arrest in May 2022, Cooper has been sitting in jail as his case makes its way through the legal system. At hearings, he repeatedly expressed his frustrations with a lack of mental health support in the jail. Meanwhile, he continued to rack up additional charges from behavior that he says stems from his worsening mental state and changes in medication. Cooper has received 10 additional charges for seven incidents in jail, including spreading soap and water on the floor of his cell, spitting and cursing at guards, and throwing food.

After a year of seeking a defense that he was not guilty due to mental illness, Cooper pleaded no contest on May 8 to three felony charges from the May 2022 incident. As part of the plea deal, all but two of the charges he received while jailed were dismissed, according to court records.

In a video call on May 24, Cooper said he felt entering the plea deal was his only option, as his lawyer advised him a jury trial would likely result in more prison time.

Cooper spoke with The Post-Crescent on multiple occasions by phone and video chat from January through May, during which he discussed his case and experience with mental health services in jail.

He's not alone in dealing with mental health-related issues from jail. Josette Smith, behavioral health coordinator at the Outagamie County Jail, said about a quarter of the approximately 350 inmates request to see a therapist.

Outagamie County has mental health care available for inmates, including access to set-up sessions with a therapist and telehealth visits with a psychiatrist to prescribe medication. But in the short-term setting of jail, care options are limited.

Successful NGI pleas 'extremely, extremely rare'

Cooper was arrested May 19, 2022, after a two-hour standoff with Appleton police. During the incident, he pointed a gun at someone in Iris Place, a peer-run respite home for people facing mental health or substance abuse challenges, turned the weapon to himself and climbed to the roof of a St. Bernadette Parish campus building at 1213 S. Matthias St. and fired two shots into the air, according to a criminal complaint.

The incident arose from a mental health crisis, Cooper said. He was charged with three felonies — first-degree recklessly endangering safety, discharging a firearm in a school zone, and possessing a firearm while an adjudicated delinquent of a felony — in addition to two misdemeanor charges of disorderly conduct and bail jumping.

Cooper had previous charges on his record, but that incident was the first time he had been charged with a felony.

Cooper said he has borderline personality disorder, which impacts his ability to regulate his emotions. He also deals with post-traumatic stress disorder and ADHD, and has a history of run-ins with police since coming to Wisconsin from Philadelphia at age 11. His childhood was chaotic, he said, as he was exposed to violence and abuse, was in and out of foster homes, and at times had to feed himself out of dumpsters. Before his arrest in May 2022, Cooper said he went to the emergency room around 30 times in about a year for struggles related to his mental illness.

In Wisconsin, people charged with crimes can be moved from a jail to an extended stay in a mental hospital in one of two ways — they can be found not guilty by reason of mental disease or defect, known as an NGI plea or pleading insanity, or they can be found incompetent to stand trial. It's very rare to be found not guilty by reason of mental disease or defect.

In September, Cooper pleaded not guilty by reason of mental disease or defect. An evaluation conducted by the Wisconsin Forensic Unit did not find enough evidence to support the NGI plea.

He has since changed attorneys, and on Feb. 8, Outagamie County Judge Yadira Rein ordered funding for a second examination. Cooper said he never learned the results of the second evaluation before entering a plea on May 8.

Cooper had a competency examination early on in his case, but was found competent to proceed. Competency refers to whether a defendant has been able to properly understand what's going on during the process of court proceedings.

People who are approved to be transferred from jail to a mental health facility for either NGI or competency face waiting lists that can be an entire year.

When she first stepped into her role nearly 13 years ago, Smith said, a waitlist of 30 people seemed long. Now, people waiting to be moved out of jail into a mental health facility often have to wait for more than 150 people ahead of them.

"That's people sitting in various jails throughout Wisconsin that are on this waiting list to go, and there's only so many beds," Smith said. "It's really sad, because that means some of these people, most of these people are sitting in jail, are very mentally ill."

Amanda Skorr, an Appleton-based attorney and Cooper's public defender, said an NGI plea requires proving that a person's mental health condition was the reason they were unable to control their behavior when committing a crime. Factors like intoxication or even anger at the time of the crime prevents a person from being able use an NGI defense, Skorr said.

"They're extremely, extremely rare, actually, in the criminal justice system," Skorr said. "I would be making up the number, but I've done thousands and thousands of cases in my career, and less than half a dozen clients who have been found NGI."

Skorr said it's common for lawyers or defendants to request a second NGI evaluation. Funding for the first evaluation is covered by the court, but any subsequent evaluations are funded by defendants themselves, or, if represented by a public defender, the public defender must get approval to hire an expert to conduct the evaluation.

If a second evaluation has a different finding than the first, the defense and prosecution may have disagreeing experts testify against each other at trial, leaving it up to the jury to decide which carries more weight, Skorr said.

What therapy treatment is available in jail?

While waiting for their court cases to proceed, many dealing with mental health struggles have to rely on the services available in county jails.

According to a 2020 study from the National Alliance on Mental Illness, about 44% of people in local jails and about 37% of people in state and federal prisons in the United States have a history of mental illness. Skorr estimated around 80% of the clients she represents have either a mental illness, an addiction or both.

The 2020 NAMI study also found 45% of people with a history of mental illness who are held in local jails receive mental health treatment.

It’s a paradox that people sent to jail and prisons are told serving time can help them “get better” when there's a lack of mental health support available to them, said Robyn Van Bogart, former Outagamie County Mental Health Court coordinator. Jails in particular have fewer treatment programs than prisons, in part because it's considered a short-term stay as inmates await an outcome in court.

“Typically the services, if they’re available, while (someone is) in the jail is going to be an intern coming in and working with those individuals who may need it. But it’s very hard to get any type of treatment,” Van Bogart said.

Van Bogart, now a clinical therapist with Outagamie County Crisis, ran the Outagamie County Mental Health Treatment Court until early April. The court helps people with felony or misdemeanor charges receive treatment for issues that have landed them in the criminal justice system, after they have been convicted and sentenced. In 2019, before running the treatment court, Van Bogart was an intern at the jail — in fact, she was the first intern Smith worked with.

Jail interns, Smith said, can provide more regular therapy sessions to inmates than Smith or her staff have the capacity for. Smith said she has always had at least one intern for the last four years.

"I love having interns," Smith said. "We're able to get people one-on-one counseling, like an hour a week."

The regular sessions are "a really nice opportunity to do some more of those different kinds of therapies — some learning coping skills, mindfulness, meditation, coping with trauma, things like that," Smith said.

Outagamie County Jail inmates who want to see someone for mental health needs can request it through an electronic kiosk system, which is available to most inmates at any time of day, Smith said.

Smith then responds to these requests during the day, prioritizing people with the most urgent needs. Outside of interns, she has two behavioral health staff members — one full time, and one part time — to assist with these calls.

Some inmates with behavioral issues get placed in restrictive housing, which limits their time outside of a cell and restricts their access to the kiosks. Cooper was put in a restrictive housing unit for some time during March and April.

However, Smith said even inmates in restrictive housing can be moved out of their cell into an interview room for therapy sessions.

While people in jail have simple access to visits with mental health professionals, the care they provide is often "short-term" and "solution-focused," aimed at helping people get out of a state of crisis, Smith said. It's not the intensive, long-term therapy that is offered at mental health institutions.

"Pretty much everybody's pretty intense when they first come in, rightly so. So we just try to prioritize, 'What's the priority right now? What can we focus on right now to make some type of change right now and help you feel a little bit better?'" Smith said.

In severe cases, like if an inmate expresses suicidal ideation, Outagamie County Crisis gets involved.

Jail restricts some types of medication

Beyond talking to a behavioral specialist or intern, Outagamie County Jail inmates can be prescribed medication through a contracted jail psychiatrist, Dr. Robert Vickrey.

Vickrey is based out of Madison and communicates with inmates through telehealth, Smith said.

The jail doesn't allow inmates to bring in medications from the outside, Smith said. Instead, upon intake, the jail nurse can order medications from their own pharmacy. However, the jail tends not to use medications that have a high risk of being abused, like benzodiazepines, which are taken to relieve anxiety.

Cooper said he was taken off some of his medications, including 4 mg of Clonazepam, a benzodiazepine used to treat seizures and severe anxiety. According to FDA guidelines, 4 mg a day is usually the maximum dose of the drug given to adults to treat panic disorder.

Cooper says he wasn't weaned off the medication, which he estimates he had been on for seven or eight years. As a result, he said he experienced extreme paranoia, anxiety and hallucinations.

However, Smith said the jail has a strict policy on weaning people off of benzodiazepines, involving monitoring vital signs and providing medications to assist with withdrawal symptoms. After they are weaned off, inmates have the option of seeing a medical provider who can provide an alternative medication, Smith said.

"The withdrawal from benzodiazepines is insane," Cooper said, later adding, "When I was taken off of those things, it was very hard. I felt like I was in danger all the time, and I had a false sense of what was going on."

Cooper said that when he was near other people in the jail, he would think he overheard statements that referred to him. He said that paranoia led to behaviors, like spitting at guards, that resulted in more charges since he entered jail. In Wisconsin law, spitting at a jail guard is a Class I felony, punishable by up to 3½ years in prison, fines of up to $10,000, or both. Cooper received three of those charges in the year he's been in jail.

"I didn't have the right mind to be able to just, you know, sit back or whatever," Cooper said. "I was actually afraid for my life. I thought crazy stuff was going on that wasn't."

If people booked into Outagamie County Jail have been regularly taking medications as prescribed up until their jail intake, those medications automatically continue, Smith said, as long as they were able to properly notify jail staff about them during intake.

"What's hard with this is sometimes when people are booked in, for example, they're not in a good place. They're either mad and they don't tell us (about) their meds, or they're under the influence. I have people that are booked in that say, 'I don't even remember being booked in,'" Smith said. "So there are potentials for gaps, but that would probably be the only reason why."

If, however, a person had not been regularly taking medications he or she was prescribed and requests to have that medication in the jail, the person must be evaluated by the jail psychiatrist, Smith said.

Beyond avoiding medications that are commonly abused, Outagamie County Jail also tends to not use drugs that may have been prescribed for something other than what is listed on the FDA label.

"We also have some meds that aren't necessarily being prescribed in the community for what they're intended for. Now, that's the doctor's right out there, whatever, they can do that. But in the jail, we tend to be more safe and conservative and don't do a lot of that off-label prescribing," Smith said. "So if someone comes in on something like that, they will be seen by the doctor and prescribed an alternative."

Smith said the drug changes can cause people to be unhappy, particularly if they've been taking a medication for a long period of time. But she said the psychiatrist always prescribes an alternative medication in those situations.

"I don't have the list of what is or isn't approved from the jail, but I know for sure that I hear that from my clients all the time, 'They're not giving me the meds that I'm supposed to be taking,'" said Skorr, Cooper's attorney.

Smith said the jail wouldn't take someone off a medication if it's the only effective remedy for a particular need, even if it it's one jail doctors don't prescribe.

"We certainly wouldn't take somebody off meds if that was the only thing that worked," she said. "We would look at each person individually."

Can more be done?

Outagamie County Jail, like the other 73 jails in the state, has limitations to the mental health care options available.

“There’s challenges for providing treatment to jail inmates,” said Bernie Vetrone, director of Outagamie County Criminal Justice Treatment Services. “Number one is the cost, obviously, and counties don't have unlimited resources. Number two … jails are designed for short-term status. Most of our people up in our jail, they're not in jail long enough to offer an intensive treatment program. So basically, the best we can offer is stabilization for those very severe cases.”

The county has programs in place for support in the criminal justice system for people facing mental health and addiction difficulties, including the Mental Health Treatment Court. However, most programs are only available to people after they have been convicted of a crime — which often follows a stay in jail.

In 2022, the average length of stay in Outagamie County Jail was 25.76 days. It was 29.26 days in 2021, 33.59 days in 2020 and 26.89 days in 2019, said David Kiesner, the corrections division commander for the Outagamie County Sheriff's Office. Data isn't available for years before 2019, Kiesner said.

Outagamie County Jail has a population of around 350 people, out of a 750-person capacity, Smith said. Before the COVID-19 pandemic, the jail was at around 500 people.

"Even though we're down in numbers, I feel the chronicity of the clients is up a little bit," Smith said. "COVID didn't do well for people mentally, and then just an increase in substance abuse stuff."

Despite more people in jail requesting help for mental health needs, Smith said she doesn't think the jail is understaffed. And while she said "there will always be people that would want more services," she said some inmates who are seen once a week are receiving more regular treatment than they would otherwise have out in the community.

"I love it there. I think we do good. I think we do make a difference," Smith said.

While Cooper has repeatedly said he feels that mental health treatment available in jail is not adequate, during an April video call, he said he recently had a breakthrough during a therapy session.

"I'm starting to realize — like, I never put two and two together, it sounds kind of stupid, or whatever, I guess I didn't grow up correctly to understand it, so I'm learning — the therapist kind of broke it down to me ... (that) as a human being, you're entitled to feel any way you want to, you can feel mad, sad, angry, upset, but you don't get to react to it in that manner," Cooper said. "I've always been emotionally unstable, and that was a big thing."

In the April call, Cooper said he wishes he had not sought the NGI plea and advocated for his mental health, because the process has extended his time in jail, during which he received additional charges that he worried would land him a longer prison sentence than if he had elected for the quickest course of action.

"I feel like I've wasted this whole time even trying to advocate for my mental health rights, because it's done nothing but slow me down here. It's literally just made me stay in the jail longer, and now I've got more charges," Cooper said in April. "I don't know, it's probably the worst thing I could have done."

Rather than facing the prospect of waiting potentially another year to go to trial, then possibly being found guilty and sentenced to multiple decades behind bars, Cooper chose to take the plea deal. His sentencing is set for 1:30 p.m. June 21. He said he's hopeful his sentence will take into account health treatment needs.

Contact Kelli Arseneau at (920) 213-3721 or Follow her on Twitter at @ArseneauKelli

This article originally appeared on Appleton Post-Crescent: Treatment limited for jail inmates struggling with their mental health