Because of the incidence of significant and often severe psychiatric problems within jails, and because staff and other resources are usually limited, some hard decisions have to be made with regard to the requests for mental health services to inmates. Treatment decisions must take into account the severity of the psychiatric problems, the availability of secure mental health facilities, the legal and custody status of the inmates, the value of using psychoactive medications, and the possibility of scheduling regular supportive counseling sessions or immediate crisis intervention. In many instances, one of the key elements of jail mental health treatment is the removal of an inmate from the jail environment. Devising a referral system that is appropriate both to the needs of the jail population and to the staffing pattern of the mental health team is another key element in running a jail psychiatric program. Such a system must ensure that all inmates needing assistance will be seen, but must also allow efficient triage decisions to be made. Despite the severity of the mental health problem in county jails, political decisions determine how much staff and facility resources are committed to jail mental health treatment. It is critical that the mental health staff work fulltime in the jail in order to understand the interpersonal complexities of the jail situation and in order to develop a positive relationship with the custody staff.