The Abyss: Inmates with mental health and substance abuse disorders cycle through jails relentlessly
For the last two weeks, WFAE — with support from the PBS series, "FRONTLINE" — has been examining the problem of inmates living with mental illness. This week we focus on ways to help former inmates stay out of jail. And the ways the system fails to do that.
When I met Anthony Muckenfuss last September in his mother’s modest Asheboro, North Carolina, home, he was surrounded by three generations of family, and two dogs clamoring for attention. It’s a warm family scene. It’s in sharp contrast to the electronic monitor strapped to Muckenfuss’ ankle.
Muckenfuss had been released from the Randolph County Detention Center on Aug. 15. He served time there for possession of heroin, methamphetamine and counterfeit $100 bills.
It’s hard to imagine as he bends over to help his 80-year-old grandmother or cuddles with his younger cousin, but when he’s high on meth, Muckenfuss said he’s violent. Like the time in 2021, he used a knife to hold up a Home Depot in Greensboro during the intense rush of a meth-fueled euphoria.
Muckenfuss said he has spent most of his adult life behind bars. Like many addicted inmates, Muckenfuss also has a serious mental illness. Court records show he’s been charged with dozens of robberies, larcenies and other property crimes. All, he said, to support his expensive drug habit.
People with severe mental illness are more likely to end up behind bars, studies show. Add in substance abuse problems, which a lot of inmates with mental illness deal with, and the risk goes way up. They’re also more likely to end up in jail a second time. And a third. It’s part of a downward cycle of mental illness, addiction and incarceration that’s hard to break.
There are ways to break the cycle. Studies show connecting former offenders with medical care helps them stay out. But a lot of offenders fall through the cracks in North Carolina’s fractured mental health and legal systems. Muckenfuss is one of them.
He was 7 or 8 when he began hearing voices.
“At first, I couldn't really understand them,” Muckenfuss said. “Then gradually [it] got to where, you know, it was telling me to do different things or, you know, just making me really paranoid.”
By 11, he was abusing sleepwalking medication. Then he started to smoke weed, he said. By 15 or 16 he moved to cocaine, he said. Then methamphetamine. Then a $200-a-day heroin habit.
“It seemed like it spiraled out of control after that,” his mother, Angel Chavis said, speaking of his high school drug use. He was “going in and out of jail and getting into trouble. And he wasn't himself. He’s always been a sweet, loving person, especially with children and elderly.”
Muckenfuss was later diagnosed with schizophrenia. The voices in his head told him to cut himself. Just a “little bitty here and there,” he said. “Nothing that wouldn’t be too noticeable, but it would take the feeling away a little bit.”
Cutting himself felt good, he said. “It takes my mind off whatever strong emotion I’m feeling. And it helps me focus on something else.”
“I like to see the blood,” he said.
Muckenfuss’ arms were covered in scars. Most were from cutting, but some were from bites, he said. In jail, it was harder to get a knife, so he swallowed things. Spoons and ballpoint pens, his records show. He lengthened his neck and pushed his head back to demonstrate how he swallowed a 9-inch piece of metal from a shower rod. “Push it down and kind of swallow.”
His medical records show he’s had surgery to remove items he’s swallowed. One time he pulled out the surgical stitches holding together his abdomen while he was at the Guilford County Detention Center. So the jail sent him to a special “safekeeping” unit at the local prison which houses dangerous offenders.
Muckenfuss was frequently suicidal when incarcerated, his records show. One time he was found hanging in his cell. He said sometimes jails would put him in isolation to keep him safe, but that made it worse. So he’d find a way to hurt himself.
“I do it to lash out at them for something they’ve done to me. Like being locked down 24 hours a day, seven days a week,” Muckenfuss said. “It really, really messes with you after awhile.”
Muckenfuss' lawyer, Richard Wells, said the drug his client was given — Clozapine — lessened the hallucinations. It’s one of the best medications for some people with schizophrenia. But some jails, such as the one in Guilford, don’t routinely list it among the drugs they typically provide, in part because those who take it require close supervision. He got a lot worse when he couldn’t get it, Wells said.
Muckenfuss said he’d swallow things so jails would give him Clozapine. “I just wanted to be who I knew I could be on that medication.”
Cases like Muckenfuss’ are tough on jail staff, said Eddie Caldwell of the North Carolina Sheriffs' Association. “When you have folks in the jail who are noncompliant, who are violent for reasons that may be tied to mental illness, that creates additional and more difficult and dangerous work for the detention officers working in the jail,” he said. And all those procedures and surgeries are costly for taxpayers, he said.
Trying to stop the cycle
Those costs could be reduced by keeping ex-offenders like Muckenfuss from cycling back into the criminal justice system. Studies show that former inmates are less likely to end up back behind bars if they get treatment and medication. But when Muckenfuss was released from jail last August, he had trouble figuring out how to pay for the medicine he needed.
He didn’t have health insurance. And he didn’t qualify for Medicaid. Under North Carolina rules, single adults have to be blind, elderly or disabled in order to be eligible for coverage. Muckenfuss might have been able to get Medicaid coverage by qualifying for disability benefits. But he didn’t know that. Nobody told him.
Seven months later, after almost a decade of stalling, the North Carolina legislature voted to expand Medicaid coverage to everyone earning less than 138% of the federal poverty level — or about $19,000. But that hasn’t gone into effect yet. And it came too late for Muckenfuss.
Muckenfuss was able to get 10 minutes a week of telehealth care with a local nurse practitioner. The jail referred him to the provider, and the local managed care organization in his area, Sandhills Center, paid for that.
Sandhills is one of six North Carolina managed care organizations responsible for managing the mental health care of the most seriously ill who are uninsured or underinsured, as well as those with Medicaid. It told WFAE it uses state funds to pay for clients who don’t have Medicaid. But those funds are “limited,” so the services it covers “may not be widely available.”
Without coverage, Muckenfuss had trouble paying for the medicine to control his hallucinations. The medication he was prescribed at the time, which wasn’t Clozapine, cost over $250 a month. His mother said that was more than either of them can afford. So Muckenfuss was rationing some Clozapine from an earlier prescription, he said.
“I’ve been taking a little bit of it here and there just to kind of keep myself even,” he said. But it was not enough to keep the hallucinations away. Especially at night.
“I sometimes think I’ll hear stuff outside, thinking people’s out there looking out the window or I’ll see shadows in my room,” he said.
“This is part of the abyss people fall into when they are released from prisons and jails,” said University of North Carolina Medical School professor Dr. Evan Ashkin. He’s never met Muckenfuss. But he said his story is common.
Ex-offenders with chronic illnesses frequently end up back in jail because they can’t access all the care they need, Ashkin said. They need someone to help them connect to services. That’s true even in states which have expanded Medicaid.
“Many, many people do not understand how the system works. Why would we expect someone in and out of incarceration with severe mental illness to be able to advocate for themselves without some type of case management navigator and constant program during this very vulnerable period of time when they’re released.”
Navigators are critical, Ashkin said. He started the NC Formerly Incarcerated Transition Program in six counties to help ex-offenders transition back into society. It’s part of a national program. But it doesn’t operate in Randolph County, where Muckenfuss lives.
In the program, each ex-offender gets a primary care doctor and a community health worker who’s a former offender. They help newly-released inmates develop a recovery plan. And they help them access medicine, transportation to appointments, education, employment and housing if they need it.
“Without that kind of assistance the climb is too steep, and most people fail,” Ashkin said. “They're just back in the system.”
Most of the former inmates in his program are homeless, Ashkin said, and they have to focus on survival.
“What do you do if you’re living in a tent or you’re in a shelter and have to be out at 6 a.m.? Where do you keep your meds? Are you able to hang onto them?” he asked.
When medicine is lost or stolen, symptoms recur. Patients can become psychotic. Passersby get upset. Police are called; the next stop is jail, Ashkin said.
That may be especially true for people with severe mental illnesses, like Muckenfuss. Data show they have a better chance of staying on the outside when they’re connected to benefits like Social Security. But they have to know how to apply.
Eventually, Muckenfuss told me, he spoke with his therapist, and she was able to send his prescription to a more affordable pharmacy.
Last September, Muckenfuss told WFAE that he was determined to stay out of jail this time — even without insurance or someone to help him navigate the system. He’d been making calls to get into a drug rehabilitation program. They were expensive, he said, but he found one in Virginia that was willing to give him a scholarship. He couldn’t go at the time because he was on house arrest, but he was making plans.
“The first step is rehab,” he said. Then he wanted to get his GED and find a trade. “Maybe one day I’ll start a family when I get my stuff together. Live a normal-ish life,” he mused.
Last winter, Muckenfuss got a job working with his brother at a local company, Carolina Custom Finishing. His mother said he was as happy as she’d seen him in years. But she worried he wasn’t taking the full dose of his medicine.
But on Feb 24, 2022, Muckenfuss didn’t go to work. His brother found him dead in his bed. His autopsy isn’t complete yet, but his mother suspects he died of an overdose.
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.