In the small town of Polson, Montana, a grim reality unfolds. When someone accused of a crime needs mental health support, they often end up in a tiny, isolated jail cell. This is not a rare occurrence. Many people find themselves in this situation, waiting for a spot in the state's psychiatric hospital. The cells are small, roughly 30 square feet, and the conditions are harsh. Some inmates stay in these cells for months, not convicted but not stable enough to be released. They sleep on narrow cots next to toilets, with only a fluorescent-lit hallway visible through a small window.

The Lake County jail has two of these isolation cells. Last year, a man spent 129 days in one, waiting for a bed at the Montana State Hospital. Another man, in the next cell, faced daily stints in the jail's emergency restraint chair, a steel contraption with straps for shoulders, arms, and legs. He experienced psychotic episodes and often asked to be locked in the chair until his screams subsided. The jail's mental health doctor saw him regularly, but the episodes continued.

This situation is not unique to Polson. Across the U. S. , nearly half of the people in local jails have a mental illness. In Wyoming, more than half of the sheriffs reported housing people in crisis awaiting mental health care for months. Nevada has struggled with this issue despite imposing daily fines for delayed treatment. In Montana, counties jail mental health patients when the state hospital is full. Many people arrested for minor crimes end up in jail for months, their mental health worsening.

Montana officials have known about this problem for years. The state hospital has 270 beds, but staffing shortages can reduce that number. The Montana Department of Public Health and Human Services backed bills to shield the state from liability for delays when the hospital is full. They also announced grants to help set up jail-based mental health stabilization services. However, counties say the necessary local services do not exist.

The number of inpatient beds for people with serious mental illness has decreased nationwide. The intended fix, local homelike centers, has not filled the void. One of Montana's biggest providers, Western Montana Mental Health Center, had to close some of its crisis sites due to money problems. Governor Greg Gianforte has promised to invest in rebuilding the state's behavioral health system, but mental health workers in small towns find such promises hard to trust.

Lake County is known for its natural beauty, but it also faces significant mental health challenges. Vincent River, the jail's sole mental health clinician, has worked there for 25 years. He is often unavailable because he is the only psychologist in four counties evaluating whether a person in jail needs psychiatric care. Some people are released without care if they linger too long on the state hospital's waitlist. River tries to stabilize people while they are jailed, but the jail cannot force someone in psychosis to take medication without a court order and a qualified doctor.

The jail's conditions are poor, with lawsuits filed due to overcrowding. There isn't even space for the jail's restraint chair, so strapped-down prisoners are left in a hallway or locker room. Many gradually get better and leave isolation, but some do not. They languish, psychotic and lonely, at the mercy of their voices. Locals are working to fill some gaps, but someone truly in crisis has only two options: jail or an emergency room.

The emergency room at Providence St. Joseph Medical Center in Polson leaves patients isolated and without privacy. Those who deteriorate enough to be deemed dangerous are sent to jail. Dr. Rebecca Bontadelli, an ER physician, said patients can be housed in the room for days as staffers search for an open psychiatric bed. Some reject care in the meantime, feeling like they are in prison.

Locked Away: When Jail Becomes the Mental Health Ward

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