A man bound hand and foot struggles to sit upright and hollers, “This is inhumane!”

Another pulls his knees to his chin and, wide-eyed, whispers about telekinesis and the CIA.

“Someone cut off all my toes,” a third man with scars streaking his face says quietly. “I’m so glad I’m finally in the hospital.”

But this isn’t a hospital.

The Cook County Department of Corrections in Chicago is one of the largest single-site pre-detention facilities in the world, with an average daily population hovering around 9,000 inmates. It is estimated that 35 percent of this population is mentally ill.

According to a May 2015 report by the National Alliance on Mental Illness, Illinois cut $113.7 million in funding for mental health services between 2009 and 2012. Two state-operated inpatient facilities and six City of Chicago mental health clinics have shut down since 2009. The report goes on to detail that Governor Bruce Rauner’s 2016 budget proposal to slash $87 million of funding for mental health services could cause an estimated 16,533 adults to lose access to care.

Emergency room visits for patients having a psychiatric crisis increased by 19 percent from 2009 to 2012. A 2013 report by Illinois mental health care provider Thresholds found that the increase in ER visits and hospitalizations resulting from the $113 million budget cuts cost Illinois $131 million—almost $18 million more than the original “savings.”

Now more patients than ever are being treated in jail rather than at a mental health facility. Cook County Jail has become one of the largest, if not the largest, mental health care provider in the United States. The Cook County Sheriff’s Office estimates that it costs $143 per day to house a general population inmate. But when taking into account the treatment, medication, and security required to incarcerate a mentally ill person, the daily cost doubles or even triples.

When people are arrested—even before they visit bond court—within hours they are interviewed by social worker Elli Petacque-Montgomery and her team to screen for mental illness, a procedure unique to Cook County. Among the 60 people screened for mental illness on November 10 of last year after their arrest, 63 percent of women and 37 percent of men were considered mentally ill. Five had previously been involved with the Department of Children and Family Services, often indicating childhood abuse or neglect.

Petacque-Montgomery’s team quickly assesses crisis situations and immediately places acutely psychotic, violent, or suicidal arrestees in single cells away from other inmates. People who are psychotic are then sent to CERMAK, the jail’s division for physically ill and acutely mentally ill patients. Those with minor mental illness are sent to Division Two, Dorm Two, where they live in dormitory-style bunk beds instead of cells and receive therapy and medication.

After being diagnosed with mental illnesses when they were arrested, the four men interviewed below—Milton, Daniel, Tommy, and Andrew—were all serving time and receiving treatment in Dorm Two.

Tommy: Serving time for driving on a revoked/suspended license, driving under the influence

This would be my 11th time in Cook County. Why am I here? They say because anxiety. So I take anxiety pills…they help; they help a lot. I used to be a lot more antsy…I think this was diagnosed when I first came in. I think, but I’m not even sure, you know? I wasn’t even paying attention to what they were asking. I was just answering them, and I ended up here.

Our counselor has been very helpful. She’s very professional, very attentive to every single one of us. From day one she tells us this is a family and everybody gets treated as a family…. I thank God for her.

Growing up in Chicago…we go through a little phase I would say trying this, trying that…but I never really stuck to drugs. Alcohol, oh, that’s everywhere, so I just had a little bad luck getting caught driving a little intoxicated….

This program…everybody’s trying to go home, everybody’s trying to work on their problems, their behaviors. They’re giving you the help, so the last thing on everybody’s mind is going back to your old behaviors.

I get real frustrated real quick, but now I know what the problem is. So when I get out of here I’m going to go to the doctor and continue my pills because it helps me a lot….I thank God that Cook County has this opportunity where we can take our pills.

Being in jail, the littlest thing would get me frustrated—like commissary wouldn’t come on time; stupid things, like why is that officer screaming? I know it’s her job, but little things, you know? Like why can’t I watch this TV show? But as you get older you start to notice you can’t have it your way and this program here teaches us that. Before, I would break things, like a dummy, break things or scream out, lash out. And that would get me into trouble….But now, I’m OK. Thank God I got diagnosed.

This division of the jail, this is Hotel California right here—you can’t get no sweeter than this. This is the best one here. Other parts of the jail…you got some people who think they can handle everything by pushing people around…so if you don’t know anything about that you tend to get taken advantage of….A lot of people here, this is their first time in jail and they think this is Cook County. It’s not. I try to tell them, you think this is bad? Make this your last because this is nothing, this is the tip of the iceberg.

Daniel: Serving time for possession of heroin

I’ve probably spent three years of my life in jail. When I was 17 I did 18 months straight. I’ve been through the prison system a few times….I was in the youth homes when I was a kid, first time was when I was 13. So I’ve been through the system a little bit.

They got me on antidepressants. They got me on Prozac, so that got me over here. When I was a kid, when I was 11 or 12, they put me in a psych thing. There was a lot of shit going on with my family…they thought I was depressed so they put me on psych meds and I’ve been off and on that for years.

I would like to stay clean. I think I have a good shot. I want to stay clean. I think I can do that.

If you’re in a regular tier, especially in County, there would be a lot of gang-banging and shit like that. It’s not like that here. There’s a lot of young kids over here, but at least I’m away from the noise and the gang-banging. It’s my first time being in treatment in jail like this. It’s different. It’s better than being in a cell because you can move around a little bit.

A lot of people in the treatment are addicts. A lot of people in the jail population are too, but they’re not copping to it. There’s a lot of drug addicts where I’m at.

I’d like to get out of Illinois when I finish my probation. I’ve just been in trouble here for so long. I think it’s time to go.

Andrew: Serving time for possession of a controlled substance

I’ve been diagnosed with depression and anxiety disorders, so I take meds for those things. I was diagnosed many years ago and I was looking for treatment and I was having trouble finding it, so I was self-medicating with alcohol.

My sister is my only family that has ever been supportive of me. I’m estranged from my father—he remarried after my mom died. I wrote him a letter when I got in here, telling him what had happened and where I was, and I never heard anything from him.

I got a letter from Social Security saying that they found out I was incarcerated and they had stopped my payments and that I was responsible for paying them back for the four months that they had paid. So they first thing I have to do when I get out of here is go to the Social Security office and get that fixed.

I’ve heard different stories about whether mental health problems could be hereditary or bloodline or something like that but I have no way of knowing because I’m adopted. So it could be in my biological history but I’ll never know.

I was getting medication from a place called the Ecker Center, but I couldn’t get the medication that I wanted. They tried a few different meds on me and they didn’t work so I just gave up.

Jail is jail, but I’d rather be in this situation than in the general population. This is easier to cope with than being locked in a cell, so I’m grateful for that.

Milton: Serving time for theft of lost or mislaid property

I’m from Dallas County, Alabama, but I was born and raised here in Chicago, on the South Side. I stay in trouble, been in trouble since I was young, you know, pretty much led me here.

When I got here, the psych nurse had me come down and talk to her, asking me what’s been troubling me, what’s been troubling me all my life…She gave me a med, I don’t know what it was…but it kind of brought me down. Being in that program down there, ooh, it’s an experience. It’s an experience.

I’ve been in jail quite a few times, all right. I’ve watched this place change. It used to be like, back in the days when you come in here you had to fight your way through this place. Either the officers will beat you up or you fighting the gangs. If you’re not in a gang, that’s bad for you.

I don’t even know how many times I’ve been to jail. Can’t remember my disabilities….The lawyer asked me that and I said, ‘I don’t know, I really don’t know.’ It’s been so many times. After high school it went downhill. I signed up for the Marine Corps, didn’t make it through that, and it’s been…downhill, I mean hard as I try, just downhill.

Our parents got sick and they died at an early age, both of them, they died like a month apart….I remember it like it was yesterday. I couldn’t have been no more than five or six; we’s at the grocery down the road, we lived out in the country down in Alabama, way out in the woods, and we came back home, and mama had her eyes open. She was laying there with her eyes open. My dad couldn’t take it. I guess he just….One morning we had to go to school and he had threw up everywhere; took him to the hospital and he was gone, we didn’t see him no more. First thing came to my mind was, what’s going to happen to us?

My oldest sister brought us here to Chicago, but the brothers and sisters who stayed down there are more prosperous than the ones who came here. Just me and my baby brother came here, and my sister came here…and she was killed. Her husband shot her….I came in, went to my sister’s house…seeing her, there was still blood on the floor.

But you know, you learn to deal with these things, all these heartaches….I’ll be better when I get out of here, though. This is a dead house….It’s like a death trap for me. I got to get out of here.

I know I’m messed up! I’ve been doing the same thing for a long time, you know. It’s hard to stop. I’ve had a psych evaluation before; when I was young, I stabbed a girl in the head with a pen. They asked me why I do that and I said she tried to push me off a balcony….It’s a mad thing. You can be crazy and still function properly and yet you’re crazy. I don’t get it.

I’m on medication here but I don’t know exactly what it is….I’m not a bad person, but if you keep pushing me…you can’t go in the woods and keep pushing an animal, you know.

You got these jails and you can’t do nothing, can’t control nobody. If they start helping the community more, put more useful things in, neighborhood things, it might be different, change. You don’t have basketball courts in the neighborhood no more, you don’t have help keeping them up. Instead of the guns and the policing…you could put a baseball diamond up, teach them on their baseball field.

As soon as I get out I want to get me something to drink and I’ll probably go by the store around my house and get me a nice small steak, and take it home and beat it up, sit down, eat it, take a hot bath and lay back. Get the crazies off my mind.

Elli Petacque-Montgomery: Social Worker, Director of Mental Health Policy and Advocacy at Cook County Jail

It was no surprise that when they closed all the hospitals, the major hospitals in Illinois, and folks didn’t have insurance, that they would end up in here.

The more they closed the hospitals, the more they closed the community mental health agencies, the more that people became uninsured and they lost the case manager in their life—the person to link up, [to tell them] ‘Here’s what you need to do to get your medication, here’s the bus you need to be on.’…Once they cut out constant case management, these people really didn’t have a link to get help and a lot of them lost their housing when they were acutely psychotic and needed to be hospitalized. There were no hospitals to go to, so we ended up with a lot of homeless people in Chicago, mentally ill on the street.

Those people would then, just like anyone else, be hungry and cold and you would see what we call crimes of survival; people that would just show up at the 7-Eleven, they’re thirsty and they’re drinking and there’s a village of voices in their head. They’re disoriented, they don’t know where they are, and the police are called, they’re brought in here.

By the time they get to us, they’ve been off their medicine so long, they’re so disoriented they absolutely don’t know where they are—so they think they’re waiting for the army—or the delusions are so severe they think someone has literally cut their toes off. So our job here is to do our best to advocate on the behalf of those people suffering from mental illness, catch them early and give them resources first thing before bond court and also when they’re in jail.

Our goal is to try to convince people to get help…and at least give them choices, give them emergency numbers to call, to give them a plan to think about, and let them know [that] until they tackle and get help with their mental illness and their substance abuse, they’re going to keep coming back over and over and over again. Our main objective is to try to stop that cycle and to get them help with the limited resources that are in Chicago right now.

People that historically would have gone to public hospitals or state hospitals are ending up here….We are the de facto mental health hospital now. It is far more expensive to try to manage mental illness and handle incarceration at the same time. It’s also counter-therapeutic: to have someone in a cell and then try to do therapy in a jail that holds anywhere from 8,000 to 10,000 people is incredibly challenging.

Someone might need to address post-traumatic stress disorder or their anxiety, their depression, their substance abuse—they’re not going to get that in a jail setting. It’s just not going to happen.

Someone I talked to today said to me, ‘I just can’t afford the meds, they’re too expensive.’ You hear that over and over and over….I look at someone suffering from severe mental illness as someone who has cancer. If we were to say these are all people with cancer, the country would have handled this differently. Or if we were to look at it as diabetes even, everyone would have their insulin. It would be a nonissue. There would be much more care and concern and unfortunately the stigma is still out there. We’re making strides, but we’re not anywhere close to where we need to really make the dent that we need to.

Sometimes I have people that beg me to stay here. I have a female I just interviewed who begged me not to let her out of this jail. Because she’s severely bipolar she will use heroin—which she has been doing for eight years—to deal with her illness. She hasn’t told anyone. She was diagnosed when she was 18 and she’s literally not told her family. If we could keep her in here she would stay, so she could get her meds, not do heroin, and get treatment.

Velma Ball: Correctional Rehabilitation Worker

There’s a lack of help for mental illness in the world; there aren’t as many mental health facilities for people to go to…we’re probably mainly a mental institution now.

In here we need more funding, more help with mental illness, more attention to inmates’ medication and their psychiatric needs. I think in here they’re medicated but they’re not dealt with psychiatrically adequately….We’re not adequately staffed to accommodate the mental illnesses and types of mental illnesses that these people have.

To me, the mental illness in females is a lot worse than males….These people have kids, you know it’s just a domino effect. I think we as women, we are emotional beings, so we need support and I don’t think they get the support here that they probably need to maintain their medication, to become a mother, to hold down a job, to be an effective parent. I think when they become incarcerated they get crushed.

Dr. Dena Williams: Director of Behavioral Health, Mental Health Care Transition Center at Cook County Jail

We try to do as much as we can here; sometimes the treatment that they receive here is more than they receive on the outside, because a lot of the clinics have been shut down. We try our very best to pull in as many resources as we can to try to connect them, and try to also partner with agencies once they get discharged. That’s the key piece—once they get out we want to make sure there is a continuity of care. So we really, really try our best to find those clinics that are still available and give them those resources to tap into once they leave.

There are not enough resources on the outside. We have people who are suffering from a mental illness who decompensate because they don’t have access to medication, and law enforcement might not be trained with how to deal with it, so instead of sending them to the hospital, they get arrested and come to jail.

In an ideal world, money and more resources need to be put into more programs and treatment availability on the outside. There needs to be funding for mental health programs and mental health treatment and access to medication.

Particularly in a city like Chicago, you do see a lot of individuals, both male and female, who come in who have experienced some sort of trauma just living in an underserved environment. If we can do something with the adolescents and the children, I think it would save a lot of people from coming here.

I think it’s very, very important to start outreach to a younger crowd, so even going in a juvenile detention center, offering programs similar to this would really, really help with the lack of resources some of these young girls and boys have. It would be essential for them to receive that help and receive that support, so hopefully they will make different choices and don’t end up in our custody.

Cicely Bailey: Supervisor, Treatment Alternatives for Safe Communities, Court and Probation Services in Cook County

Typically a lot of mental illness is undiagnosed. Sometimes we are lucky enough to catch them and persuade them to get the mental health evaluation, and then stabilize them in every way that we can. But a lot of the mental health problems they self-medicate with drugs.

They need mental health care facilities in place. Otherwise everything is going to peak, as far as crime—recidivists, they’re going to go back to jail—all those things are going to peak again because these people are going to be without care….I’m just scared. I’m scared. I don’t know what’s going to happen, but I foresee a lot of problems.

Have you heard the stories of those that do things to go back in jail just to get the medication they need? That’s the scary part too. I just see the numbers rising in jail or they’re staying in there longer. Sometimes we get an order from the judge that says “release to TASC only,” which means they can’t get out until we find a facility that will take them—and if you can’t find a facility, one week goes by, two weeks go by, so the wait list is going to be long, and then that means they are going to stay in jail longer, which is unfair to the client. We can’t find a place in the community to address their mental health needs so they’re staying in jail….It’s sad.

Gerald Smith: CERMAK Corrections Officer

Working here you have to be comfortable in your own skin. You have to be comfortable being in uncomfortable situations. Patience is a virtue here.

It’s a revolving door here; you’ll see some of the same people numerous times. Some people we know by name, we know by face. A lot of these people that do take meds will have a moment where they feel fine and they think they don’t need them anymore and when they stop taking them, they don’t recognize their behavior, their demeanor, all of it regresses. And then by that point they’re not in their right mind to go back to taking the meds properly.

We’ve had as many as 50 people up here on this unit even though there’s only 24 beds. So we have guys on mattresses on the floor. It’s always full.

The majority of us who work up here have been attacked physically. They need more space here. There are more and more people coming in every day with mental illness.

Printiss Jones: CERMAK Superintendent

We’re in the dark here. The people that are in our custody shouldn’t be here. The state should be ashamed of themselves and the court should be ashamed of themselves.

No matter how many classes you take, it does not prepare you for what you see here. I’ve seen detainee patients so agitated, so upset that you can see them struggling within themselves, the veins are popping out of their neck, you start to worry about a medical crisis—a stroke, something of that accord. We know, we’ve learned that this is not their fault. We know how hard this is. This is heartbreaking; this is heartbreaking stuff. I’ve seen my officers wipe a tear and try to be strong.

Yesterday we had a lady that fully clothed just went and stood under the shower. Forty-nine years of age. The officers are talking to her, the mental health specialists are talking to her, medical staff is talking to her. We finally get her to come out. She’s just soaking wet. So everyone’s saying, ‘Oh, my God, let’s get her a blanket, let’s talk to her,’ and nothing is working. All this woman is saying during the whole episode is, ‘I’m not going to the mall! I’m not going to the mall! You’re not making me go to the mall!’ We go and get a wheelchair out and put it to the side of her. The staff coaxed her into the chair and she started crying and said, ‘Why are you making me go to the mall?’

We escort her to her room, the officers help her get her wet clothes off and give her medication and she goes to sleep. And you come back and look in her room and you see this woman who was just in a severe crisis and is laying there in a balled-up position with a blanket over her. What are we doing? What are we doing?

I’m still learning a lot of things about the severely mentally ill, but it’s challenging; it’s comical at times, it’s dangerous a lot. They’re real unpredictable, everyone’s on their toes.

You can’t just take a mentally ill person and lock them away. Society has already shown it doesn’t work. Why would we do it here? Not one of these people should be here.

* * *

Lili Holzer-Glier is a photographer based in Brooklyn, New York. Her work has appeared in The New Yorker, Vogue and The New York Times. Her first book, Rockabye, documents the Rockaways post–Hurricane Sandy and was published in 2015 by Daylight Books.