For nearly a year and a half, a woman has been languishing in Greene County jail, waiting to be transferred to a state mental health facility.
The woman was charged with a misdemeanor, found incompetent to stand trial and ordered by the court into state-run psychiatric treatment, Greene County Sheriff Jim Arnott told The Independent.
She’s been waiting there for a Missouri Department of Mental Health bed to open up for almost 450 days, Arnott said.
Had she been convicted of the misdemeanor, Arnott said, the maximum sentence would have been 1 year. She would have gotten out in November.
“[The Department of Mental Health’s] main priority should be, how can we get people into beds quicker,” Arnott said, adding: “Quicker than a year and a half, which is absolutely an injustice.”
“These are people who are mentally ill,” he added. “That’s the only reason they’re in here.”
There are 418 Missourians across the state on a waiting list for a mental health bed, up from around 300 at this time last year.
These are people who were arrested, found incompetent to stand trial and ordered into mental health treatment designed to allow them to have their day in court — a process called competency restoration that generally includes therapy and medication.
The average time these individuals wait in jail before receiving treatment is 14 months, according to department data.
Efforts to remedy the problem in the 2023 legislative session, including through a pilot program and increasing outpatient competency restoration, have been slow to get off the ground.
Greene County, which was included in the pilot program, decided not to participate. Clay County’s program was in operation for just three weeks last year before staff turnover put it on pause.
Only three people are currently enrolled in the jail-based treatment pilot program statewide, according to Debra Walker, a spokesperson for the state's Department of Mental Health. And only one person is currently in the outpatient treatment program.
Walker said the agency is working on solutions but “none of them will impact the numbers quickly.”
Last year, Department of Mental Health Director Valerie Huhn told the House budget committee the problem would get much worse before it gets better.
“It’s probably going to be 1,000 individuals,” Huhn said, “long before we’re at 100 individuals.”
‘Deprives them of humanity’
Mary Fox, the director of the Missouri State Public Defender system, said the wait times for mental health treatment are the worst she’s seen. She has been going to courthouses throughout the state trying to get some of the cases dismissed.
Public defenders have identified at least 12 cases of individuals in Missouri being held longer than their maximum sentences would have been, Fox said, without receiving competency restoration.
“It's gotten so bad that people aren't getting any treatment within the time period of when their case should be over and done with,” Fox said.
One client was having paranoid delusions and called the police himself, convinced he was being watched. The police then arrested him because his license plate was expired and because he didn’t stop driving when they put on their lights.
Fox said he’s waited in jail for longer than he would’ve for the maximum sentence on those two charges.
In a recent case filing, Fox called detention beyond the maximum sentence “unconstitutional, illegal and improper.”
Walker said the agency is “aware of such circumstances.”
“Individuals are admitted in the order in which the court order is received, and admissions are triaged based upon clinical acuity,” she said, adding that DMH is also working to provide medication and case management to individuals while in jail, through mobile teams of clinicians.
While individuals wait in jail, their mental health often deteriorates, said Annie Legomsky, who runs the state public defense system’s holistic defense services program.
Many are placed in solitary confinement, isolated for 23 or 24 hours a day, she said, and can end up with irreparable damage.
“It just completely deprives them of humanity, and it’s the antithesis of anything you could call a therapeutic environment,” she said. “We see clients who do just really sad things like eating their own feces, having suicidal ideation and actions, who are just completely decompensating.”
And there isn’t anything those individuals can do: Their case is on hold until they’re restored to competency to stand trial, so they can’t get released after they’ve waited the maximum sentence.
“They can't do anything to, kind of, control their fate,” Legomsky said. “They're at the mercy of (the Department of Mental Health) getting them the treatment they need.”
In states including Oklahoma, Kansas, and Washington, lawsuits filed by groups like the American Civil Liberties Union over similar wait times have succeeded, arguing the practice violates individuals’ rights to due process and the Americans with Disabilities Act.
So far, similar litigation hasn’t been filed in Missouri. A spokesperson for the ACLU of Missouri declined to comment.
Legislative efforts
Missouri has faced a years-long struggle with this issue, due to increasing numbers of court referrals for competency restoration, staffing issues and limited psychiatric hospital capacity. In Aug. 2013, there were only 10 people waiting for an inpatient bed, but by Sept. 2021, that number had risen to 106 — and has continued to grow.
In 2023, the state legislature approved $300 million to build a psychiatric hospital in Kansas City.
The plan is for the hospital to have 100 beds for competency restoration patients, but it isn’t slated to open until 2028 or 2029, Walker said.
The legislature passed a law giving the Department of Mental Health the authority to treat people within jails, called jail-based competency restoration. It also passed a law giving the department the authority to provide treatment on an outpatient basis if the person can be safely released.
The budget included $2.5 million for the jail-based competency programs to be established in jails in St. Louis, St. Louis County, Jackson County, Clay County and Greene County. The program was designed to provide room, board and medical care for 10 people at each jail.
Three counties signed contracts for the program last year. Walker said a contract is pending with St. Louis City.
Walker said the Clay, Jackson and St. Louis county programs are “in their early days of getting up and running.”
Sarah Boyd, spokesperson for Clay County sheriff’s office, said their pilot program has hit some roadblocks and is on pause, though the office hopes it will resume soon.
There are seven individuals held in jail in Clay County waiting for treatment, and the longest has been there since the beginning of March 2024.
The Clay County pilot program was in operation for under three weeks — from Oct. 27 through Nov. 14. The Department of Mental Health and its contracted partner were only able to hire one clinician instead of two, Boyd said, and that person left the job in November.
“The initial feedback was that the program was successful. Within the first couple of weeks, the clinician was able to make recommendations to bring the inmates back to competency fairly quickly,” Boyd said. “She even found some of them should not have been declared mentally incompetent to stand trial, and we worked with the court system to rectify that, based on her recommendations.”
Boyd said the state and the contracted agency are interviewing clinicians to try to bring the program back within a few weeks. She said jail staff alone aren't equipped to provide the level of mental health treatment many of the patients need.
"This has been an issue for us for a long time, and we are excited to be part of a potential solution," Boyd said.
Arnott, Greene County’s sheriff, says he opted out of the program. He said he had never heard about it until he received the contract, and it was his understanding the contract would’ve required the Greene County jail to receive more patients from throughout the state.
“I'm not going to participate in a warehousing contract of people that are mentally ill that shouldn't be in the jail in the first place,” Arnott said.
He said he modified the contract and sent it back to state but his changes were rejected.
Walker said counties were selected for the program based on the number of individuals they had waiting for inpatient beds — at least 10 people. Jails with fewer than 10 qualifying individuals, like Clay County, "would need to make jail-based competency restoration beds available for neighboring counties" in order for the project to be "fiscally sustainable for the state."
"Numerous discussions and exchanges occurred with representatives from Greene County," Walker said, "but ultimately an agreement was unable to be reached."
The St. Louis County program has started, Walker said, and there are three individuals currently participating. The Jackson County program recently hired clinicians and anticipates a start date in March, she said.
Neither county returned a request for comment.
The money that would have gone to the Greene County program is being used for the state's team of mobile clinicians who provide medication and case management to those in jails.
Fox and Legomsky, from the public defender’s office, said the agency should be prioritizing offering treatment in the community for those who can be safely released from jail.
“Our concern is you cannot take care of people with mental health issues in the jail setting,” Fox said. “That's not a healthy setting for anyone, let alone someone with a mental health issue.”
Although the 2023 legislation authorized outpatient treatment for individuals who could be safely released, both Fox and Legomsky say there’s been little progress.
Fox estimates at least two-thirds of those on the waitlist, or around 280 people, are low-level cases that don’t pose a risk to receiving competency restoration treatment in their communities.
She said the state has been slow to train community partners — that the training didn’t happen until November of last year even though the legislation was effective in August 2023.
“They have totally failed in getting that program up and running,” she said.
Walker said several provider groups have received training, which is ongoing. She didn’t answer a question about when that training began.
Walker said, to date, there have been only two people placed in the outpatient restoration program, one of whom was successfully restored and the other is currently receiving treatment.
Those currently waiting in jails for a bed to open up are "being assessed to determine if outpatient competency restoration is a viable option," Walker said.
"If so, the recommendation will be made to the committing court. Ultimately, the committing court would need to agree to change the individual’s commitment order to allow for outpatient competency restoration," Walker said.
This session
The Department of Mental Health says it will know more about budget and legislative priorities after Gov. Mike Kehoe’s State of the State address Tuesday.
Last year, former Gov. Mike Parson didn’t recommend a funding increase to the judiciary for pretrial services, which would have bolstered programs that divert those accused of crimes away from jail and to treatment for issues like substance abuse. Missouri Supreme Court Chief Justice Mary Russell highlighted the issue in her address to the legislature last year, saying: “We know the success of these programs can be far-reaching.”
State Rep. John Black, a Republican from Marshfield, led the House’s subcommittee on appropriations for health, mental health and social services in 2023 and 2024, which heard about these issues when debating the department’s budget.
Black said in a text to The Independent that the legislature has “added money for competency restoration in the last few years to address the problem. Implementing new programs frequently encounters issues.” He added: “We need to work on those obstacles and will continue to do so to help those people we are trying to help.”
State Rep. Betsy Fogle, a Springfield Democrat and the ranking minority member of that subcommittee and of the House budget committee, said the issue raises alarm.
Fogle said the state’s detention issue is indicative of broader problems with the “way we treat individuals in the state with significant mental health needs,” referring to adults with mental illness being held in nursing homes and children in hospital rooms.
“I'm proud of the work that we did as a General Assembly to try to move the needle on some of these issues and pass legislative sessions," Fogle said, "but you can see in the data that we're trending the wrong direction."
This story was originally published by the Missouri Independent, part of the States Newsroom.
