Treatment as an Alternative to Jail for People with Mental Illness
By Rebecca A. Clay
Imagine you’re a police officer who spots a man trespassing, urinating in an alley, or engaging in some other illegal behavior. When you confront him, he mutters, won’t look you in the eye, and just seems a little strange. Not knowing what else to do, you put him in jail.
And there he sits, not getting treatment for what turns out to be a serious mental illness. The trauma of incarceration actually makes the man’s psychiatric problems worse. Soon after his release, he gets arrested again.
That’s just the kind of scenario that the Targeted Capacity Expansion Grants for Jail Diversion Programs is designed to prevent. Launched by SAMHSA’s Center for Mental Health Services (CMHS) in 2002, the program targets the unnecessary incarceration of nonviolent adult offenders with mental illnesses.
Instead, it uses police crisis intervention teams, mental health courts, and other strategies to divert people away from the criminal justice system and into community-based mental health and substance abuse treatment (see a grantee’s story).
“We want these individuals to receive appropriate treatment,” said U.S. Public Health Service Commander and Project Officer David Morrissette, Ph.D., LCSW, noting that forthcoming research from the U.S. Department of Justice (DOJ) suggests that 16 percent of inmates have serious mental illnesses. “We want to break the cycle of arrest, incarceration, and release.”
Jail diversion programs for people with mental illness began as a response to the failures of deinstitutionalization, explained Henry J. Steadman, Ph.D., Director of the National GAINS Center in Delmar, NY. The CMHS-funded center, which includes the TAPA Center for Jail Diversion, collects and shares information about effective services for people with mental or substance abuse disorders who come in contact with the criminal justice system.
Twenty years ago, said Dr. Steadman, there was just a handful of jail diversion programs scattered around the country. Today there are nearly 500.
Federal funding from SAMHSA and other agencies has spurred that proliferation, said Dr. Steadman. “Before that,” he explained, “the movement didn’t have much oomph.” Since 2002, SAMHSA has made 34 jail diversion program grants.
* The Sequential Intercept Model Viewed as a series of Filters. Created by Mark R. Munetz, M.D. and Patricia A. Griffin, Ph.D.
Whether SAMHSA-funded or not, jail diversion programs typically focus on a particular point in the continuum of criminal justice involvement, said Dan Abreu, M.S., CRC, LMHC, Associate Director of the GAINS Center.
“How people encounter the criminal justice system is fairly linear, and at every point along the line you have opportunities to engage people in service,” he explained. “You want to prevent penetration into the criminal justice system.”
In fact, the field relies on a “sequential intercept model” developed with GAINS Center support by researchers Mark R. Munetz, M.D., and Patricia A. Griffin, Ph.D.
The model outlines five potential “intercept” points.
- Law enforcement and emergency services. The first opportunity occurs when the police encounter some sort of problem on the street. To take advantage of that opportunity, communities have developed crisis intervention teams. First developed in Memphis, TN, these programs give officers specialized mental health training and send them out to respond to any call that may involve people with mental illness.
- Initial hearings and detention. The first appearance in court is another opportunity to divert low-level offenders. Courts may hire mental health professionals or develop relationships with outside organizations to assess offenders and advise judges.
- Disposition hearings. To address more serious misdemeanors or felonies, many communities have developed specialized mental health courts or regular courts that focus on problem-solving and treatment rather than punishment.
- Re-entry. Sometimes a person slips through earlier intercepts and winds up in jail or prison. The point when inmates are returning to their communities represents another opportunity to connect them with services.
- Community supervision. Many communities have specialized parole and probation programs that ensure former inmates get the treatment they need and stay out of jail.
How well do such programs work? In the past, said Dr. Steadman, there have been few systematic studies examining the outcomes of jail diversion.
The challenges are enormous, he said. “A lot of these people live marginal lives, so it’s difficult to try to track them over time to see what happens,” he said. “And you can’t randomly assign people to jail diversion.”
Now Dr. Steadman and his colleagues are overcoming those challenges. They’re analyzing the effectiveness of 14 of the first 20 SAMHSA jail diversion grantees. Instead of a separate control group, he explained, “each case is its own control.” The researchers simply compared 579 participants’ reports of how they were doing the year before they entered the program and the year after.
The preliminary data look promising, said Dr. Steadman, noting that diagnoses included bipolar disorder, schizophrenia, and depression.
Seventy-five percent of participants had fewer arrests the year after their participation than the year before, for example. Factors that increased the likelihood of arrests included prior arrests, prior jail days, and illegal drug use. Housing status also played a big role, with stable housing related to fewer arrests.
The amount of time participants spent in jail also dropped. Fifty-two percent didn’t spend any time in jail in the year after participating in the program. Almost 76 percent reduced the number of days spent in jail post-enrollment compared with the year before diversion.
The preliminary analysis also shows that participants experience significant improvements in their functioning and significant reductions in their alcohol and illegal drug use, added Dr. Steadman.
Data also reveal something else: what Dr. Morrissette calls “an overwhelming number” of program participants who have experienced childhood sexual abuse, rape, or some other extreme trauma. SAMHSA now asks all existing jail diversion grantees to provide trauma services to participants.
In addition, the focus of the grant program itself has shifted to accommodate the discovery of trauma’s importance. The program currently focuses exclusively on offenders with PTSD or other trauma-related mental illness or substance abuse.
“When you think these days about whether there’s a large cohort of people who are experiencing significant trauma, you think about all the veterans who are coming back from Iraq,” said Dr. Morrissette. “As a result, we’ve given priority to serving veterans.”
In 2008, the new Jail Diversion and Trauma Recovery Program made its first grants to half a dozen states. These states will establish pilot programs in communities, learn from the experience, and then replicate the programs statewide.
Funding for more general jail diversion programs is still available—from DOJ’s Justice and Mental Health Collaboration Program.
“This is a really flexible program that lets communities take a look at their criminal or juvenile justice system continuum and identify where they have gaps and could be creating interventions,” said Ruby F. Qazilbash, M.P.A., Senior Policy Advisor for Substance Abuse and Mental Health at DOJ’s Bureau of Justice Assistance.
The 76 communities that have received grants since the program’s beginning in 2006 have developed specialized law enforcement response programs, mental health courts, “behind-the-walls” services within correctional facilities, and other diversion programs.
The Bureau of Justice Assistance also funds five Mental Health Court Learning Sites, which provide a peer support network for local and state officials.
“SAMHSA and DOJ are trying to leverage our resources as much as we possibly can so we’re making efficient use of our dollars and not duplicating each other’s efforts but complementing them,” said Ms. Qazilbash.
For more on jail diversion, visit SAMHSA’s Web site.
Helping Young Offenders Return to Communities
Incarceration vs. Treatment: Drug Courts Help Substance Abusing Offenders
Treatment in Lieu of Jail: Diversion Succeeds
* Editors Note:
The graphic of the “Sequential Intercept Model” was created by Mark R. Munetz, M.D., and Patricia A. Griffin, Ph.D., of the SAMHSA-funded National GAINS Center. The graphic appears in “Use of the Sequential Intercept Model as an Approach to Decriminalization of People with Serious Mental Illness,” an article published by Psychiatric Services online. [Psychiatr Serv 57:544-549, April 2006 doi: 10.1176/appi.ps.57.4.544]