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The mental health care system in North Carolina has been failing for years. Perhaps nowhere is that more evident than those who get caught up in the criminal justice system, out of sight, therefore out of mind for the general public and policymakers. But their plight — and the brokenness of the mental health system — affects everyone in the state.

'Life sentence on the installment plan'

Gaston County Sheriff's Office and Jail
Mona Dougani
/
WFAE
The Gaston County Sheriff's Office and jail.

For those living with severe mental illness, the chances of becoming homeless can be high. According to a 2015 survey by the Department of Housing and Urban Development, one in four homeless people suffer from mental illness. Once homeless, they’re more likely to end up behind bars.

Going to jail can start a downward spiral. Many lose jobs or benefits — even health care. Some will cycle between jail and the streets for years — often for minor crimes like trespassing.

Last week, WFAE — with support from the PBS series, "FRONTLINE" — examined the problem of inmates who wait in custody for months because they’re too sick to stand trial. This week we focus on inmates who cycle in and out of jail, serving what many in the court system call a “life sentence on the installment plan.”

It’s a symptom of our fractured legal and health care systems. And that’s what is happening to Miguel Maldonado, whom we first met last August.

Like many of the stories in this series, this one is troubling. We grappled with how to tell it, and how to do so with respect. WFAE feels it’s important for you, the reader, to hear from Mr. Maldonado and others who are stuck in the “fracture.” We tried unsuccessfully to reach his family. When we first met Maldonado, he didn’t have an attorney. He had waived his right to one. When he later requested an attorney, WFAE consulted with Gaston County Public Defender Stuart Higdon to ensure that we told this story accurately and with as much sensitivity as possible.

Miguel Maldonado leaving a courtroom.
Dana Miller Ervin
/
WFAE
Miguel Maldonado leaving a courtroom.

Maldonado told us he lived on the streets of Gastonia. His arrest records said the same thing. But I met him in jail. He was picked up for indecent exposure last July 25. He was barefoot, wearing an oversized orange jail jumpsuit that was draped loosely over his shoulders. It was buttoned only to his hips. The deputy told him to button a few more buttons.

Maldonado said he couldn’t. “That will hurt my bones,” he told the deputy.

Maldonado said the jumpsuit was too small. But it was hanging off him, loose and open. His booking sheet said he’s 5 feet 8 inches tall and 145 pounds.

Maldonado is 40. He’s been cycling in and out of jail here for almost two decades, and in the last decade he has had 92 charges filed against him, court records show. All are nonviolent crimes. Seventy-three are for second-degree trespass — one of the lowest level misdemeanors.

He blamed his troubles on his bones. He said they are not in the right place.

“When I come to jail for trespassing, they don’t give me the right size. I’m a big boy, and I can’t fix my body because I forget my mind.”

The public defender’s office wanted us to meet Mr. Maldonado. He’s well known among its attorneys.

Gaston County Public Defender Stuart Higdon
www.linkedin.com/in/stuart-higdon-676a7192/
Gaston County Public Defender Stuart Higdon.

“Everyone in the office understands the charges against him are entirely because of his mental health,” Higdon said.

Court records show Maldonado keeps getting arrested because he goes back to places where he’s been arrested before for trespassing. Such as a local 7-11, where he stole two candy eggs. He even returns to places that have banned him from the premises, like the McDonald’s on Gastonia’s East Franklin Boulevard.

It’s not if he will come back to jail, but when, said the jail’s administrator, Assistant Chief Deputy Becky Cauthran. “We all know him,” she said. “There are a lot of people I would say are almost like family.”

In October, a judge found that Maldonado didn’t have the mental capacity to understand the charges against him or assist in his own defense. That means he was incapable of standing trial. We don’t know his exact diagnosis — that’s privileged information. But the law says only those with a mental illness or, “mental defect,” such as an intellectual disability, can be found incapable.

Maldonado said he doesn’t have mental health problems. He just needs the “right clothes and the right shoes.” The district attorney dismissed the charges against him, and Maldonado went back to the streets.

That happens a lot. North Carolina law says those who are incapable to proceed have to be restored to competency so they can stand trial. But the wait times for a bed in a state psychiatric hospital are long. WFAE’s investigation found that, in Maldonado’s part of the state, half of those charged with felonies wait more than 363 days for a state hospital bed so they can be restored.

Julia Ingram and Layna Hong contributed to this graphic. Data collection by Mona Dougani, data analysis by Julia Ingram and Robert Benincasa.
Julia Ingram and Layna Hong contributed to this graphic. Data collection by Mona Dougani, data analysis by Julia Ingram and Robert Benincasa.

Most of Maldonado’s charges are misdemeanors. The longest sentence for second-degree trespass is only 20 days. Since you can’t be held longer than the maximum sentence, prosecutors often dismiss the charges.

Some, like Maldonado, end up back on the streets.

“There is a phrase in the legal circle,” Higdon said. “Some people do life sentences and some people do life sentences 30 days at a time.”

Older court records show Maldonado’s last known home address is a shelter that shut down years ago. But recent ones show “streets of Gastonia” as his address.

Maldonado said his family has a house in Chicago, but there’s no room for him.

Gaston County Assistant Chief Deputy Becky Cauthran (standing).
Dana Miller Ervin
/
WFAE
Gaston County Assistant Chief Deputy Becky Cauthran (foreground).

“It’s a revolving door for a lot of these people with mental health issues,” said Chief Cauthran. “They’re committing crimes like begging or criminal trespassing because they’re on the streets. A lot of their family members have given up on them because they’re a nuisance to them and they can’t get the help they need.”  

Cauthran said the jail has tried to get him help in the state mental hospital, but the wait was too long. Maldonado had to be released when his sentence was up, before he could get a bed.

The jail even contacted his mother at one point when he was being released from jail, Cauthran said, but he refused to go with her when she came to pick him up.

Every county in North Carolina works with a local managed care organization whose duties include managing care for people struggling with mental illness. In Gastonia, Partners Health Management is that organization.

Partners offers former inmates help with mental health counseling, psychiatric care, housing referrals, even so-called “diversion programs” designed to keep them out of jail, said M. Rachel Porter, chief administrative officer. But it doesn’t track them when they leave jail.

North Carolina’s Department of Health and Human Services would like to see more pre-arrest diversion programs for people living with mental illness as well. It’s piloting them in 13 counties and wants the legislature to approve more funding for these with the federal money the state will receive because of Medicaid expansion.

Cauthran estimates that more than half of the inmates at the Gaston jail have mental health issues. That’s on par with a 2017 Bureau of Justice Statistics study. Its data, the most recent available, was collected in 2011-12 and found that more than 40% of jail inmates have a history of mental illness.

Those with severe mental illness — such as schizophrenia or bipolar disorder — are more likely to be arrested for the lowest level misdemeanors like trespass than those without the diagnosis, a Columbia University study found. They’re also 50% more likely to end up behind bars for most crimes.

“People who are suffering psychiatric illnesses, maybe psychosis, [are] wandering about in front of a store or sidewalk yelling,” Higdon said, “and the immediate response is to call the police to have this addressed.”

That first arrest can start a downward spiral from which people living with mental illness struggle to recover, Higdon said. After 30 days in jail, inmates will start to lose some Social Security benefits and Medicaid. And if they’re in jail for longer, they can lose food stamps, too. Figuring out how to reinstate those benefits when released can be especially challenging for those already struggling with mental health problems.

“If they were housed, they often become unhoused when they get out,” Higdon said. “They can get separated from medication. They can lose their support network. And so a lot of times, these people when they’re finally getting out, they’re literally starting over and they’re having to go back to square one.”

The result is a permanent underclass of disadvantaged people, Higdon said, cycling in and out of jails.

The exterior of the Wake County Annex Detention Center in Raleigh.
Mona Dougani
/
WFAE
Dr. David L. Rosen is a professor at the University of North Carolina’s School of Medicine. His research focuses on incarceration and public health. Rosen’s team conducted a survey of the availability of health care in the jails of four southern states, including North Carolina. The results have yet to be published but he discussed the findings here with WFAE.

But mental health care in jails is inadequate, said University of North Carolina School of Medicine professor Dr. David L. Rosen.

In a yet-to-be-published study, he found that 90% of jails have no psychiatric providers onsite. Three-quarters of North Carolina jails rely on telehealth for mental health care. But these jails typically offer about three hours a week for every 100 inmates they house. That’s less than two minutes per person.

“Really, nearly all of the jails say that they have access to providers,” Rosen said. “But when you actually look at the number and the hours that the providers are actually spending on site, it's really quite, quite, quite small.”

Eddie Caldwell, of the North Carolina Sheriffs Association, told us: “To say there are limited mental health resources in county jails is indisputably correct. There are very limited mental health resources in jails. There’s also the challenge of providing mental health care when that person is either going to get out very soon or go on to prison.”

With a clinical social worker onsite for mental health needs, Gaston’s jail offers more care than most. But Chief Cauthran said inmates who improve often don’t get care when they leave.

“So it's a continuous circle going on and on with no answers, with no end in sight for these people that are coming in with mental illness,” she said.

Maldonado’s still cycling. His charges were dismissed in October, but he was back in jail twice in November. Twice in December. And back again a few weeks ago.

Mona Dougani contributed to this story.

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This story is part of a collaboration with "FRONTLINE," the PBS series, through its Local Journalism Initiative, which is funded by the John S. and James L. Knight Foundation and the Corporation for Public Broadcasting.

Dana Miller Ervin is a reporter at WFAE, examining the U.S. health care system.