Adrian Perez hobbles into the courtroom in leg chains and jail slippers. He sits. He pokes at his black beard. He rocks.

He’s 34 years old, and he knows he has schizophrenia. He knows he hears voices no one else can hear.

He wants to get better but he doesn’t know how to get better.

Instead, he cycles in and out of the Cochise County justice system. He’s been locked up in the county jail at least 16 times in 13 years. He’s been charged with misdemeanors like shoplifting or disturbing the peace, which are handled in justice court, and he’s also been charged with two felonies in Cochise County Superior Court. One case, in which he took a neighbor’s truck for a joyride, was dropped because of Adrian’s mental illness. Today he’s facing a second felony charge for allegedly stealing an auto part.

This time around, he’s been isolated in solitary confinement in the jail for 23 hours a day for close to two months. There is no doubt, his family says, that solitary is making Adrian sicker.

Confining people with serious mental illness (often shortened to SMI) in jailhouse solitary cells has been repeatedly identified by correctional officials, advocates and psychiatrists as detrimental and cruel. But because there’s no aggregate reporting system in place no one knows exactly how many people with mental illness are confined to jailhouse solitary cells – or for how long. And in many county jails the practice persists.

Adrian welcomes court hearings because they get him out of solitary. On this September morning, Adrian is in Cochise County Superior Court, charged with stealing a device that measures the working speed of an engine, called a tachometer, from an auto parts store. The tachometer cost $112.29. Adrian sold it for five bucks to buy cigarettes. He is charged with trafficking in stolen property.

Because Adrian has been found incompetent by psychiatrists to stand trial due to his mental illness, Judge Tim Dickerson might later drop the auto part case. But first the lawyers have to file papers and the judge has to issue rulings. That could take weeks.

The art-deco style court building is nearly a century old. The courtroom has tall, geometric windows and rows of small, uncomfortable chairs. Adrian stands behind a wooden podium with his public defender and addresses the judge.

“I want to get help as soon as I can,” Adrian says.

A white-bearded bailiff ushers Adrian out of the courtroom. Adrian’s accustomed to walking in shackles, but he’s lost a lot of weight lately and yanks up his baggy red-and-white-striped pants with his cuffed hands, which gives him a lopsided gait.

In a few hours, he’ll be back in solitary at the Cochise County jail, getting sicker.

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Independent Lens Stories for Justice, in collaboration with the Arizona Center for Investigative Reporting, present Out of Sight, Out of Mind – an independent film about mental healthcare in rural America.

Directed by James Burns, Produced by Chris Herde.

Small County Jails A Dumping Ground

To report Adrian’s story, the Arizona Center for Investigative Reporting examined hundreds of pages of court and police records and reviewed government reports and research papers from correctional groups and nonprofits that advocate for people with mental illness who end up in jail. The Center attended community criminal justice coalition meetings, reported on proceedings in the Cochise County jail and Cochise County Superior Court, and interviewed Adrian, his family, his jailers, county and state health professionals, advocates for people with mental illness, psychiatrists, lawyers and judges.

Despite decades of reform efforts on behalf of people with SMI, small county jails and their solitary cells remain a neglected dumping ground for this vulnerable group of Americans.

Few want them there. Not their families. Not their jailers. Not the lawyers who have filed class action lawsuits throughout the nation intended to reform prisons and jails for people with SMI. Not the state legislators scattered across the country who have passed laws limiting solitary confinement. Not the advocates, judges, lawyers, behavioral health providers and county correctional officials who are trying to figure out new ways to keep people with SMI out of county jails.

Expensive reform efforts – class action lawsuits, court diversion programs, state laws – often aim to fix the problem after, not before, the person with mental illness has entered the criminal justice system. And the reforms often target prisons while neglecting the large numbers of people with mental illness confined in smaller American jails.

While people with SMI make up about 4.6 percent of the nation’s adult population, they make up about 20 to 26 percent of jailhouse inmates. They’re booked into jails about 2 million times a year, stay longer, and are more apt to return to jail.

The average jail stay is less than a month. But inmates with SMI who live in poverty and can’t pay their bail, like Adrian, can stay for several months or even a year. And if they can’t adjust to the general jailhouse population, if they are at risk of hurting themselves or other inmates, many end up in solitary confinement, where their SMI often worsens.

“The largest behavioral center in the county is my jail and that is common in most rural communities in the United States,” Cochise County Sheriff Mark Dannels says during an interview in the sheriff’s substation in Sierra Vista in September.

The population of Cochise County is about 126,770, scattered across 6,000 or so square miles of high desert and sky island mountains. Mental health services are hard to access in remote rural areas – so much so that in a recent health assessment, county residents singled out mental health and substance abuse treatment as the top health priority.

The southern stretch of Cochise County flanks the Mexican border, and Dannels is known nationally as an immigration hardliner. He’s a stocky Midwesterner, 55 years old, who settled in Cochise County after a stint in the military.

“Are we helping them or hurting them? I will tell you right now we’re hurting them.”

Mark Dannels, Cochise County Sheriff

Dannels is the first to admit jail is no place for a person with mental illness. He’s trying to collaborate with county mental health advocates, the courts and providers to come up with ways to keep people with SMI out of his jails.

These are “severe mental health folks,” Dannels says. “Are we helping them or hurting them? I will tell you right now we’re hurting them.”

He rubs his forehead. “But what else do we do?”

“In the general population, they’re assaulted or picked on,” he says. “These are the severe ones that take their clothes off, that are smearing feces on their bodies, I don’t have a place to put them.”

Solitary was part of a well-intended reform movement. American jail and prison administrators began replacing corporal punishment with solitary confinement more than a century ago. It sounded so much kinder. But it didn’t take long to see the harmful impact of solitary on inmates, especially inmates with serious mental illness.

The federal Bureau of Prisons claims to have limited the use of solitary in its prisons. But the Office of the Inspector General for the U.S. Department of Justice found in 2017 that some inmates with mental illness remained in solitary cells.

Some state prisons, including those run by the Arizona Department of Corrections, have been forced by class action lawsuits to limit solitary for people with SMI.

Jeffrey Metzner, a forensic psychiatrist who teaches at the University of Colorado School of Medicine in Denver, and a nationally recognized expert on correctional mental health systems, says isolation often exacerbates serious mental illness. It reinforces abnormal social interactions, increases social withdrawal, and heightens the risk of suicide, he says. In the “worst places,” inmates have “so little control of anything,” he says, they smear or throw their feces so detention officers will “feel as helpless and angry as they feel.”

Public policy change in this arena traditionally comes from litigation, but that’s slowly changing as states start to limit the use of solitary. Most efforts focus on state prisons, and largely ignore jails. Eight states this year passed laws limiting solitary confinement. Arizona is not one of them. In 2015, the American Civil Liberties Union backed a bill requiring Arizona prisons to keep records on the solitary population. That bill died. And this year, a bill seeking to limit solitary confinement of pregnant and postpartum women prisoners also failed.

While policymakers debate solitary, Adrian keeps ending up there.

“I don’t know why,” Adrian says. “I don’t know why they do it.”

A Devil Inside Him

Once, a horse kicked Adrian Perez in the head. He was visiting his grandparents on their ranch in the Mexican state of Chihuahua, and the horse spooked at something and ran right over Adrian, then a small boy. After his grandmother wiped off the blood, Adrian seemed fine.

Adrian’s brother Richy, only a year older than Adrian, took it harder than anyone. Richy felt obligated as the big brother in his Mexican-American family to take care of Adrian.

The boys’ father, Blas, was a Mexican farmworker who settled in eastern Cochise County after obtaining legal permanent residency in the United States. Their mother, Blanca, mostly raised the four kids, Richy, Adrian, Eric and Ana.

Blas bought land in Winchester Heights, a remote farmworker community about 15 miles outside of Willcox. On weekends, the boys mixed cement and carried construction blocks as their father built the family a three-bedroom house. The family moved in after Blanca was diagnosed with terminal lung cancer. As the eldest, Richy promised his mother he’d always take care of his siblings.

After Blanca’s death, Adrian seemed more withdrawn. When his dad told him to straighten his room or clean the yard or do his homework, Adrian either talked back or broke things.

Looking back on it, Eric says, the family “didn’t understand mental illness very well.”

Richy joined the Army National Guard, but took care of Ana and Eric when his father and Adrian moved briefly to El Paso. In Texas, Adrian was certified as a bilingual electrical assistant, and Blas went to trucking school in hopes of earning more money.

A few months later, in 2004, Blas died in a trucking accident.

Richy quit the National Guard and worked in the fields near the house he had inherited from his father. Richy was 21, old enough, he thought, to take full responsibility for Eric, 14, and Ana, 12. Adrian tried to help but couldn’t hold down a job for long.

Adrian’s mental illness remained undiagnosed for years. None of the siblings remember when, exactly, Adrian started hearing voices. One insulting voice, which Adrian called “Tony,” made home life even more chaotic. Adrian episodically screamed at Tony while batting at the air and throwing things.

Ana thought Adrian had a devil inside him.

Adrian, left, is shown with his brother Richy in this undated photo from their childhood. Photo courtesy Richy Perez

The undiagnosed schizophrenia likely caused Adrian to chase four people up and down a Willcox street in 2006. No one was hurt, but someone called the cops, who tackled Adrian, shackling his legs and cuffing his wrists. In the back seat of the patrol car, Adrian panicked, slamming his head repeatedly against the door and bars in front of the window.The officers turned on the siren and lights and hightailed it to a small county jail annex in Willcox. When they forced Adrian into a restraint chair, he fought even harder, breaking a staffer’s prescription glasses.

Adrian pleaded guilty to criminal damage and resisting arrest, promising to pay $135 for the broken glasses. And he spent three months in jail, in part because he couldn’t pay his $3,000 bail. He didn’t pay his mounting justice court fines, and failed to appear in court to explain why.

When Adrian came home from jail, he often walked 15 miles from the house in Winchester Heights to Willcox. If Adrian didn’t return home, Richy says, he automatically called the Cochise County Jail, figuring his brother was there.

One day in 2008, Adrian walked into a neighbor’s yard, and, right in front of him, drove away in the neighbor’s red Nissan pickup. Sheriff’s deputies arrested Adrian on a felony charge – knowingly taking unauthorized control over a means of transportation – and a misdemeanor, criminal damage.

In a way, it’s the best thing that could have happened, because it led to his schizophrenia diagnosis. Adrian’s public defender requested a so-called “Rule 11” psychiatric examination to see if Adrian was mentally competent to stand trial for the felony charge in Cochise County Superior Court. He wasn’t, a psychiatrist said. He smiled inappropriately and couldn’t communicate in any meaningful way. It was suggestive of psychosis.

A judge sent Adrian to the Arizona State Hospital in Phoenix to see if he could be “restored to competency” in order to stand trial for taking the red Nissan. This is a common practice in both federal and state courts. Advocates say it benefits the criminal justice system, not the person with mental illness, who can spend six months being “restored” while not getting appropriate, sustainable mental health care.

Still, Adrian finally had a diagnosis – “Schizophrenia, Undifferentiated Type” – at least three years after he showed symptoms of the illness. Richy, who’d long wondered if the horse kick had caused Adrian’s bizarre behavior, began to realize his brother had a complicated condition likely spurred by genetic and environmental factors.

Adrian understood he had schizophrenia, but he thought the doctors could fix it.

Arizona State Hospital psychiatrists tried different combinations and doses of medication to treat Adrian’s psychosis. Even so, staffers noted Adrian was often “confused and internally preoccupied.” After six months, the doctors could not restore Adrian to competency.

A Cochise County Superior Court judge dropped Adrian’s 2008 felony charge for taking the neighbor’s truck on a joyride.

Rifles border the Cochise County Sheriff’s seal on a wall at the department headquarters in Bisbee, Arizona. Photo by Terry Greene Sterling/AZCIR

Driving 90 Miles For Treatment

Adrian’s siblings say they often tried but couldn’t always get him necessary mental health services.

Because Adrian was poor and lived with a serious mental illness, he was entitled to community-based mental healthcare paid for by Arizona’s Medicaid agency, AHCCCS. It should have included, among other things, psychiatrists, meds, counseling, caseworkers, therapy, skills training, transportation, supported employment, personal care services and family and peer support.

That’s the sort of “community based mental health care” that a young lawyer named Chick Arnold envisioned for people with SMI when he filed a class action lawsuit against the state of Arizona and Maricopa County in 1981. Arnold v. Sarn was settled in 2014, and helped force the state of Arizona to provide comprehensive community mental health care to people living with SMI.

But mental health experts, family members and advocates say the care is difficult to access in rural Arizona – including Cochise County.

When Arnold hears about Adrian’s case, he calls it “dreadful.”

He’s pushing for more oversight to ensure people with SMI get the care they are entitled to.

Adrian and others like him in rural counties can run into frustrating roadblocks. In Cochise County, public transportation is limited. The county currently has three full time practicing psychiatrists – and they’re all in Sierra Vista. People with SMI sometimes get treated by psychiatrists who don’t reside in the county but provide “telemedicine” via video screen, or by onsite nurse practitioners. The county has two in-patient mental health treatment centers with a total of 38 beds. Behavioral health providers change titles and alliances, making it difficult for people with SMI to access help.

“We go through [behavioral health] providers down here kinda like disposable napkins. They come and go, come and go,” Sheriff Dannels says.

Because Willcox, a railroad and cattle ranching town, only has about 3,500 residents and limited mental health services, Eric and Richy have driven Adrian to appointments in places as far away as Safford (a 90-mile round trip, in Graham County) and Benson (a 68-mile round trip).

When Adrian was in jail, he got his antipsychotic meds from the Cochise County Health Department. When he was living at home, Adrian was back on AHCCCS. Sometimes, Adrian ran out of medicine. Caseworkers came and went. And Richy says Adrian was never offered job training or supported employment. Adrian wanted to work in the fields, Richy says, but no one would hire a guy with schizophrenia.

Eventually, Ana and Eric left home. Richy stayed – and struggled. He worked. He drank. He worried about Adrian.

Richy and Adrian built a small shed in the backyard. Adrian called it his “cabin” and spent hours in it, taking apart electrical gadgets and listening to Cypress Hill belt out songs like Insane in the Brain.


Adrian’s “cabin,” where he listened to music and tinkered with electronics, is shown here in 2019. Photo by Terry Greene Sterling/AZCIR

For a while, Adrian was under court order to get “Title 36” outpatient mental health treatment. Usually, this type of court-ordered treatment lasts a year. Adrian was compliant, getting AHCCCS-funded meds and therapy in nearby Willcox, and was staying out of jail.

Then Richy checked into a six-month rehab program in September 2018. A social worker placed Adrian in a group home in Douglas, but he ran away. He began living on Willcox streets. He was not complying with the court order to get outpatient treatment.

Three months later, Adrian allegedly stole two Steel Reserve beers and a bottle of Kung Fu Girl wine from the Safeway in Willcox. He sat outside of the grocery store drinking wine and yelling at customers. A Willcox police officer arrested Adrian on 10 misdemeanor charges – including two counts of disorderly conduct, criminal nuisance, littering, shoplifting, criminal damage, obstruction of government operations, drug paraphernalia use (the cop found a meth pipe nearby), escape in the second degree and consumption of liquor in public.

When police went through Adrian’s backpack, they discovered he’d stolen food and a pair of socks from a nearby store. And he’d swiped a medical alert display and two surgical prep packs from the local hospital.

Adrian pleaded guilty in Willcox Justice Court to shoplifting and agreed to pay $676 in restitution. Then he was released from the Cochise County Jail to Sonora Behavioral Health Hospital in Tucson to continue mental health treatment.

But for reasons that aren’t clear in the records, Adrian left Sonora Behavioral Health about a month later. That’s when he allegedly stole the tachometer and got charged with the felony. Adrian returned to jail. He couldn’t pay his $3,500 bail as he awaited a resolution of his auto part theft case.

Adrian stayed in jail for six months. He was released in July for yet another court ordered stay at an inpatient mental health facility – this time at Community Bridges in Benson. This time, Adrian had agreed to get treatment as part of a “mental health diversion program” that would spring him from jail. But Adrian ran away, the facility reported. It was the second time that he’d refused court ordered treatment.

Adrian was on the streets for a few days, then made his way back to Richy, who was fresh out of rehab. The brothers lived together at home for about a week. But because Adrian had violated his agreement with the court to get mental health treatment at Community Bridges, a deputy took him back to jail – and solitary.

The New Asylums

People with mental illness have ended up in American jails since the mid-twentieth century, when a nation-wide “deinstitutionalization” of asylums began. Those asylums had been created in the early nineteenth century, in part to rescue people with mental illness from abusive jails and prisons, former Washington Post reporter Pete Early writes in his 2006 book, Crazy.

For months, Early, who has a son with SMI and has become an advocate for people with mental illness, embedded himself in the county jail in Miami, Florida. “Our jails and prisons have become our new asylums because there is nowhere else for the mentally ill to go,” he concluded.

The Cochise County Jail, a complex of brown and white buildings topped with razor wire, sits at the end of a road that winds past black cattle grazing beneath a cluster of thorny desert mesquite trees.

Each time Adrian goes to jail, he enters the booking area. He is patted down. He changes into his jail uniform in a small adjoining room with benches and a toilet. Once dressed, he puts his hands on the wall, kneels on a bench, and allows his restraints to be put on. Then he is photographed, fingerprinted, and a white medical bracelet with a computer code is attached to his wrist. He generally starts out in the general population. But his behavior, or the behavior of other inmates who torment people with SMI, lands him in solitary, the only place his jailers say they can keep him safe.

The jail was built back in the early 1980s, and is cramped and poorly designed. Detention officers are forced to do their paperwork in the hallway. The jail is loud, too. During a recent tour, Kenny Bradshaw, the jail commander, says staffers call the clang of slamming metal doors “thunder.”

The plumbing is faulty. The elevated inmate exercise courtyard leaks rainwater into the jailhouse. The inmate commissary is no bigger than a closet. And the bleak special handling unit with six solitary cells was designed to punish the most dangerous inmates, not people like Adrian who can’t think straight.

The jail tour doesn’t include the solitary pod. Bradshaw says the pod smells of feces and a guy in one of the pods is in a highly agitated state. A visitor would only make him worse.

There is a tiny room where a detention officer monitors real-time videos of the solitary cells, and one screen shows Adrian. He’s moved his mattress against his door and is lying on it in a fetal position.

“A lot of our maximum security cells were used for very dangerous combative assaultive inmates,” Bradshaw says. “We can’t use those cells for those kinds of inmates anymore. A lot of time we have to put mental health inmates in there because they’re so disabled they can’t survive or be put in general population…I don’t think we’re doing them any good by doing that.”

It doesn’t help that the family of an inmate with SMI who killed himself in 2018 sued Dannels and the county for the inmate’s alleged wrongful death. The inmate had been in solitary, but Joel Robbins, his attorney, is unsure whether he was in solitary when he died. (Dannels and the county haven’t responded to the lawsuit, filed at Cochise County Court in September.)

The jail itself can house up to 250 people. These days, about 30-50 inmates on any given day in the jail “really need psych services,” Bradshaw says. The Cochise County Health Department provides in-jail mental health treatment, including meds prescribed by a psychiatrist via a video monitor. But even the sickest inmates have the right to refuse treatment unless the court orders it.

Adrian, left, poses for a photo with his brother Richy after running away from a mental health facility in July 2019. Photo courtesy Richy Perez

Reaching Out

Because lawsuits and state laws haven’t been more effective in limiting the numbers of seriously mentally ill inmates in jails, counties are trying to figure out solutions themselves.

Of the nation’s 3,141 counties and county equivalents, 507 counties, including all of Arizona’s counties, have joined Stepping Up, a national initiative that aims to keep people with SMI out of jail. The initiative, set up by the American Psychiatric Association Foundation, the National Association of Counties and the Justice Center of the Council of State Governments, encourages data collection, stakeholder collaboration and measuring results.

Pretty Yavapai County in north central Arizona, where almost a quarter million residents share more than 800 square miles of grasslands, mountains and yellow pines, has come up with a model program with measurable results.

In 2015, Sheriff Scott Mascher and his chief deputy, David Rhodes, decided to come up with a way to keep inmates with SMI out of the county jail.

They knew they couldn’t do it alone. They huddled with health care providers, other law enforcement agencies, court and housing officials, social workers and family members, among others. Today, the Yavapai Justice and Mental Health Coalition focuses on community-based treatment aimed to keep people with mental illness out of jail, and, if that isn’t possible, to collaborate on in-jail and post-jail mental health treatment plans to reduce recidivism. But it’s expensive.

By 2018, the sheriff and his team had hustled together a total of about $2 million from the Arizona Legislature, the Department of Justice and the Yavapai County Attorney’s Office for their Reach Out Initiative. That should last three years.

Northern Arizona University measured 2018 results.The university reported 1,104 people were diverted from entering Yavapai County jail. Bookings declined by nearly 10 percent.

But in Cochise County, collaboration hasn’t been as successful. Superior Court Judge Laura Cardinal, who sees people with mental illness cycle in and out of her courtroom, jail, and mental health evaluations, blames it on “bureaucratic siloing.”

“Everyone agrees we need to develop solutions,” Dannels, the Cochise County sheriff, writes in a text message to the Arizona Center for Investigative Reporting. He thinks he’s got one – taking over a section of the nearly empty Cochise County Juvenile Detention Center. He hopes to move jail inmates with mental health issues into a secured wing of the detention center where they can get treatment. He’s working with county leaders to see if they can “move that needle.”

Out Of Solitary, For Now

One day in late October, Adrian calls Richy on the phone. Adrian is out of solitary, out of jail, and in Canyon Vista Medical Center, a hospital with a locked mental health floor in Sierra Vista. It’s more court-ordered treatment.

Adrian says he’s getting shots that make the voices easier to deal with.

Richy hasn’t heard Adrian sound this good in several years. Richy is 36 now, and hasn’t had a drink in over a year. He’s married, goes to church and feels his life is finally coming together. But he never forgets his brother.

Sometimes Adrian calls Richy twice a day.

On one of these calls, Richy patches in the Arizona Center for Investigative Reporting. Adrian slurs his words and talks fast all at once. His voice is surprisingly deep.

Does he still hear Tony the bad voice?

“Yea, yea,” Adrian says. “Sometimes when I go to bed I understand that he’s here…They [the voices] are kind of mean they’re kind of scary but I can deal with it.”

He says if anyone needs electrical work, he’d be happy to do it.

And then it’s time for dinner, and he hangs up.

A few days later, a hospital social worker calls Richy. Adrian assaulted somebody. The details aren’t clear. Maybe it was in the hospital. Maybe it was on the way to another court hearing.

Now Richy doesn’t know where Adrian is. He calls the jail over and over.

Then he finds out Adrian is back in the hospital.

At least Adrian is safe and out of jail, Richy thinks.

For another day.

This article and film collaboration were supported by a grant from ITVS.

Adrian Perez is shown in this 2019 booking photo from the Cochise County jail. Photo courtesy Cochise County

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Terry Greene Sterling, editor at large for AZCIR, is a Phoenix based journalist and book author whose work has appeared in magazines and newspapers throughout the U.S.