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This article was produced for ProPublica's Local Reporting Network in partnership with Mississippi Today. Sign up for Dispatches to get stories like this one as soon as they are published.

Nearly 40 years ago, a federal appeals court ruled that Alabama officials could not jail people in mental health crisis who were sent to the state for help. Jailing people going through the state's civil commitment process, the court decided, amounted to punishment. And about 30 years ago, after Kentucky was labeled the worst state in the nation for jailing mentally ill people without charges, legislators there banned it.

But a new survey of counties and an analysis of jail dockets in Mississippi, which has no such law, has found that people going through the civil commitment process for mental illness are regularly jailed as they await evaluation and treatment, even when they haven't been charged with a crime. Some counties routinely hold such people in jail — people awaiting treatment for mental illness or substance abuse were held in jail without charges at least 2,000 times from 2019 to 2022 in 19 counties alone, sometimes for days or weeks.

Nationally, Mississippi is a stark outlier. Mississippi Today and ProPublica conducted a nationwide survey of disability advocacy organizations and state agencies that oversee behavioral health. None described anything close to the scale of what's happening in Mississippi.

Civil commitment laws are meant to ensure people get treatment even when they don't recognize that they need it, said James Tucker, an attorney and the director of the Alabama Disabilities Advocacy Program. Locking them up as they wait for a treatment bed doesn't fulfill that goal.

“The bargain for your lack of freedom is that the state has decided you need treatment,” he said. “The minute that order is entered, the state has a constitutional duty to deliver treatment.”

At least 12 states plus the District of Columbia prohibit jailing people undergoing commitment proceedings for mental illness unless they have been charged with a crime.

Mississippi law, however, allows people going through the civil commitment process to be sent to jail if there is “no reasonable alternative.” If there are no publicly funded beds in appropriate facilities, local officials sometimes decide they have no other option.

“We Forbid the Use of Jails”

In the 1970s, a federal class-action lawsuit against Alabama officials alleged that it was unconstitutional to jail people going through the commitment process for mental illness while they awaited hearings. It was common at the time: Probate judges in three-quarters of the state's counties had jailed people, according to discovery findings cited in a court ruling.

Lawyers for the plaintiffs — everyone in the state who had been committed or would be in the future — cited previous lawsuits that had uncovered fire hazards, overcrowding and a dearth of mental health and routine medical care in Alabama's county jails.

The district court ruled against the plaintiffs' constitutional claims, reasoning that if the local jail was the only option in a county, it was the least restrictive facility that would also protect society.

But in 1984, a panel of judges on the 11th U.S. Circuit Court of Appeals rejected that reasoning. Circuit Judge Thomas Alonzo Clark wrote in his opinion that nothing prevented counties from placing people in a public facility in another county or in a local private facility that was equipped to handle mentally ill patients.

Clark cited a doctor's testimony that jail often worsened psychosis, made it harder to treat people and increased suicidal tendencies.

“We forbid the use of jails for the purpose of detaining persons awaiting involuntary civil commitment proceedings, finding that to do so violates those persons' substantive and procedural due process rights,” the judge wrote.

The reasons that Alabama officials provided for placing people in jail were similar to Mississippi officials' arguments today. But Mississippi is in a different federal circuit, and the practice there has not been tested with a class-action lawsuit.

A sister of one woman who had died in a Mississippi jail in 1987 tried and failed to convince a federal judge that the woman's rights had been violated when she was incarcerated without treatment.

Mae Evelyn Boston, an Oxford woman who had dealt with paranoid schizophrenia for most of her adult life, had a psychotic episode shortly after giving birth. Her older daughter, Everlean, was 12 years old; she remembers her mother saying she was going to kill the baby because the girl “had a demon in her.”

One of Boston's sisters initiated commitment proceedings — making Boston one of more than 100 people jailed for that reason from 1984 to 1988 in Lafayette County, according to a deposition cited in a 1990 ruling by U.S. District Judge Neal Biggers. When deputies arrived to take her mother into custody for evaluation, Everlean recalled, it took six of them to get her onto the ground before handcuffing her and placing her in the back of a cop car.

Once Boston was in jail, guards did not complete a medical screening required by department policy and didn't know Boston had given birth via cesarean section 12 days before, Biggers wrote. She died two days later from heart failure caused by blood clots.

Everlean Boston remembers her mother smoking cigarettes and listening to the blues on quiet Sundays at home. The day deputies took her mother away was the last time she saw her. “I never got to say goodbye,” she recalled. “I never got to say I loved her. It hurts.”

Biggers concluded that the “medical care customarily provided by the county for mentally ill detainees does not fall below constitutional standards” and that what happened with Boston represented a “scheduling error” and an “isolated instance.” The county, which argued it had provided adequate care for Boston, had the right to detain people like her “in the interest of societal safety,” he found, and those people were not entitled to placement in the “least restrictive alternative” such as a hospital. Biggers considered the Alabama appeals court ruling from a few years earlier, but concluded it didn't apply because it was based on specific facts about that state's jails.

“The court declines to hold that use of jails for temporary detention of persons awaiting civil commitment proceedings is unconstitutional per se,” Biggers ruled.

Since then, at least nine lawsuits have been filed over the deaths of Mississippians incarcerated during civil commitment proceedings. None of those lawsuits directly challenged the constitutionality of being jailed during the commitment process. The U.S. Supreme Court has not ruled on the matter, academics and attorneys with expertise in civil commitment said.

In the years after Boston's death, Mississippi continued to stand out.

In 1992, the National Alliance for the Mentally Ill and Public Citizen's Health Research Group conducted a national survey about the practice of jailing mentally ill people.

Almost a third of city and county jails in Mississippi responded. About 76% of respondents said they detained people who had not been charged with a crime and were awaiting an evaluation, treatment or hospitalization for mental illness. That was the second-highest percentage of any state in the country and far higher than the national average of 29%.

An unnamed Mississippi jail official said in the organizations' report that jails were a “dumping ground for what nobody else wants.”

The report gave its “Worst State Award” to Kentucky, where 81% of responding jails reported holding people without criminal charges for mental evaluations.

Two years later, Kentucky's legislature voted unanimously to ban the practice. The state health agency and its federally designated disability rights organization told Mississippi Today and ProPublica that Kentucky jails today are not used to hold people without charges awaiting mental health evaluations.

Few States Compare to Mississippi

Officials with the Mississippi Department of Mental Health emphasize that they do not support the practice of jailing people during the commitment process. But a spokesperson said they “have heard anecdotally from other states regarding challenges of individuals waiting in jail.”

Nationally, even basic data like the number of people committed each year is elusive. After reviewing some of Mississippi Today and ProPublica's findings, the Treatment Advocacy Center, a national nonprofit that advocates making it easier for people with mental illness to get treatment, started planning a project to understand how often people are jailed without charges during the commitment process across the U.S.

Mississippi Today and ProPublica contacted agencies overseeing mental health and disability advocacy organizations in every state to find out whether Mississippi is an outlier. It is.

Respondents in 42 states and the District of Columbia said they were not aware of people being regularly held in jail without charges during the psychiatric civil commitment process. In a handful of those states, respondents said they had seen it once or twice over the years.

In two states, people can be sent from state psychiatric hospitals to mental health units inside prisons. In a few others, respondents said they had seen people jailed for noncompliance with court-ordered treatment for mental illness or substance abuse.

Respondents in three other states — Alaska, South Dakota and Wyoming — reported that people sometimes are sent to jail to await psychiatric evaluations, but the information they provided suggested that it happens to fewer people, and for a shorter period, than in Mississippi.

In 2018, staffing shortages at the Alaska Psychiatric Institute caused people to be held at the Anchorage Correctional Complex until they could be evaluated. The next year, an Anchorage judge ordered an end to the practice except in the “rarest circumstances,” finding that it had caused “irreparable harm.”

A subsequent settlement declared that jails shouldn't be used unless no other option was available and that such detentions should be as short as possible.

But detentions do still occasionally happen in the state when people in rural areas await transportation to an evaluation center, said Mark Regan, legal director at the Disability Law Center of Alaska. According to the Alaska Department of Family and Community Services, people awaiting evaluation were held in jail 555 times from mid-2018 through late February 2023.

Across South Dakota, people without charges sometimes have been held in jail during the commitment process, according to law enforcement agencies and Disability Rights South Dakota, but such holds are limited by law to 24 hours; in Mississippi, the vast majority of cases analyzed were for more than 24 hours. The South Dakota Department of Social Services said it doesn't track how often it happens and declined to answer questions.

And in Wyoming, a person can be held in jail for up to 72 hours on an emergency basis before a hearing, but they must have a mental examination within 24 hours. Such holds in jail have occurred “in very rare circumstances,” according to the state.

Attempts to constrain the use of jails date back at least to 1950, when the federal government sent governors model legislation that limited the incarceration of people for mental illness to “extreme emergency” situations. The National Institute of Mental Health called incarcerating such people “among the worst of current practices.”

Some states adopted the legislation. Mississippi did not.

This article first appeared on Mississippi Today and is republished here under a Creative Commons license.