Beyond Bars
JUDGE LEIFMAN ENCOUNTERS THE CHALLENGE
“When I first became a judge, I discovered a situation familiar to many of my colleagues but seldom discussed outside the courtroom — a situation that my legal and judicial training had not prepared me for. Day after day, defendants stood be- fore me, disheveled and distraught. Most were charged with relatively minor offenses such as loitering or panhandling.
Some exhibited impulsive behaviors, speaking in pressured, incoherent sentences. Others were guarded and withdrawn, appearing to have little understanding of the circumstances in which they found themselves. Homelessness, substance abuse, and trauma were symptoms of a larger set of personal and social factors contributing to their unfortunate and often repeated involvement in the criminal justice system. These people of many backgrounds shared one thing in common — serious and persistent mental illness.
When I first came across defendants experiencing acute men- tal illness, I followed the lead of my fellow judges by appoint- ing experts and ordering psychiatric evaluations to determine their competence to proceed with their court cases. Although these evaluations tended to be very costly and meant that defendants would remain in jail for weeks or possibly even months, the idea of releasing a person in acute psychiatric distress to the streets with nowhere to live and no supports seemed a far more cruel response to the situation. I assumed that once evaluations by mental health experts were complet- ed and the need for treatment was documented, the mental health treatment system would step in, if not voluntarily, then by court order.
Before long, I realized my assumptions were wrong. Even though I had expert opinions indicating that people were indeed experiencing severe psychiatric symptoms — and in many cases requiring immediate hospitalization — state law prohibited judges presiding over misdemeanor cases from ordering treatment in the forensic mental health system. In- stead, the law required people to be released to the commu- nity on the condition that they participate in treatment, but there was no mechanism to ensure that treatment, housing, or any other type of support was actually provided.
Judge Steven Leifman, Special Advisor on Criminal Justice and Mental Health, Supreme Court of Florida, and Associate Administrative Judge, County Court, Criminal Division, 11th Judicial Circuit of Florida; Tim Coffey, Coordinator, 11th Judicial Circuit, Criminal Mental Health Project
Decriminalizing Mental Illness:
Miami Dade County Tackles a Crisis at the Roots
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cords for offenses that were all too obviously the result of untreated mental illness. This contributed to a revolving door of neglect and despair; caused a huge backlog of cases in the justice system; placed enormous burden on the courts, jails, and law enforce- ment agencies; and left taxpayers to foot the bill.
Not wanting to continue to be a witness to the parade of misery passing through my courtroom, I was deter- mined to figure out why and where the system was failing. With the help of many dedicated stakeholders from the community mental health, criminal justice, and social services systems, I set out to learn as much as I could about the community mental health sys- tem and how it intersected with the criminal justice system.”
IDENTIFYING THE ROOT CAUSE
A 2-day summit was convened in 2000 to review the ways in which the community collectively responded to people with mental illness before and after they became involved in the justice system. What we dis- covered were embarrassingly dysfunctional and frag- mented systems.
Before the summit, it was apparent that people with mental illness were over-represented in the justice system. What was not so apparent, however, was the degree to which stakeholders were unwittingly contributing to and perpetuating the problem. Many participants were shocked to find that a single per- son with mental illness was accessing the services and resources of almost every other stakeholder in the room, including law enforcement agencies, emer- gency medical services, mental health crisis units, emergency rooms, hospitals, homeless shelters, jails, and the courts. This happened repeatedly as people revolved through a criminal justice system that was never intended to handle overwhelming numbers of people with serious mental illness and a community mental health system that was ill equipped to provide the level and capacity of care necessary for those ex- periencing the most acute forms of mental illness.
Stakeholders were largely disconnected from one an- other and no mechanisms were in place to coordinate resources or services. Everyone was so busy doing his or her job that no one was looking at the bigger pic-
and had little incentive to learn, because of barriers to accessing information and laws that prohibit reim- bursement for services provided to people who are incarcerated.
For people who had no resources to pay for services, crisis units, hospitals, and the jail were often the only options to receive care. Ironically, although many people could not access the most basic prevention and treatment services in the community, they were readily provided some of the most costly levels of institutional care over and over again. The degree of fragmentation in the community not only prevented the mental health and criminal justice systems from responding more effectively to people with mental ill- ness but actually created increased opportunities for people to fall through the cracks. By the conclusion of the summit, we began to realize that people with untreated serious mental illness may be among the most expensive populations in the community, not because of their diagnoses but because of the way they are treated.
As we’ve come to better understand the problems and context of people with mental illness involved in the justice system, we learned three critical lessons:
>> First, our criminal and juvenile justice systems are
in the midst of mental health crises at the local, state, and national levels. The current level of de- mand for deep-end services in settings such as emergency rooms, crisis units, state hospitals, and ultimately jails and prisons is inappropriate and unsustainable and contributes to enormous social, fiscal, and personal tragedies. The backlog of cases in the justice system involving people with mental illness impedes the administration of justice and contributes to needless pain and suffering.
>> Second, the problems facing the mental health
and, consequently, criminal justice systems in the United States today relate to the fact that the cur- rent community mental health system was devel- oped at a time when most people with severe and disabling forms of mental illness resided in state hospitals. Most community mental health systems were designed around people with more moderate treatment needs, not around the needs of people
who experience highly acute and chronic mental illness. Intensive supports necessary to live suc- cessfully in the community are many times in short supply or altogether unavailable.
>> Third, state expenditures on mental health services
have become disproportionately skewed toward providing expensive, acute-care services such as crisis stabilization and hospitalization in state- funded facilities, not to mention services pro- vided in jails and prisons. Such heavy investment in these kinds of back-end services has come at the cost of being able to adequately invest in a responsive and comprehensive continuum of pri- mary and preventive care in the community.
CRIMINAL MENTAL HEALTH PROJECT PROVIDES SOLUTIONS
The 11th Judicial Circuit Criminal Mental Health Project was established 10 years ago in an effort to better respond to the needs of people with serious mental illness and co-occurring substance use dis- orders involved in or at risk of becoming involved in the justice system. Initially, the CMHP worked to di- vert misdemeanor offenders from the criminal justice system into community-based treatment and support services. Today, the CMHP has expanded to serve de- fendants arrested for lower level felony offenses and other charges as are determined appropriate. It has developed collaborations with other local problem- solving courts including domestic violence court and drug court and has developed partnerships with community mental health and substance abuse treat- ment providers, housing providers and other social services agencies, consumer and family advocacy groups, countywide criminal justice and law enforce-
the most expensive popula-
tions in the community, not
because of their diagnoses
but because of the way they
are treated.
Beyond Bars
ment agencies, and state and federal social welfare agencies.
FUNDING
Initial support for the development of the CMHP was provided through a grant from the National GAINS Center that enabled the courts to host the summit meeting in 2000. The GAINS Center provided tech- nical assistance and helped the community map existing resources, identify gaps in services and service delivery, and develop a more integrated ap- proach to coordinating care. Stakeholders included judges and court staff, law enforcement agencies and first responders, attorneys, mental health and substance abuse treatment providers, state and local social service agencies, consumers of mental health and substance abuse treatment services, and family members.
Using information generated from the summit, pro- gram operations were initiated on a limited basis.
Additional funding was secured from a local phil- anthropic foundation to conduct a planning study of the mental health status and needs of people arrested and booked into the county jail, as well as the processes in place to link people to community- based services and supports. Information from this planning study was used to develop a more formal program design and to secure a 3-year federal tar- geted capacity expansion grant from the Substance Abuse and Mental Health Services Administration, which enabled the CMHP to significantly expand its staffing and operations. At the conclusion of the federal grant period, the county assumed continua- tion of funding for all positions. Because of the pro- gram’s early success and demonstrated outcomes at the misdemeanor level, in 2008 the CMHP was awarded a 3-year grant by the state of Florida to further expand postbooking diversion operations to serve people charged with less serious felonies.
Efforts are currently underway to secure long-term sustainability for felony operations and to develop strategies to increase program capacity.
Since its inception, the CMHP has received ongo- ing support from the Florida Department of Children and Families. This support has included funding case management positions as well as providing resourc- es to secure housing, medications, and transporta- tion for program participants. Early in its develop- ment, the CMHP also benefited from a partnership established with faculty from Florida International
University. This partnership facilitated activities around program planning and evaluation and the preparation and submission of funding proposals.
JAIL AND FORENSIC HOSPITAL DIVERSION PROGRAMS
Today, the CMHP operates a total of four different diversion programs and is working with the county to develop of a first-of-its-kind mental health diver- sion complex. All programs are complemented by support components designed to improve access to basic needs and economic self-sufficiency.
Diversion programs and support components in- clude the following elements:
Prebooking jail diversion program targeting crisis intervention team training for law enforcement officers
Crisis Intervention Team training is designed to educate and prepare law enforcement officers to recognize the signs and symptoms of mental illness and to respond more effectively and appropriately to people in crisis. When appropriate, people are assisted in accessing treatment in lieu of being ar- rested and taken to jail. To date, CIT training has been provided to more than 2,500 officers from 36 law enforcement agencies across the county.
Additional CIT-related training courses have been developed or adapted to target emergency dispatch (e.g., 911) call takers, law enforcement crisis ne- gotiators, correctional officers, other nonpolice law enforcement agencies, and executive management of CIT programs.
Since the implementation of CIT, significantly fewer people in psychiatric crisis are being arrested and booked into jail, law enforcement agencies are ex- periencing fewer injuries to officers and civilians, fewer instances of use of force involving officers and people with mental illness have occurred, and more people are being linked to appropriate care in the community.
Postbooking jail diversion program targeting people arrested for misdemeanor offenses All defendants booked into the jail are screened for signs and symptoms of mental illness by correc- tional officers using an evidence-based screening tool known as the Brief Jail Mental Health Screen.
People charged with misdemeanors who meet pro- gram admission criteria are transferred from the jail to a community-based crisis stabilization unit
within 24–48 hours of booking. On stabilization, legal charges may be dismissed or modified in ac- cordance with treatment engagement. People who agree to services are linked to a comprehensive array of community-based treatment, support, and housing services that are essential for successful community re-entry and recovery outcomes. Pro- gram participants are monitored by CMHP for up to 1 year after community re-entry to ensure ongoing linkage to necessary supports and services. Most participants (75-80 percent) in the misdemeanor diversion program are homeless at the time of ar- rest and tend to be among the most severely psychi- atrically impaired people served by the CMHP. The misdemeanor diversion program receives around 300 referrals annually, with program recidivism rates of just 22 percent, far below most other re- cidivism estimates.
Postbooking jail diversion program targeting people arrested for felony offenses
Participants in the felony jail diversion program are referred to the CMHP through a number of sources including the public defender’s office, the state attorney’s office, private attorneys, judges, correc- tions health services, and family members. All par- ticipants must meet diagnostic and legal criteria as well as be eligible to apply for entitlement benefits such as Supplemental Security Income, Social Se- curity Disability Insurance, and Medicaid. At the time a person is accepted into the felony jail di- version program, the state attorney’s office informs the court of the plea the defendant will be offered contingent on successful program completion. Simi- lar to the misdemeanor program, legal charges may be dismissed or modified on the basis of treatment engagement. All program participants are assisted in accessing community-based services and sup- ports, and their progress is monitored and reported back to the court by CMHP staff. To date, the felony diversion program has served roughly 150 people, and participants have demonstrated reductions of roughly 75 percent in both numbers of arrests and days incarcerated after program enrollment.
Postbooking forensic hospital diversion program targeting people arrested for felony offenses and adjudicated incompetent to proceed to trial The forensic hospital diversion program was recently implemented as a state-sponsored pilot project to serve people in Florida’s forensic mental health
system and to control growth in demand for services provided in state hos- pitals. People served are charged with third-degree and nonviolent second- degree felonies, have been found incompetent to proceed to trial, and require placement in a state hospital in the absence of a less restrictive al- ternative. The program seeks to provide a more cost-effective alternative to forensic hospitalization, while providing enhanced interventions targeting long-term recovery, reduced recidivism, and successful community living.
Admissions for competency restoration in state hospitals in Florida typically result in a length of stay of around 6 months at a cost of $60,000 per indi- vidual. It is estimated that the forensic hospital diversion program can pro- vide a full year of services to program participants — including competency restoration services, recovery services, and community re-entry services — for $32,000 per individual. At current capacity, the program is projected to divert 40 people per year from admission to state hospitals, which is projected to result in a savings to the state of $1.1 million while funding an additional 7,200 days of new community-based treatment services.
MENTAL HEALTH DIVERSION COMPLEX
In support of all diversion programs, Miami-Dade County and the CMHP have been actively working to develop a first-of-its-kind comprehensive mental health diversion, treatment, and community re-entry complex near downtown Miami. Development of this project, which is funded in part through a general obligation bond issue approved by voters, will involve renovating and expanding a former state forensic hospital that has been leased to the county.
The complex will consist of programs operated by community-based treat- ment and social services providers to create a full continuum of care and support, including a crisis stabilization unit, a short-term residential treat- ment program, a transitional housing program, day treatment and day ac- tivity programs, intensive case management, specialized services address- ing the unique needs of people with mental illness involved in the justice system (e.g., trauma treatment and treatment for co-occurring disorders), outpatient services, and job training and employment services. All programs will incorporate peer support and peer leadership components. Space will also be provided for agencies and programs that address the comprehen- sive social needs of people served, such as legal services, public welfare and entitlement programs, and immigration services.
chiatric crisis are being arrested and booked into jail, law enforcement agencies are experi- encing fewer injuries to officers and civilians, fewer instances of use of force involving officers and people with mental illness have occurred, and more people are being linked to appropri- ate care in the community.
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Beyond Bars
In addition to community-based treatment and support services, the complex will house a secure medical unit serving inmates in the custody of the county’s corrections and rehabilitation department who are being evaluated to determine eligibility for diversion. The complex will also include a courtroom to expedite and facilitate legal hearings.
The vision for the mental health diversion complex is to create a centralized, coordinated, and seamless continuum of care for people who are diverted from the criminal justice system either before or after booking. By housing a comprehensive array of ser- vices and supports in one location, it is anticipated that many of the barriers and obstacles to navigat- ing traditional community mental health and social services will be removed, and people will be more likely to engage treatment and recovery services.
SOCIAL SECURITY BENEFITS
All CMHP participants are assisted with individual- ized transition planning and linked to community- based treatment and supports as appropriate.
Services provided include supportive housing, supported employment, assertive community treat- ment, illness self-management and recovery (Well- ness Recovery Action Planning), trauma services, and integrated treatment for co-occurring mental illness and substance use disorders.
Most people served by the CMHP are indigent and are not receiving entitlement benefits at the time of program entry. As a result, many do not have the necessary resources to access adequate housing, treatment, or support services in the community.
To address this barrier and maximize resources, the CMHP developed an innovative plan to improve the ability to transition people from the criminal justice system to the community.
On the basis of an agreement established between Miami-Dade County and the Social Security Admin- istration, a gap-funding program was developed to provide assistance for people applying for federal entitlement benefits such as Supplemental Security Income or Social Security Disability Insurance dur- ing the period between application for and approval of benefits. If approved for benefits, people applying for Social Security are compensated retroactively to the date of initial application. Participants applying for benefits and receiving assistance from the CMHP sign an interim assistance reimbursement agree-
ment, which allows the county to be reimbursed for housing costs when an individual is approved for Social Security benefits and receives a retroactive payment.
In an effort to ensure that program participants who are eligible for entitlement benefits receive them as quickly and efficiently as possible, the CHMP uses a best practice model referred to as SOAR (SSI/SSDI, Outreach, Access and Recovery). This approach was developed as a federal technical assistance initia- tive to expedite access to Social Security entitle- ment benefits for people with mental illness who are homeless. All CMHP participants are screened for eligibility for federal entitlement benefits, with staff initiating applications as early as possible using the SOAR model. Program data demonstrate that 88 percent of the CMHP participants who ap- ply for benefits using SOAR are approved on the initial application. By contrast, the national average across all disability groups for approval on initial application is 37 percent. In addition, the average time to approval for CMHP participants is 62 days.
This achievement is remarkable compared with the ordinary approval process, which typically takes 9–12 months or longer.
LESSONS LEARNED: COLLABORATION IS KEY
The CMHP’s success and effectiveness depends on the commitment, consensus, and ongoing efforts of traditional and nontraditional stakeholders through- out the community. In the past, treatment providers regularly talked with other treatment providers and criminal justice agencies regularly talked with other criminal justice agencies; however, treatment pro- viders and criminal justice agencies rarely bridged the gap between their respective systems. In estab- lishing the CMHP, a mental health committee was established within the courts and a local chapter of a statewide advocacy organization known as Florida Partners in Crisis was formed. The purpose of these bodies was to facilitate and encourage communica- tion and information exchange.
As a representative of the courts, the CMHP is in a unique position to bring together stakeholders who may otherwise not have opportunities to engage in such problem-solving collaborations. By working together across systems and communities to craft more appropriate, responsive, and coordinated pro-
grams and services, it is possible to prevent people from unnecessarily entering the criminal justice sys- tem and to increase opportunities for recovery.
The justice system was never intended to serve as the safety net for the public mental health system and is ill equipped to do so. The current shortcom- ings of the community mental health and criminal justice systems did not arise recently. No one cre- ated these problems alone, and no one will be able to solve these problems alone.
Miami-Dade County Judge Steven Leifman has served as Special Advisor on Criminal Justice and Mental Health for the Supreme Court of Florida since April 2007. In this capacity, Judge Leifman is responsible for chairing the Court’s Mental Health Subcommittee which authored a ground-breaking report entitled, Transforming Florida’s Mental Health System. Judge Leifman also serves as Chair of the Eleventh Judicial Circuit of Florida’s Mental Health Committee, and is responsible for creating the Eleventh Judicial Circuit Criminal Mental Health Project. Judge Leifman is a former Assistant Public Defender for Miami-Dade County, Florida.
Tim Coffey has nearly 20 years of experience in the fields of behavioral health, public health, and social science research and evaluation. Having worked in a variety of healthcare, academic, and government settings, he has been involved in basic and applied research activities addressing mental and behavioral health issues. As coordinator for the Eleventh Judicial Circuit Criminal Mental Health Project, Coffey is respon- sible for the development, implementation, and evaluation of a variety of court-based projects and programs designed around the needs of people with mental illnesses involved in the criminal justice system
