Critical Issues - Jail Diversion Programs

Building Bridges Between Mental Health and Criminal Justice: Strategies for Community Partnerships

In Broward County, Florida, Judge Ginger Lerner-Wren presides over what is believed to be the nation's first county court specializing in offenses committed by persons with a mental illness. In Memphis, Tennessee, members of the municipal police department's Crisis Intervention Team (C.I.T.) respond to more than 7,000 incidents each year involving persons with mental illness, often resolving the situation on the scene or diverting the individual to an emergency services facility rather than making an arrest. Community mental health providers serving several metropolitan areas in Connecticut participate in a state-funded program to identify persons with mental illness and/or substance use disorders in local courts and jails to ensure that they receive timely and appropriate services.

These and similar programs across the nation are providing services to individuals with mental illness who are involved with the local criminal justice system. Although only a small minority of persons with mental illness are ever incarcerated, more than half of all adults in jail have a mental illness or substance use disorder.1 The likelihood that a person with mental illness will be incarcerated increases dramatically if the person has a co-occurring substance use disorder. An influential study of jails in Cook County, Illinois, for example, found that 72 percent of incarcerated persons with a current "severe mental illness" also had either an alcohol or substance use disorder. For those in jail who had experienced a severe mental illness at some point in their lives, the rate of co-occurring substance use disorders was 94 percent. 2

Many individuals with mental illness or co-occurring mental illness and substance use disorders are incarcerated not because they have committed violent or other serious crimes but because law enforcement and the courts are not prepared to handle incidents involving disruptive behavior stemming from their illness or because there is simply nowhere else to take them. "There are fewer and fewer resources to serve these individuals," notes Bonita Veysey, Ph.D., Senior Research Associate at Policy Research Associates ( PRA) in Delmar, New York. "There are fewer resources for the indigent - less public care. One agency that cannot refuse to respond to persons in crisis is law enforcement."

Increasingly, however, agencies spanning law enforcement, corrections, courts, mental health and substance abuse are cooperating to ensure that incarcerated persons with serious mental illness or co-occurring mental illness and substance use disorders receive the services they need while in jail and, when appropriate, are diverted from a court or detention center to a community-based mental health center.

Mental health collaborations with local criminal justice systems, according to experts, fall into two primary categories: (1) "pre-booking" interventions that usually occur at the scene of an incident and (2) "post-booking" (pre-adjudication) interventions that take place once a person has been arrested and/or incarcerated. Some communities use one approach or the other; a few, such as Lane County, Oregon, and Albany County, New York, provide both pre- and post-booking interventions.

Within these broad categories, there are a range of variations, according to Martha Williams Deane, M.A., director of a PRA pre-booking diversion research project funded by the National Institute of Justice, and Lisa Keller, J.D., of the National GAINS Center for People with Co-Occurring Disorders in the Justice System, a federally funded resource and system change center.

In communities such as Memphis, uniformed police officers receive special crisis intervention training that enables them to respond to incidents involving persons with mental illness and co-occurring mental illness and substance use disorders. In Birmingham, Alabama, and Lane County, non-uniformed mental health professionals employed by or under contract to local law enforcement agencies assist patrol officers in responding to such incidents. In Albany County, mobile community mental health center employees respond to such incidents as part of a team with police; while in nearby Rensselaer County, New York, mental health staff based at community mental health centers cooperate with police in responding to such incidents. These are a few of the varied treatment and diversion approaches now being implemented throughout the country.

To identify exemplary practices in the diversion and treatment of persons with co-occurring mental illness and substance use disorders in local criminal justice settings, two agencies within the federal Substance Abuse and Mental Health Services Administration (SAMHSA) - the Center for Mental Health Services (CMHS) and the Center for Substance Abuse Treatment (CSAT) - are providing funds for an ambitious three-year knowledge development and application program involving nine sites that offer community-based mental health and substance abuse treatment in lieu of arrest and/or incarceration.

The program's goal, according to Susan Salasin, Director of CMHS's Mental Health and Criminal Justice Program, is "to find out what programs and strategies work best under what circumstances." CMHS and CSAT jointly provide $6 million per year for the program.

Research Triangle Institute of Raleigh, North Carolina, the program's coordinating center, is responsible for data gathering and evaluation. In addition, SAMHSA funds the GAINS Center to provide consultation and technical assistance to program sites.

Changing the Way Police, Consumers, Family Members and Mental Health Providers Interact

More than a decade ago, the Memphis Police Department and the University of Tennessee Medical Center pioneered the Crisis Intervention Team (C.I.T.) program. Under the Memphis model, which has been adopted by a number of communities around the country (including Waterloo, Iowa; Albuquerque, New Mexico; Portland, Oregon; and Seattle, Washington), specially trained police officers are on call during their regular patrol duties to respond to incidents involving persons with mental illness or co-occurring mental illness and substance use disorders.

In some cases, C.I.T. officers responding to such incidents are able to resolve matters on the spot without taking further action. In others officers transport an individual to an emergency services facility for evaluation, follow-up services and referral. Once the police officer brings the consumer to the emergency services facility, mental health staff assume responsibility for providing services to the consumer, enabling the police officer to resume patrol duties.

Such cooperative and speedy handling of cases is a key factor in garnering law enforcement support for the program, according to Lt. Sam Cochran, C.I.T. Coordinator for the Memphis Police Department. The C.I.T. program, he notes, has dramatically reduced the amount of time that Memphis police officers spend waiting at an emergency services facility during the intake process.

Police officers who are accepted into the Memphis C.I.T. program take part in an in-depth, 40-hour training program that includes presentations by mental health clinicians from the University of Tennessee Medical Center and other local mental health providers, as well as veteran C.I.T. officers. During this training period, officers meet and talk with onsumers and family members in their homes, at community mental health centers and at the nearby state psychiatric hospital.

This person-to-person interaction promotes greater understanding and empathy among police officers for consumers and their families, Lt. Cochran notes. What makes the C.I.T. model so effective, however, is not simply the initial training activities but the day-to-day experiences of officers, consumers and family members. "A sense of trust develops among all parties," Lt. Cochran explains. "It seems to happen by osmosis."

Extending Mental Health Services to the Criminal Justice System

Every morning, clinical staff of local community mental health providers funded by the Connecticut Department of Mental Health and Addiction Services visit courts in Hartford, New Haven, Bridgeport/Stamford and New London County. They review the previous day's arrest logs for the names of individuals who are current or past community mental health center clients and accept referrals from court officials who have received training in identifying persons exhibiting signs of mental illness or co-occurring mental illness and substance use disorders. Staff members then meet with these defendants in court to evaluate their mental health status and discuss options for obtaining community-based mental health services and other supports that could result in alternatives to incarceration.

With the client's approval, the staff member meets with the public defender and other court officials to develop a release plan, which is then presented to the judge at the initial court hearing. In situations involving minor offenses, the judge may dismiss the case on the condition that the defendant participates in agreed-upon services. In other instances, the judge may withhold final disposition of the case for a period of time to ensure compliance with the release plan. When the judge requires an individual to remain incarcerated, program staff arrange for services to be provided in jail.

Gail Sturges, L.C.S.W., Director of Forensic Services for the Connecticut Department of Mental Health and Addiction Services, points out that the primary goal of the state program, which is also a participant in the SAMHSA-funded alternatives to incarceration initiative, is to ensure that persons with mental illness or co-occurring mental illness and substance use disorders who are arrested and/or incarcerated receive needed services. In some cases, this involves diversion to a community-based mental health program. In others it means providing services and ensuring continuity of care within the criminal justice system.

Clinical staff at the four Connecticut program sites work closely with law enforcement and the courts, Ms. Sturges notes. Some staff members are based in courthouses; others work at nearby community mental health centers. "We are sensitive not to intrude into the adversarial process," she explains. "We don't necessarily go to the judge and say, 'Please release him.' But we try to make sure that a person with a serious mental illness or co-occurring disorder has access to services whether or not he or she remains in jail."

Even though program staff work collaboratively with the criminal justice system, Mrs. Sturges notes, their primary responsibility is to act on behalf of the consumer, not to serve as an adjunct to either the defense or prosecution. "We view our work as extending the front door of the community mental health system into the criminal justice system," she observes.

Building a Bridge Between the Courts and Mental Health Consumers

Judge Ginger Lerner-Wren of Broward County, Florida, was appointed in June 1997 to preside over a newly established county court specializing in cases involving persons with mental illness. During the past 10 months, in addition to her regular duties as a county court judge in Fort Lauderdale, Judge Lerner-Wren has heard more than 200 cases involving individuals with mental illness who are charged with misdemeanors.

Most cases involve relatively minor charges such as trespassing, loitering and disorderly conduct. In some circumstances, however, the court hears cases involving persons with mental illness or co-occurring mental illness and substance use disorders who are charged with more serious misdemeanors such as battery.

Every day at 11:30 a.m., Judge Lerner-Wren stops regular county court proceedings to convene the special court. After making an initial determination about whether the case is appropriate for this court, the judge confers with a court monitor from the community mental health system, the public defender, the state's attorney and others to gather information about the defendant and the case.

In some instances, the matter is immediately resolved with a voluntary referral to a community mental health provider; in others the judge grants a continuance while the defendant is evaluated at a community mental health center or an inpatient setting. During this period, the state's attorney, the public defender, community mental health staff and the consumer and his or her family work together to develop a services plan to be presented to the judge.

According to Judge Lerner-Wren, who served previously as the plaintiff's monitor in a federal class action suit involving the South Florida State Hospital, one of the court's primary missions is to minimize the amount of time that persons with mental illness and co-occurring mental illness and substance use disorders spend in jail or in other interactions with the justice system. "We work very, very hard to ensure dignity and respect for those who appear before the court," she points out. "There is a philosophical recognition that we are working toward the decriminalization of persons with mental illness."

Identifying Key Characteristics of Effective Programs

While there are many approaches to diversion and treatment in local criminal justice systems, effective programs appear to share several characteristics, experts point out. These include:

  • Leadership and oversight by a broadly representative, culturally diverse task force whose members include representatives of law enforcement, the courts, consumer and family organizations, and mental health and substance abuse agencies. It helps if task force members are sufficiently high in their organizations' hierarchies to institute needed changes.

  • Coordination, cooperation and trust among agencies. Partners develop an understanding of and respect for each other's mission, viewpoint and operations.

  • Continuity of care to ensure that consumers receive services both while they are incarcerated and after returning to the community. Program staff work with consumers during the transition from incarceration to community services to ensure that they receive appropriate services.

  • Integration of services among the mental health, substance abuse and criminal justice systems. Given the prevalence of co-occurring mental illness and substance use disorders among persons incarcerated in jails, there is a growing understanding of the need to integrate services in these three areas.

  • Dedicated "champions" and "boundary spanners" who cross organizational and professional lines to engender commitment and enthusiasm and promote cooperation among individuals and organizations.

Promoting Accessible, Effective Community-Based Services

Jail diversion and treatment programs help not only to ensure that persons with mental illness and co-occurring mental illness and substance use disorders receive needed services and supports during and after involvement with the criminal justice system, but they also serve to highlight the need to increase the availability of comprehensive and effective community-based mental health services and supports. If, as many mental health and criminal justice experts believe, a shortage of effective, community-based services exacerbates the problem of persons with mental illness and co-occurring mental illness and substance use disorders becoming involved with the local criminal justice system, diversion and treatment programs can play a vital role in prompting action at state and local levels to ensure that these services are available and accessible.

1The National GAINS Center for People with Co-Occurring Disorders in the Justice System. (Spring 1997). "The Prevalence of Co-occurring Mental and Substance Abuse Disorders in the Criminal Justice System," Just the Facts. Delmar, NY: The GAINS Center. 2Abram, K., and Teplin, L. (October 1991). "Co-Occurring Disorders Among Mentally Ill Jail Detainees: Implications for Public Policy," American Psychologist 46(10): 1036-1045.

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