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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.

How the mental health system affects North Carolina’s jails and the people that work there

Beck Cauthran is the administrator and assistant chief deputy at Gaston County Jail.
Dana Miller Ervin
Beck Cauthran is the administrator and assistant chief deputy at Gaston County Jail.

‘There’s a lot of sadness you see.’

If you ask your sheriff about North Carolina’s mental health system, they might tell you their jail is evidence it’s broken. For the past five weeks, WFAE has been reporting on the fissures in the system.

We’ve examined what happens to inmates living with severe mental illnesses, who wait years in custody before they get their day in court. We’ve looked at what happens to people with mental illnesses who cycle in and out of jails, serving what some attorneys call a “life sentence on the installment plan.”

And we’ve examined the high price some former inmates pay because they can’t get the care they need when they leave jail.

Problems in North Carolina’s mental health system overflow into its hospital emergency rooms. Hundreds of children and adults wait for days or weeks in ERs because they need a bed in a psychiatric ward, but none is available. They have nowhere to go.

The state’s jails are also on the frontlines of the mental health crisis. Jail staff have to tend to inmates with mental health issues, even though they’re not fully equipped to do so. That can take a high toll on those jails — and the people who work there.

A false bomb threat

At 11:22 a.m. on June 16, 2022, a receptionist at Bessemer City High School called 911 about a possible bomb threat. The receptionist told the operator the caller identified himself by name and had warned that explosives were buried under a pile of dirt near the wheels of a parked school bus.

Twenty summer school students were sheltering in the lunchroom when droves of police, firefighters, emergency medical personnel and K-9 teams descended upon the Gaston County high school. No bomb was found.

Police quickly traced the call to 30-year-old Dillon Ledford, a homeless man with a long record of drug crimes, larcenies, motor vehicle offenses, even soliciting sex with a minor online. An ex-girlfriend helped police locate him. She told them Ledford had been in and out of jails and mental institutions, the police report says.

He was arrested on charges of making a false threat of mass violence against a school. Later, a psychological evaluation found he appeared to be suffering from psychosis, including delusions and paranoia, associated with schizophrenia.

WFAE met Ledford a few weeks later at the Gaston County jail. He’s an intense man, with a wiry build and messy blond hair. He said he was being terrorized by artificial intelligence. And he wants to warn people about the plot, which, as the evaluation suggested, appeared delusional.

Dillon Ledford is still in jail because a court decided he can't understand the charges against him or assist in his own defense.
Dana Miller Ervin
Dillon Ledford is still in jail because a court decided he can't understand the charges against him or assist in his own defense.

“They're social engineering people with names [like] Elon Musk and they're basically using linguistic anthropology to name the people,” Ledford said. “They’re tracking explosives, they're tracking international crime. And I’ve been tracking it myself.”

Ledford said he’s repeatedly tried to report the “terrorist plot.” He was frustrated that no one was listening. He said he called a half-dozen federal agencies such as the National Security Agency and the Secret Service, but he said they can’t stop electronic attacks.

It’s a confusing narrative, and Ledford gets upset when he thinks WFAE won’t warn people.

“It’s just a smidgen of what we encounter with numerous — 50 or 60 — people a day that have some kind of mental health illness,” said Gaston County’s jail administrator, Assistant Chief Deputy Becky Cauthran.

Some of these people need way more treatment than we can give them

Cauthran estimates half of the jail’s inmates have psychiatric problems. With a clinical social worker for mental health onsite, the Gaston jail offers more mental health care than most. But Cauthran said it's rarely enough.

“Some of these people need way more treatment than what we can give them inside a detention facility,” she said. “This is not a long-term facility, but it has become [one] for some people with mental health illnesses.”

Cauthran says that the wait times that inmates endure are also hard on detention officers.
Dana Miller Ervin
Cauthran says that the wait times that inmates endure are also hard on detention officers.

Ledford’s still in jail. A court decided that he can’t understand the charges against him or assist in his own defense. He needs psychiatric care before going to trial. His lawyer, Veronika Monteleone, asked for an evaluation of his mental capacity soon after he was booked into jail last July.

“The more you speak with him and you really listen to the content of what he's saying,” Monteleone said, “the more concerned you become about what exactly is going on with him and his mental capacity.”

The psychological evaluator said Ledford appeared to be suffering from psychosis. But the District Attorney wanted a second evaluation. That evaluator agreed Ledford lacked the mental capacity to stand trial, but by then nearly seven months had gone by. So it was February before Ledford finally got on the waitlist for a state hospital where he could get enough treatment to be able to go to court. WFAE’s investigation found half of all inmates wait more than 363 days for a bed in western North Carolina, where Leford is.

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.

Those waits are hard on inmates. They’re also hard on detention officers, Cauthran said.

“They're sitting here for months and months and months waiting to get in that facility, which is backlogged,” she said. “And now they're sitting inside a jail. And then you have officers who are having to tend to people with some serious mental health issues that are sometimes combative, assaultive and out of control. And we're trying to control them.”

Ledford was subsequently placed in protective custody, his lawyer says. The reasons are confidential, but it's frequently necessary when inmates are suicidal or at risk of harm from others. But prolonged isolation of mentally ill inmates can worsen their health, the American College of Correctional Physicians warns, so it can be a downward cycle, and officers have to deal with it.

You have to learn how to speak with inmates without them feeling threatened

Cauthran’s staff get Crisis Intervention Training so they can de-escalate tense situations with inmates in mental health crises. They’ve also started to take classes in what she called “verbal judo” to help officers keep control in difficult situations.

“You have to know how to be able to speak to [inmates] without them feeling threatened,” Cauthran said, “So you have to learn how to be able to speak with people with different mental health illnesses differently.”

Sometimes that even involves whether an officer should step forward, or take a step back.

“Sometimes your mannerisms, the way you move your hands, the way you speak, can have an effect on the way they see you,” Cauthran said. “So yeah, we are doing a lot of training on that.”

Cauthran said she learned that the hard way.

“I’ve had inmates who were mentally ill that mixed up milk and their feces and stirred it up in a cup and then cornered me with it,” Cauthran said. “I’ve had urine thrown on me. I’ve had my nose broken. So yeah, I’ve seen a lot of things happen with people that are very aggressive that are mentally ill.”

Sheriffs lobby to get folks the care they need

Locking up inmates living with mental illness can make deputies’ work more dangerous, according to a national research forum for police. And it increases the likelihood that officers will use force.

Eddie Caldwell of the North Carolina Sheriffs’ Association believes fewer people would end up in jail if more mental health care was available. The Association lobbied state lawmakers to expand Medicaid so more people will have access to care.

Eddie Caldwell of the North Carolina Sheriffs’ Association believes fewer people would end up in jail if more mental health care was available.
Courtesy of North Carolina Sheriffs Association
Eddie Caldwell of the North Carolina Sheriffs’ Association believes fewer people would end up in jail if more mental health care was available.

“Sheriffs feel like, if folks got the care they needed outside the jail, many of them would not commit the crimes that bring them into jail,” Caldwell explained. “Or if they did commit the crimes, they wouldn’t be in this bad of physical or mental shape when they get in jail.”

Caldwell said putting those with mental illness behind bars also imposes other costs.

“It also ties up a lot of bed space,” he said. “In some counties, the jails are overcrowded or full, and a lot of those beds are being occupied by folks that need mental health treatment.”

That’s expensive. Caldwell estimates North Carolina jails spend $70 to $100 or more per night to house each inmate. But the cost can be much higher if an inmate needs hospitalization. County taxpayers pick up the tab.

There’s another expense. When someone shows up at an emergency room and needs a psychiatric hospital bed, officers have to drive them to a hospital with an open bed. Since there’s a shortage of those beds, many officers end up driving patients clear across the state.

“It's a never-ending battle, trying to find enough people,” Cauthran said. “There aren’t enough officers to cover the mental health [needs] that we have and also continue to do the other part of their job, the majority of their job with the primary responsibilities.”

Gaston deputies drove 83,000 miles transporting 293 people to hospitals in 2021 alone, according to records Cauthran provided. It took 3,000 hours of deputies’ time.

In March, after 10 years of debating the issue, North Carolina passed a law expanding Medicaid eligibility to single adults who earn less than 138% of the federal poverty limit — $20,000 a year. That will go into effect if and when North Carolina enacts a budget.

Eddie Caldwell says he’s optimistic, but he’s waiting to see the details. And he’s staying in touch with Kody Kinsley, North Carolina’s secretary for health and human services. He contacted Kinsley before the Medicaid bill was passed and again on the day of the bill signing at the governor's mansion.

But the debate in Raleigh obscures another cost that doesn’t get as much attention. Officers’ mental health is affected by the jail environment, too.

“If we can get either treatment or alternate placement for the folks that need to be in a medical facility or need medical care or mental health care, that will lessen the burden on the day-to-day detention officer who has to be there for a 12-hour shift,” Caldwell said.

The toll on jail personnel

Working that 12-hour shift with inmates living with mental illness is hard, said Gaston Jail’s Sgt. Monica Becton. WFAE visited last week and walked with her down a corridor that housed women with mental health problems. They’re in individual cells 24 hours a day because they’re a danger to themselves or the officers, Becton said. The smell of urine was intense. Becton said many refuse to use a bathroom. Some smear feces on themselves. Shouting echoed through the hall.

Gaston Jail’s Sgt. Monica Becton.
Dana Miller Ervin
Gaston Jail’s Sgt. Monica Becton.

“In college, you read about the mental facilities where people had to lay in their, you know, their feces and their urine, and just the echoing of the screams,” Becton said. “And that's what it reminds me of that we have back there. Our officers are not trained to deal with that on a day-in, day-out basis, on an extensive, long period of time basis. So it is difficult.”

Becton said it’s a heavy weight on her shoulders. And it makes her angry that the inmates can’t go to a hospital like they used to be able to when she began the job 24 years ago. It's hard not to bring that home, and family members often can’t understand, she said.

“I just need to go outside and be by myself for a little bit because I don't want to talk about it again,” Becton said. “I don't want to rehash it, and I need that time to decompress. So it's very hard on families to not be able to understand because until you do this, and until you walk these halls, you can't fathom what we go through every day.”

There isn’t much data on jail detention officers, but a California survey of prison officers found many become depressed or anxious as a result of their jobs. They’re also more likely to be suicidal.

They see a lot of bad things, Cauthran said. Dealing with inmates who really need to be in a psychiatric hospital is one of them, she said.

“There’s a lot of sadness that you see,” Cauthran said. “It affects an officer. It affects the way they look at the outside (world).”

When Cauthran leaves the jail, she focuses on her pets. She said officers need a hobby to help them from thinking about the troubled inmates they see all day long. Like Dillon Ledford, who bounced between group homes and foster families as a child, when he said he first started to hear voices.

“You know that a lot of these people just come from broken families,” Cauthran said. “And that if they would have had a chance on the outside, that maybe things would have been a lot different for them.”

Mona Dougani contributed to this story.

“FRACTURED” is part of a collaboration with the PBS series “FRONTLINE” 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.