Barbaric conditions in mental institutions were a common target of journalistic exposés during the asylum era of the nineteenth and twentieth centuries. These days, though, most accounts of gross maltreatment of the mentally ill concern jails, not hospitals. Deinstitutionalization emptied America’s asylums in the name of providing more humane treatment, but that approach has left many seriously mentally ill people on the streets, where, untreated, they can spiral into disorder and violent behavior—often putting them behind bars. This year, Alisa Roth’s book Insane: America’s Criminal Treatment of Mental Illness and a series of articles by the Virginian-Pilot on mental illness in American jails have detailed the many ways in which incarceration tends to worsen serious mental illness.
For starters, jails are full of criminals. Serious offenders often harass, harm, and degrade those locked up for more minor offenses, including the mentally ill. Jails are noisy, and the population is highly transient (the standard stay is less than a month), making for “an especially unstable and disorienting social environment,” in Roth’s words. Effective treatment depends on an accurate diagnosis, but that can be a complicated process under ordinary circumstances (there’s no brain scan or blood test for mental illness), and even worse for a newly arrived jail inmate who may never have seen a psychiatrist before. When the mentally ill have trouble following jail rules, their difficulties can come across to corrections officers as insubordination.
Their propensity to break rules and commit additional crimes behind bars helps explain why mentally ill inmates often stay in jail far longer than typical inmates. They behave erratically, so it’s hard for them to mix with the general inmate population; but putting them in solitary confinement is unlikely to improve their condition. Recovery from mental illness requires not only therapy and medication but also meaningful opportunities for recreation and employment tailored to needs and capabilities. These aren’t likely to be abundant in jail, since, among other reasons, the unpredictability of release dates frustrates the development of plans for care. Incarcerated Americans have a constitutional right to mental-health care, thanks to Supreme Court and federal court rulings, but, far too often, those guarantees don’t equate to real-world benefits.
One partial response to this crisis: jail-diversion programs, which redirect mentally ill low-level offenders out of the criminal-justice system and into needed treatment. Such programs recognize that thousands of Americans now languish behind bars not because they’re criminals but because they’re sick. Though they make up only 4 percent to 5 percent of the adult population, the seriously mentally ill account for 20 percent of jail inmates. Political partisans on both sides of the spectrum routinely cite the high incidence of serious mental illness among the incarcerated as evidence of the need for a complete overhaul of the mental-health-care system, but that ambitious project will likely take generations. Diversion programs, or “alternatives to incarceration,” at least prevent some sick offenders’ conditions from worsening.
One of the most admired diversion initiatives in the U.S. got under way in 2000 in Miami-Dade County: the Criminal Mental Health Project (CMHP). Its creator and director is Judge Steve Leifman, a county court judge with the Criminal Division of Florida’s Eleventh Judicial Circuit. Leifman’s success in disentangling the mentally ill from the criminal-justice system has won him numerous accolades, including a Public Official of the Year award from Governing and a Rehnquist Award for Judicial Excellence from the National Center for State Courts. He serves on prominent boards and commissions in the field, has led mental-health-reform task forces at county and state levels, and has testified before Congress.
The temptation to expand any successful social-services program is often irresistible, but as it approaches the end of its second decade, Leifman’s program is retrenching, seeking to strengthen its ability to help the hardest cases. The Mental Health Diversion Facility (MHDF), planned to open in 2020, is a 200-bed former state forensic hospital. Leifman and his team are directing a $42 million renovation of the building. A combination of tight security—forensic hospitals serve the criminally insane—and custom-tailored amenities and programming will, Leifman hopes, enable his program to reach the many “high utilizers” of public services whom diversion has failed to help, leaving them to cycle through the courts and jails. The new facility is central to the future plans of a program that offers valuable lessons about what’s going right in mental-health-care reform today.
Any effort to keep mentally ill people out of jail must focus first on the point of contact with police. While many communities provide mentally ill offenders with some alternative to incarceration, Leifman’s initiative stands out because it reaches people both before and after they’re arrested. The “prebooking” component of the CMHP consists of “Crisis Intervention Training” (CIT), which instructs policemen in how to de-escalate encounters with the mentally ill. (See “CIT and Its Limits,” Summer 2017.) The typical 911 call involves someone requesting police assistance to impose order on an out-of-control situation. Asserting a “command presence” is the standard police approach; CIT, by contrast, teaches different modes of comportment, since projecting an authoritative manner, while useful in bringing to heel unruly parties, may exacerbate disorder with someone in psychiatric crisis.
The CMHP, operated out of the county court office, provides pro-bono CIT instruction to Miami-Dade’s three dozen police departments. Throughout the 40-hour course, officers hear from mental-health professionals, other police officers, and “peers”—mentally ill individuals in recovery, whose history of overcoming mental illness is believed to make them especially qualified to help others do the same. The curriculum covers the varieties of serious mental illnesses, their symptoms, and standard approaches to treating them; how serious mental illness differs from developmental disorders; how it overlaps with substance abuse and posttraumatic stress disorders; and state law regarding civil commitment. De-escalation is taught through role-playing and general guidance: “When you don’t know what to say, say nothing”; “Use voice volume lower than that of individual”; “Attempting to use logic/rationality with a psychotic person is counterproductive, will most likely escalate person.”
The urgency of CIT is rooted in a concern over police shootings, up to 25 percent of which, by some estimates, involve mental illness. Countywide, Leifman’s initiative has trained more than 6,000 patrol officers in CIT, and police shootings of the mentally ill have dropped since the late 1990s. But in Miami-Dade, equal emphasis is placed on CIT’s ability to minimize unnecessary arrests. From 2010 to 2017, only 149 arrests were made out of about 83,000 mental-health-related calls to the City of Miami and Miami-Dade police departments, the county’s two largest public-safety agencies. That’s a lower rate than the rate of arrest for all calls during that time.
Not every mental-crisis call can be brought under control without arrest, so Leifman’s CMHP continues its diversion efforts on a post-booking basis. Potential participants must have a serious mental illness and have been arrested on less-than-serious charges—misdemeanors other than traffic-related offenses or nonviolent felonies. There’s also a post-booking plan for those regarded as temporarily mentally unable to stand trial, which allows them to regain competency while getting treatment in the community, instead of in a mental hospital. The CMHP’s three jail-diversion initiatives are handling about 600 people every year.
Participation is contingent on the consent of both the defense and prosecuting attorneys, and that of the victim—in cases where there is one, such as trespassing. (Victim consent is almost always given, according to Leifman and his staff.) Further screening assesses treatment needs, such as for substance abuse (over 70 percent of jail-diversion participants have a co-occurring disorder) and “criminogenic risk,” the likelihood that they’ll do something bad again. Once CMHP staff have put together a treatment plan, which includes resolution of housing arrangements and access to all appropriate service providers, the diversion program begins in earnest. Close oversight is exercised: Are the patients showing up for prescribed therapy sessions? Are they participating in group? Have they tested positive for drugs and/or alcohol? Are they taking their meds? Are their relationships becoming healthier—or more unstable?
Such details get reported to the presiding judge during regular court visits. If all goes well, the participant “graduates” from the CMHP, meaning that his or her case is closed and the initial charges are dropped. “We’re hoping to decriminalize mental illness by not leaving people with a criminal history,” says Cindy Schwartz, director of the jail-diversion program. If participants fail to comply with the treatment, they’ll reenter the standard criminal-justice process and have their charges adjudicated like ordinary defendants.
Relative to the scope of the problem—Miami-Dade is Florida’s largest county, and, per the state’s Department of Children and Families, its rate of serious mental illness is roughly twice that of the nation—the CMHP is a strikingly compact operation. Its budget runs between $1 million and $2 million, and the central staff consists of only 23 part-time and full-time employees, about half of whom work for an independent nonprofit but are detailed to the court. One staffer directs CIT efforts, organizing about a dozen 40-hour training sessions each year; all the instructors are volunteers. The county board of commissioners and state legislature and Department of Children and Families provide crucial budgetary support, as does Washington, via entitlement programs. Without Supplemental Security Income and Medicaid benefits, Leifman and his staff would struggle to fund much of their work.
The CMHP is not itself a service provider but instead seeks to ensure that mentally ill offenders in Miami-Dade get the most out of existing programs and agencies. “We really don’t have to rebuild the entire mental health system,” says Leifman, a fierce critic of that system. “What we need to do is . . . supplement it and wrap our arms around it with a different level of services for the more acutely ill.” Close partnerships with community organizations are essential, as is deep knowledge of what resources are available for the mentally ill of Miami-Dade. Leifman chairs the South Florida Behavioral Health Network, and he’s the finance chair for the Miami-Dade Homeless Trust. Collectively, the two agencies direct about $150 million in mainly government funds to local substance-abuse, mental-health, and housing providers, many serving jail-diversion program participants.
Some of Leifman’s top staff also straddle the divide between criminal justice and social services, having previously worked for mental-health organizations and the Jackson Health System, which runs the local safety-net hospital, Jackson Memorial. A commitment to “treatment, not jail” is valuable for CMHP staffers, but the most effective ones also possess technical knowledge, ranging from how to expedite applications for Supplemental Security Income to how to distinguish those local nonprofits that truly provide specific counseling for trauma victims from those that just say that they do.
Managing the CMHP has required ample use of Leifman’s political skills. In Florida, county court judges are elected and serve six-year terms. Leifman has stood successfully for election four times, including in 2018, and he also ran for state legislature, unsuccessfully, earlier in his life. He devotes considerable time to promoting the CMHP’s work in Miami and across the state and country. Getting the word out is essential to the program’s social-entrepreneurial business model—pursuing grant funding and demonstrating results, with an eye toward securing more sustainable government revenue sources down the line (and more grants). Talking up the CMHP also helps burnish the image of the criminal-justice system, Leifman maintains, letting the public know that “we’re not just about locking people up.”
At present, a chief preoccupation of Leifman and his staff is getting the $42 million MHDF up and running. The venture is also the source of the largest political obstacle that his work has yet faced. In 2004, county voters approved a $2.9 billion bond measure, $22 million of it dedicated toward a “mental-health facility,” the function of which would be to “free up jail space and provide an effective and cost-efficient alternative facility to house the mentally ill as they await trial.” But a few years after voters approved the measure, a local CBS affiliate gained access to the ninth floor of the Miami-Dade County Pre-Trial Detention Center, or county jail. The “Forgotten Floor” report documented the miserable conditions that the mentally ill inmates experienced: “stench-filled cells,” inmates drinking from toilets because of broken plumbing, and as many as five men packed into spaces designed for one. “You would think that in 2006, we would treat people with chronic mental illness in a much better, more humane manner,” said the jail’s own chief psychiatrist. “But unfortunately, we’re reverting back to how it was in the 1600s and 1700s, which is terrible. It’s morally incomprehensible.”
An investigation by the U.S. Department of Justice led to a consent agreement that required the county to improve jail conditions. As the deadline to fulfill the agreement’s requirements loomed, some suggested repurposing the building intended for the new MHDF, and its associated bond funds, for use by the corrections department. Though Leifman fought off this attempted raid on his program’s resources, the effort stalled the progress of the new mental-health facility. Cost estimates for the MHDF swelled to $42 million, and the project incurred a $20 million deficit. Leifman secured an additional $8 million in bond funds from the Jackson Health System and $12 million set aside for “public safety” from the county government. Leifman’s adroitness in obtaining the extra capital attested to the community’s respect for his work. It also showed that other stakeholders found persuasive the claims that he has persistently made about “upstream” community treatment—that it’s not just more humane than jail but also more cost-effective.
The idea of using an old hospital that once housed the criminally insane to improve twenty-first-century mental-health care might seem counterintuitive. The history of American mental-health treatment offers many macabre examples of adaptive reuse, such as shuttered psychiatric wards reopened as homeless shelters or jails to deal with the new problems that deinstitutionalization created. But while it may not be everyone’s beau ideal of a community mental-health center, the new facility offers advantages, beginning with its size: seven stories, about 180,000 square feet, and a five-acre campus. The CMHP takes pride in its comprehensiveness, in its ability to overcome the fragmentation of the mental-health-care system, which makes it tough to reach people at all stages of recovery. Leifman describes mental health as “the stepchild of medicine. The way we do things, it would be like, you’re having chest pains, and we send you to a podiatrist!”
The MHDF will provide a continuum of care, ranging from intensive treatment in the crisis-stabilization unit on the second floor (to which some will be involuntarily committed), to dental and primary care, basketball in the gym, and employment training in the culinary arts. Such “one-stop shopping” is possible only because of the building’s size. In terms of bed count, three levels will be available: 40 beds for the crisis-stabilization unit, 120 for short-term residential treatment (stays of about 90 days), and 48 for the residential-treatment facility (180-day stays).
“Continuum of care” has fallen somewhat out of fashion in social-policy circles. Under the banner of “housing first,” homeless advocates have sought to discredit the value of temporary or transitional services in favor of permanent housing benefits, even for the severely mentally ill. But Leifman and his staff, while not disputing that housing for the mentally ill is needed, believe that the MHDF has great potential. As Tim Coffey, CMHP’s Project Coordinator, puts it: “We [too often] take people and we put them into what we would call a total institution, whether it’s jail or a locked crisis unit and then from there, we release them to the community with virtually no structure around them, and the idea here would be as folks progressed through the continuum, they may start at that most intensive level of services that is a closed unit or a locked unit, but as they progress through, they move through less and less restrictive programs.”
Neighborhood opposition hasn’t been an issue, perhaps in part because the structure was sited as a mental-health facility years ago. It has strong bones (it won’t need to be evacuated in a hurricane) and is highly secure. Through a sally port, CIT officers will be able to transport individuals to the facility who haven’t (yet) committed a crime but are nonetheless in a state of mental crisis. At a newly built courtroom, they can be evaluated on site for civil commitment under Florida’s Baker Act. Post-booking diversion patients, who may be staying in the short-term residential beds, may also avail themselves of the courtroom for regular check-ins with the judge.
The project has helped Leifman and his team appreciate the implications of interior design for mental-health policy. “We believe part of the problem is that most facilities for people with mental illnesses—they’re hideous,” he says. “They’re not very warm and welcoming; they don’t make people feel comfortable . . . And this is going to be the opposite.” A half-million dollars will be devoted to covering over the cinder blocks in the living-area spaces, “just so people don’t feel like they’re institutionalized.” The chain-link fence and razor wire will go, too, and faux-wood and engineered stone finishes will enhance the effect of living in a community. Architect Jim Cohen, of the firm SBLM, says: “Our goal was to make it look like a Marriott.”
For all its deficiencies, the old state asylum system of “institutionalized” care was at least a “system.” These days, treatment for the seriously mentally ill in America consists of scores of community-based programs, in accord with the hopes of deinstitutionalization’s proponents. Some supportive housing programs are excellent examples of the potential of community services, as is Kendra’s Law, New York State’s assisted-outpatient treatment program. But even the best of such initiatives, like Leifman’s CMHP, tend to serve a modest subset of the seriously mentally ill.
When advocates promote jail diversion for the mentally ill, they often use big numbers: 2 million sick people arrested yearly and hundreds of thousands held behind bars, a population approaching that of the asylums in the “bad old days.” But many of the individuals represented in those tallies—maybe even most—will never be eligible for diversion because of the seriousness of their illnesses and/or their crimes. After almost 20 years of strenuous efforts by Leifman and his team, the Miami-Dade County jail still incarcerates about 1,200 seriously mentally ill people. New York City, which boasts a rich array of alternatives to incarceration, holds more than 1,000 seriously mentally ill inmates on Rikers Island. Jurisdictions with and without strong diversion programs are equally likely to house more seriously mentally ill in their jails than in the largest of their remaining state mental hospitals.
But quantity aside, the CMHP is pioneering a model for enhanced care for the seriously mentally ill. In 2014, New York mayor Bill de Blasio pledged to open two “community-based drop-off” centers, where cops could take emotionally disturbed people on a prebooking basis. They have yet to open, largely because of siting difficulties. Even when they do open, they’ll offer less robust services than the MHDF. Perhaps a Miami-Dade-like approach could be applied to some unused former psychiatric facility in the city or state, or to portions of the Rikers Island complex, if its planned phaseout goes as expected. The MHDF’s evolution suggests how existing mental-health-care facilities might more easily overcome neighborhood concerns than newly built ones, and that it’s likely easier to take a secure facility and temper its “institutional” feel than to take a nonsecure facility and make it secure.
No one thinks that alternatives to incarceration like Leifman’s obviate the need for broader mental-health-care reforms that focus on civil-commitment laws, the capacity of inpatient care hospitals, the availability of permanent supportive housing, and helping families caring for seriously mentally ill relatives. But many of those reforms require state and/or federal action. Local authorities are the best candidates to run diversion programs because localities run jails, where those awaiting adjudication of charges are held. Providing the mentally ill with an alternative to incarceration doesn’t require state legislation. “We didn’t decriminalize anything,” says Miami-Dade County Commissioner Sally Heyman, a close colleague of Leifman’s. “We didn’t change any Florida statutes. . . . We’re not changing the law. It’s still a crime to do certain things.”
How effective a community can be with diversion will depend less on its willingness to tolerate low-level crime than on the extent and quality of its social-services offerings. In Leifman’s assessment, “what you need . . . are certain essential elements available for the population to help them recover. And most communities just don’t have a good system of care. So people fall through the cracks, they don’t get what they need, they can’t get housing, and it’s very, very hard for them. And we try to fill all those gaps . . . and make it possible for them to begin to recover.” It’s pointless to try to divert someone into treatment if good treatment programs don’t exist. But the diversion program itself may not need to be large, provided that the staff is experienced and knowledgeable enough to help participants find what they need in today’s bewildering mental-health-care landscape.
Top Photo: Judge Steve Leifman created the Criminal Mental Health Project in 2000. (CARL JUSTE/MIAMI HERALD/TNS VIA GETTY IMAGES)