Treatment in Lieu
of Jail: Diversion Succeeds
By Arnold Mann
When San Antonio police took 36-year-old Letty Trinidad
to jail last year, it was the culmination of a series of
incarcerations and suicide attempts fueled by drug and
alcohol dependency and major depression that had plagued
the mother of three since her teens.
This time, however, staff from the jail diversion program
at the San Antonio Center for Health Care Services (CHCS)
intervened on her behalf and arranged for her admission
to a drug and alcohol rehabilitation center.
Today, Ms. Trinidad attends support group meetings at
CHCS. She also takes classes and volunteers at the San
Antonio chapter of the National Alliance for the Mentally
Ill, learning how to help others with mental illnesses
and substance abuse. She is living on her own, with her
three children. And she found a job. "I know I can
do this," said Ms. Trinidad. "I just feel good
Ms. Trinidad's success story is one of many in Bexar (pronounced
"bear") County, TX. San Antonio is 1 of 20 community
sites nationwide currently funded by SAMHSA's Targeted
Capacity Expansion (TCE) grants for Jail Diversion Programs.
"Bexar County initiated its program to help people
with severe mental illness get out of county jails, off
the streets, into treatment programs, and back to meaningful,
productive lives," said Leon Evans, Executive Director
of the CHCS jail diversion program.
Similar success stories are unfolding in other communities
assisted by SAMHSA's TCE grants.
SAMHSA's Center for Mental Health Services (CMHS) has
awarded these TCE grants since 2002. Participating communities
receive up to $300,000 annually for up to 3 years and
contribute at least $100,000 per year from local resources
toward the implementation of the project.
In addition, CMHS funds a national Technical Assistance
and Policy Analysis (TAPA) Center for Jail Diversion,
which assists grantees in planning, establishing, and
evaluating their programs and provides technical assistance
and resources to other communities interested in developing
"The jail diversion program really is a transformational
effort," said Neal Brown, M.P.A., Chief of the Community
Support Program Branch at CMHS. "What communities
such as San Antonio are doing is getting people with
mental illness and co-occurring substance abuse disorders
out of the criminal justice system and into community
treatment programs, giving them opportunities to stay
out of jail."
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An Ongoing Problem
"Some of our jails are our largest mental hospitals,"
said Linda A. Teplin, Ph.D., a public health researcher
and expert on mental health and criminal justice issues.
She is the Owen L. Coon Professor of Psychiatry and Behavioral
Sciences at the Feinberg School of Medicine at Northwestern
University. Dr. Teplin has studied the interface between
the mental health and criminal justice systems for the
past 29 years.
According to the Bureau of Justice Statistics, at mid-year
2004, 713,990 inmates were held in local jails across
the Nation, up from 691,301 at mid-year 2003an
increase of 3.3 percent. "Our best guess,"
Dr. Teplin added, "is that as many as 90,000 of
those individuals may have a severe mental disorder."
And of those 90,000, many have co-occurring substance
abuse disorders as well.
According to the President's New Freedom Commission
on Mental Health, the problem is inescapable in nearly
every urban community. Ironically, the majority of these
individuals have committed only minor offenses such as
disturbing the peace. Typically poor and uninsured, these
individuals often are homeless and have co-occurring
substance abuse and mental disorders. They cycle in and
out of shelters, hospitals, and jails, occasionally receiving
mental health and substance abuse treatment services,
but most likely receiving no treatment at all.
Cost studies suggest that communities (and taxpayers)
can save on costs by supporting proven jail diversion
programs as an alternative to incarceration.
In Bexar County, according to a December 2004 policy
analysis report, an estimated 14 percent of the county's
jail population has severe mental illness, and 75 percent
have co-occurring substance abuse problems. Many of San
Antonio's large homeless populationsome 25,000
to 30,000 peoplehave a mental illness. The Texas
CHCS, the county's mental health authority, is spearheading
the turnaround for Bexar County in close collaboration
with city, county, and state law enforcement authorities
in addition to judicial and health care entities.
To be effective, most jail diversion programs coordinate
a comprehensive set of services at the community level.
The cooperation of all involved agencies helps integrate
mental health care and substance abuse treatment, physical
health care, and social services, such as housing, food,
Programs work to bridge the barriers between the mental
health and criminal justice systems and help identify
detainees who need mental health treatment and meet the
jail diversion criteria. This is done through the initial
screenings and evaluations at the crisis triage center,
arraignment court, or jail.
Bexar County's diversion program relies on three phases
of intervention. The first phase uses Deputy Mobile Outreach
Teams and Crisis Intervention Teams to divert offenders
with mental illness before they are arrested or booked
in the county jail. During the second phase, the program
identifies persons with mental illness within the system
and makes recommendations for alternatives to incarceration,
such as mental health bonds or release to treatment facilities.
The third phase focuses on providing appropriate services
upon their release from jail or prison.
Deputy Mobile Outreach Teams, composed of county deputies
and mental health clinicians, are available for onsite
mental health assessments and interventions 24 hours
a day, 7 days a week. Their mission is to screen high-risk
individuals with mental illness and refer or transport
them to the CHCS Crisis Center for further evaluation.
Crisis Intervention Teams are staffed by police officers
trained to work with persons with mental illness. Their
goal is to respond and to resolve conflict so that individuals
with mental illness can be safely transported to the
Crisis Center or, if necessary, the jail.
CHCS representatives also make home visits, helping
people order their lives through cognitive adaptive training
(CAT). CAT involves strategic placement of objects and
lists of things they need to do, to keep them on track
and taking their medications. "Jail diversion is
also about identifying people who need additional supports
and helping them maintain their good mental health and
reintegrating them into the community," said Mr.
The CAT program also employs recovering people with schizophrenia
to help gain the trust and participation of persons with
mental disorders. Paul Eisenhauer, a 45-year-old man who
suffers from the disorder, is doing well. He hasn't heard
voices for more than a decade. Early diversion efforts
helped him get out of jail and into a state hospital conducting
clinical trials of a new antipsychotic medication. Today,
he teaches police officers (who used to arrest him) about
schizophrenia. "They really want to know what it's
like to be schizophrenic," said Mr. Eisenhauer. "One
officer came up to me and said, 'A lot of people are scared
of schizophrenics,' and I said, 'A lot of people are scared
of cops.' "
So how is the San Antonio program doing? Interim results
show a significant number of jail diversions and potential
savings in criminal justice costs. County officials are
optimistic that added costs for mental health care will
diminish as the long-term benefits of the program take
"We're creating 'steps up' for people in jail into
residential facilities, and we're getting them involved
in active treatment and employment skills and starting
them looking for housing," said Mr. Evans. And Texas
is currently making plans to apply the Bexar County jail
diversion model throughout the state.
"What's very impressive about the San Antonio program
is the way they brought all these services togetherthe
small providers, the big providers, the county judges,
the university, primary health care, and the state legislature,"
said Mr. Brown. "They are transforming the way mental
health services are delivered. And this is exactly what
we had in mind with this programto help bring about
this kind of transformation and to change the public's
view of people struggling to overcome co-occurring mental
illnesses and substance abuse."
SAMHSA will announce the 2005 Jail Diversion Program
awards in September. For information about the program,
call the TAPA
Center at 1 (866) 588-TAPA (8272) or visit the SAMHSA
Web site at www.samhsa.gov.
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