Over 30 years ago, Dr. Sheryl Kubiak
made an observation that would alter the course of her career forever and, eventually, impact the future of Michigan’s incarcerated.
After developing and operating a long-term residential re-entry program for pregnant women addicted to crack cocaine in Detroit for nearly seven years, Kubiak noticed many of the women she was working with struggled with unacknowledged behavioral health issues, keeping them locked in a cycle that was often difficult to break free from.
“I found out then that the vast majority of people who are coming out into the community (from corrections facilities), or are involved in the criminal/legal system, have behavioral health issues that they are trying to find their way through. What happens is, a lot of times, that behavior gets misinterpreted as ‘bad behavior’ or ‘illegal behavior,' and then they get wrapped up in a system they can't get out of,” Kubiak says.
Now the Dean of the Wayne State University School of Social Work, Kubiak is the founding director of the Center for Behavioral Health and Justice
(CBHJ) — an initiative that provides research, evaluations, training and support to local communities, behavioral health, and law enforcement agencies, and other organizations in Michigan related to jail diversion, re-entry, crisis response and more.
Since its founding, CBHJ has worked on a number of initiatives focused on diversion, working to identify better ways to keep those with mental health and substance abuse disorders out of Michigan’s jails and involved in appropriate treatment — work Kubiak says she’s seen increasing support for over time.
“I think the biggest change that I've seen in my years is that people are actually recognizing and understanding that an individual's mental health is a really important component of how we think about crime, how we think about rehabilitation, how we think about poverty, how we think about re-entry. And so that shift has been monumental because what it means is that you can get bipartisan support — you can get folks that don't often talk to each other to the same table. And then people start to work together, because they realize things aren't working the way they want them to,” Kubiak says.
That support has led to ongoing efforts at the state, local and community levels to identify better ways to meet the needs of people in Michigan with mental health and substance abuse disorders. From research, advocacy, and policy changes to grants and new facilities, efforts aim to keep Michiganders out of jails and connect them with treatment in their communities instead.
Macomb County Jail.
A decade in the making
In 2013, Gov. Richard Snyder replaced the state’s earlier Diversion Strategies Workgroup with the Mental Health Diversion Council (MMHDC)
, setting a goal of “reducing the number of people with mental illness or intellectual or developmental disabilities (including co-morbid substance addiction) from entering the corrections system, while maintaining public safety.”
The council was expanded in 2015 to include juvenile experts and an action plan for juvenile diversion. MMHDC also launched jail diversion pilot programs between 2014 and 2016, and continues to advise the Executive Office on policy and other diversion initiatives. While data is lacking around how successful the programs were, statewide support for diversion has increased noticeably in recent years with the addition of new task forces, research, grants, and other initiatives.
Last year, Gov. Gretchen Whitmer established the Michigan Joint Task Force on Jail and Pretrial Incarceration
, and the Jail Diversion Fund
was established through the passage of a new law that will provide grants to local units for the purpose of creating or expanding behavioral health jail diversion programs in coordination with law enforcement and community agencies — promising to bring the years-long work of reform researchers and advocates to life in communities across Michigan.
Identifying tools, barriers, and best practices
Identifying what works — and what doesn’t — for inmates with mental health and substance abuse issues has been a key focus of Kubiak’s work over the last 30 years.
“Often jails don't have a really good screening mechanism to identify mental health […]” she says. “And so what we've been trying to do in our work is try to get a very, very simple six-item screening tool at jail intake, which then identifies if someone's in acute psychological distress or they have a serious mental illness.”
Although Kubiak acknowledges that screenings are important for jails to conduct at intake, she says widely-used screening processes can sometimes contain confusing “double-barreled” questions, making it difficult for corrections officers to differentiate suicidal ideation from less extreme mental health issues, especially when they aren’t trained in those areas.
Because of those deficiencies, Kubiak says it’s important to think of screening as one tool of many when evaluating incarcerated people for mental health and substance abuse issues, adding that observation of inmates is critical for proper assessment.
Using data for positive change
Kubiak's observations come from years of research on the inner workings of county jails across Michigan, including a 2019 cross-site evaluation of pilot diversion programs
that were funded in 2015 in Wayne, Oakland, Kalamazoo, Monroe, Kent, Barry, Berrien and Marquette Counties and in 2017 in Livingston and St. Joseph Counties.
The study, funded by MMHDC and the Michigan Department of Health and Human Services, noted that across all jails studied, 47% of incarcerated individuals were charged with a “divertable" offense (last year, follow-up research
from CBHJ found that 64% of those booked into jails during the research period were charged with divertable offenses). Researchers also found that individuals with co-occurring mental health and substance use disorders were over two times more likely to relapse into criminal behavior than individuals with only a mental health disorder — highlighting the importance of diversion efforts at intake.
In addition to mental health issues, Kubiak’s work has also focused on the diversion of those with substance abuse disorders.
“With substance use, it's more difficult because alcohol is still the number one substance that people abuse. And it's so normalized in our culture that it's difficult to kind of do a screen,” Kubiak says, adding that questions about frequency of alcohol use can sometimes help.
Due to a lack of uniform standards of care, Kubiak says some jails are better than others when it comes to getting medication to inmates with addictions.
“We've been working on getting medication-assisted therapies into the jails, so that if people are on buprenorphine or Suboxone or methadone in the community, they can continue it in the jail so they're not thrown into withdrawal,” Kubiak says.
A medical chart at Macomb County Jail.
Pregnant inmates face unique risks
Dr. Carolyn Sufrin
, director of the Advocacy and Research on Reproductive Wellness of Incarcerated People
(ARRWIP) and associate professor at the Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health, agrees that withdrawals can be especially dangerous for incarcerated people with substance abuse disorders — especially those that are pregnant.
“If [pregnant inmates] were not on medication treatment in jail or prison, their risk of having a fatal overdose in the first few weeks after returning to their communities is extremely high — and much higher than if they had never been in jail or prison,” Sufrin says.
Sufrin explains that a person’s tolerance for drugs can diminish while in jail, especially without treatment, increasing the risk of an accidental overdose after release, noting that incarceration during pregnancy is associated with a four-times greater risk
of postpartum overdose.
Sufrin, who spearheaded the groundbreaking Pregnancy in Prison Statistics (PIPS) Project
between 2016 and 2017, recently conducted the largest-ever research survey
of nearly 3,000 jails listed in the Compendium of U.S. jails, including some in Michigan. She and colleagues at ARRWIP sought information about the availability of medications for opioid use disorder (MOUD), such as methadone and buprenorphine, for incarcerated pregnant individuals in U.S. jails — something researchers worried was variable.
“It’s hard to know very much about what's happening at a national scale at jails, because there is no centralized agency that oversees jails. Everything that happens in jails is local,” Sufrin says.
The results of the National Institutes of Health-funded study confirmed researchers’ concerns about varying access to MOUD for pregnant inmates — 28% of jails surveyed continued MOUD in jail but did not initiate it, while 23% responded that withdrawal was the only form of management used in pregnancy.
“The reason why this is important is because we know that there are likely thousands of pregnant people with opioid use disorder who pass through our nation’s jails each year. We know that pregnant people should not go through opioid withdrawal,” Sufrin says, noting that withdrawal can also pose serious risks for the fetus including preterm birth and stillbirth.
While Michigan has been criticized for its lack of standardized data
to track its jail population, Sufrin’s past research
estimates that around 55,000 pregnant people are admitted to U.S. jails each year.
Although self-reported data about opioid use during pregnancy is limited, a 2019 study conducted by the CDC
found that around 6.6% of respondents reported opioid use during pregnancy; of those, 27.1% reported misuse.
According to a 2020 study from CBHJ, fewer women, compared to men, in Michigan jails self-reported alcohol misuse (34% vs. 41%
), but more women self-reported drug misuse in general and opioid misuse in particular, during the 2019 jail systems collection period. More women than men reported feeling concerned
about experiencing withdrawal during their jail incarceration.
“If [inmates] have an opioid use disorder, they’re going to jail first. If they don’t have access to medication, they’re going to go through withdrawal. Instead, jail needs to be thought of as a point of access to care,” Sufrin says, noting the importance of routinely offering voluntary pregnancy tests for all females under 50 at intake (63% of surveyed jails said they offered tests on request).
“There are a lot of important health care needs that [pregnant inmates] have that the jail is going to have to help them attend to while they’re in custody. But if the jail doesn’t know they’re pregnant, then they’re not going to be able to address those needs at all.”
Still, while access to MOUD in jails varies for pregnant inmates and is in need of improvement at a national scale, Sufrin acknowledges that many jails do offer treatment in some capacity.
“In our study, we found that 60% of the jails at least allow pregnant folks to continue medication they were on in the community. Less, about a third of them, also initiate [treatment],” Sufrin says.
A need for improved housing conditions
At the Macomb County Jail, Sheriff Anthony Wickersham says MOUD is available to pregnant inmates through the jail’s medical and mental health services. However, efforts to get treatments to inmates that need them have sometimes fallen short in jails across the nation — including at the Macomb facility. The private health care provider serving Macomb County Jail, Wellpath (formerly Correct Care Solutions), has been tied to multiple lawsuits over its jail prescription, and mental health policies in Michigan. Wickersham and a representative from Wellpath declined to comment on those past issues for this article.
Macomb County Executive Mark Hackel, who served as Macomb County Sheriff from 2001 to 2010, is still optimistic about improving conditions for inmates at the county jail in the future.
Part of those efforts includes a proposal for a new central intake and assessment facility — something Hackel says could improve living conditions for inmates while allowing for more efficient mental health and substance abuse assessment and diversion efforts.
“It’s all about a systematic approach with people that come into contact with law enforcement. Central intake and assessment is, I think, the most fundamental component of what we’re dealing with when it comes to filling jails,” Hackel says.
This isn’t the first time the Macomb County Jail has sought funds for a new facility. Efforts to update the jail go back to at least 2005 when the jail commissioned a study looking for ways to improve conditions. According to Wickersham, that plan was initially approved but stalled due to the Board of Commissioners’ budget concerns at the time.
Several years later, in another effort to identify points for improvement across its entire criminal/legal system, including overcrowding at the jail, a broader criminal justice system assessment was commissioned by Macomb County.
That report, completed in 2016
, offered praise for the County’s diversion efforts, including the promotion of jail alternatives through the use of specialty courts for veterans and those with mental health and substance abuse disorders.
Still, among other recommendations aimed at the courts and other parts of the county’s criminal/legal system, the report made three critical recommendations focused on improving conditions for inmates at the jail — recommendations Wickersham has been working to address while making plans for the proposed intake facility.
Those included building a central intake and pretrial assessment center, establishing a designated medical and mental health facility, and providing updated and appropriate housing for inmates (the 2016 report referred to the current facility as “antiquated” and “not designed to support successful offender outcomes”).
“Pretrial screenings have been around for approximately 20 years on a limited basis, along with diversions. The recommendation was to enhance the ability to screen more inmates and have a robust diversion program,” Wickersham says.
That proposed project would have cost over $300 million, increasing taxes for Macomb County residents by nearly $60 per year through a 20-year millage
“We were going to do that when COVID hit. You had people that weren’t working, so how do we ask that?” Wickersham says.
Sheriff Anthony Wickersham
After the county received $172 million from the federal American Rescue Plan (ARP), though, Wickersham developed a new plan, pitching county officials to give the jail a portion of the funds to cover the cost of a new facility without burdening taxpayers.
According to Wickersham, construction for the proposed facility would cost around $100 million, most of which would be covered by the ARP funds if approved. An additional $25,000 for the project could be provided under the passage of HB 5522
, a $328.5 million supplemental appropriations bill focused on supporting public safety initiatives across the state. The bill, which was passed by the House in December, is currently being considered by the State Senate.
“We’re at a point now where we’re ready to go with a new central intake facility, a new medical/ mental health facility, and a holding facility,” Wickersham says.
Although the project is on hold while the county evaluates two other proposed projects that will be brought forth for approval at the same time, Wickersham remains hopeful the proposals will be ready to move forward by later this spring.
Building a facility that works
To date, the proposed central intake facility is still in the conceptual phase and a Freedom of Information Act request, returned March 16, confirmed that no plans or written proposals have been drafted or prepared. While Macomb County officials declined to share any formal designs, Wickersham and Hackel shared tentative plans that have been floated throughout the planning process.
Unlike the current jail, where a patchworked labyrinth of sections constructed in the 1950s, 1960s, 1970s, and 1990s, connects one wing to another, plans for the proposed facility would place medical and mental health staff in closer proximity to inmates in need of services.
Wickersham says, ideally, he would like to make sure the new facility’s design is based on a direct supervision model. That new model would allow for the continuous supervision of inmates, rather than checking on them once every hour as corrections staff currently does.
“The doors open. They’re loud, they’re heavy. [Inmates] know we’re coming. If individuals are either going to harm themselves or do something bad, they know our routine,” Wickersham says, adding that violent offenders would still need to be placed in traditional lockdowns for safety.
Wickersham is confident that direct supervision could help corrections officers keep a closer eye on the emotional state of inmates, and be readily available if they’re needed in an emergency.
“A lot of times [inmates] are on the phone and they get the breakup, or a lot of times nobody’s going to come bond them out, so they’ve got to stay in jail. They just go in their [cell] and you don’t see that. This way, you’ll see changes in behavior,” Wickersham says.
Other possible changes include refocusing the use of bed space, and creating special beds for mental health and addiction treatment.
According to Hackel, the number of beds at the proposed facility would drop to 1100 — down 138 beds. Those changes would be aimed at diverting nonviolent offenders with mental health and substance abuse disorders to appropriate care. Wickersham says 24-hour mental health access is also being considered.
“We're reducing the size of the facility but increasing the specialty beds available, and making it more efficient in how we're handling and processing people that come into the facility from law enforcement,” Hackel says.
In addition to the new facility, the Macomb County Health Department is also working on a study aimed at both improving services available to members of the community and finding better ways to connect inmates with job resources.
“Obviously, there's the workforce — are we utilizing all the resources that we have close at hand as a county to make sure those people are getting either the right workforce training that's available to them, or job opportunities?” says Vicki Wolber, Macomb Deputy County Executive, who expects to have a budget proposal for that project by early May.
Even if the intake facility is approved, Wickersham says making sure jails work for inmates with mental health and other needs will ultimately be determined by professionals in the criminal/legal system working together for positive change.
“Are you going to succeed when you leave here? That’s what we have to work at. And it’s not just the sheriff’s problem or the correctional staff’s problem. It’s a whole system problem — everybody has to come together,” Wickersham says.
All photos by Steve Koss.