Inside the white-brick hallways of the Flathead County Detention Center, Jail Commander Jen Root walks up to a steel door and looks through a small window at the inmate.
"She's been here almost a year, just laying on her bed," she says.
Inside the cell, dimly lit by a single window, a woman is curled up under a fleece blanket, only her bright-pink fingernails sticking out.
This woman was charged with burglary in September 2022, Root says. An evaluation after her arrest determined that mental illness prevented her from standing trial, and that she required treatment at the Montana State Hospital, the state-run inpatient psychiatric hospital.
Like many inmates deemed unfit for trial due to a mental health condition, she has been stuck on a waiting list for the Montana State Hospital's 54-bed forensic unit, which stabilizes inmates through medication and treatment so they are competent to stand trial.
The woman in the Kalispell jail had spent months on the waiting list; over the summer the list reached 70 people. Meanwhile, the northwestern Montana jail where she's waiting isn't equipped to treat mental illness, and the jail staff can't force her to take her prescribed psychiatric medication.
"So, they just deteriorate within our facility," Root says of her and other inmates with serious mental health conditions.
Before their legal case can proceed, people charged with crimes in Montana must understand the charges they face and participate in their own defense. But because of bottlenecks in services here, and across the country, people in jail with serious mental illness are waiting months to receive the care needed to "restore" their competency to stand trial.
Surging demands for state psychiatric beds
For years, the Montana State Hospital has struggled to keep up with the number of people who are criminally committed to the facility.
Meanwhile, at the Flathead County jail, the number of people waiting to be transferred there has grown since the pandemic, Root says. Another factor driving jail overcrowding is Montana's recent population boom, which has pushed up housing costs. Increasing homelessness can exacerbate mental health conditions, and make treatment more difficult.
This year, state lawmakers began to address the woes of the troubled state hospital, which lost its federal funding and accreditation in 2022 amid a rash of patient deaths. The legislature created a $300 million fund to improve behavioral health care in the state and passed bills to increase transparency.
Now, state health officials are asking for more: they want lawmakers to change criminal commitment laws so that the Montana Department of Public Health and Human Serviceshas a say, before a judge orders a patient committed to the Montana State Hospital.
"That is something we would like to address with you," Chad Parker, an attorney for the health department, told the Children, Families, Health, and Human Services Interim Committee in July. "That is something we'd like to look at to try and change, to give the department some more control, to at least give us a place at the table."
But there is nowhere else to send patients facing criminal charges for evaluation and treatment, according to Republican State Rep. Jennifer Carlson, a member of the interim committee. She told NPR the health department should focus on improving patient care, instead of denying patients access.
Judges have fewer treatment options for commitments
In the hearing, Parker criticized the judges making the decisions. He contended they rarely order patients to be committed at community care facilities, as an alternative to the state hospital system. He did acknowledge that community service options have dwindled, in part due to low Medicaid reimbursement rates. Lawmakers raised those rates by about 20% this year, but it will take time to determine whether that increase will be enough to rebuild mental health services, and induce once-shuttered locations to reopen.
In the meantime, patients are funneled to the state hospital, the only current option for many inmates who need mental health care.
"When there are no available patient beds, or they are not available for some time, the department can be held in contempt or receive another sanction," Parker told the legislative committee. "And we need to address that, as well."
In an emailed statement, health department spokesperson Jon Ebelt explained that state law doesn't require courts to consider wait times before committing inmates to the state hospital for mental health care. Neither Ebelt nor Parker pointed to specific community services or other mental health facilities that could take on the burden of treating inmates in the criminal justice system, so they can become fit to stand trial.
In her work at the Kalispell District Court, Judge Amy Eddy oversees many criminal commitments to the state hospital. She says she can't comment on the health department's proposed changes to the involuntary commitment process, because they're too vague.
But she points out that the state hospital is currently the only facility in the state that can take these patients.
"If someone needs to be involuntarily medicated, which the vast majority of people do in order to stabilize, the only place that can be done...for practical purposes is the state hospital."
Involuntarily medicating inmates found to be mentally unfit is often the only way to stabilize them so they can stand trial and then be transferred to community services to help them maintain the mental stability that the medications can provide, according to experts in Montana's judicial and mental health systems.
"It's not realistic to change the commitment laws and keep people out of Montana State Hospital" unless other tools are developed, says National Alliance on Mental Illness of Montana executive director Matt Kuntz, who has worked in the past with lawmakers on changes to commitment laws.
Involuntary treatment under Montana law
However, Republican State Rep. Bob Keenan says Montana's commitment laws do need to be reexamined.
"Montana has strictness when it comes to forced medication in mental health situations," Keenan says. "That is something that needs to be looked at."
Unlike some other states, Montana guarantees a person the right to a court hearing before he or she can be forced to take medication. That can slow down treatment. It's also unclear if the state constitution would allow private mental health facilities to involuntarily medicate patients, particularly if they're only holding patients for only a few days, according to Keenan.
The $300 million state lawmakers appropriated this year aims to fund both community-based mental health services and regional mental health facilities that could take on patients who need a lower level of care than what's offered at the state hospital. But it will take years for any of those initiatives to come to fruition.
Shuttling back and forth between jail and state hospital
While additional mental health services are needed, the state also needs to work on improving care at the state hospital for the patients it does serve, says Eddy, the Kalispell judge.
Eddy points out that even when inmates make it to the state hospital for treatment, they're typically there for two weeks, instead of the allotted 90 days of commitment, before being sent back to the county jails. That makes it difficult to truly stabilize them, she says.
When inmates are discharged back to the jail, the communication and coordination is poor, Eddy says. The state hospital might not tell the jail what the inmate's diagnosis is, or even whether they're on medication.
In addition, the inmates are free to refuse the medication once again, while they await their legal proceedings. At that point, they can mentally deteriorate further, according to Judge Eddy and Root, the jail official. The local jails also might be unaware of an inmate's diagnosis or whether he or she is on medication, Eddy says.
"That makes it very difficult, having gone through all this effort to restore this person's fitness, to then keep them fit to proceed in the criminal stuff," she says.
Some inmates are left waiting once again in jail, only to be funneled back through the court process to get treatment at the state hospital.
"Then sometimes they've been here for so long, I think nobody knows what to do, and then they get released," says Root.
With limited community mental health resources, those who are released typically end up back in jail, only to repeat the cycle.
"Probably my biggest frustration with our system is the mentally ill and having people in here that should not be criminally charged," Root says. "Yes, they're not safe to be out in the public, but being in jail is not the answer either."
This story comes from NPR's health reporting partnership with KFF Health News and Montana Public Radio.
Copyright 2023 Montana Public Radio. To see more, visit Montana Public Radio.