Assignment: Psychological Aspects of Criminal Behavior

Perspective

T h e N EW ENGL A N D JOU R NA L o f M EDICI N E

May 5, 2016

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U.S. correctional institutions, local courts, and police officers frequently encounter people with untreated or undertreated serious mental illnesses, often coupled with substance-use

disorders. These encounters usual- ly stem from the alleged commis- sion of a misdemeanor — tres- passing, panhandling, petty theft — or a minor, nonviolent felony. Each year, about 11.4 million people are booked into local U.S. jails, where on any given day, 745,000 of them are held. An esti- mated 16.9% of jail detainees have a serious mental illness,1 which means that nearly 2 million peo- ple with such illnesses are arrest- ed each year.

Florida’s Miami-Dade County faces a particular challenge be- cause, among large U.S. commu- nities, it has the highest percent- age of residents with serious mental

illnesses, but Florida ranks 48th nationally in state funding for community mental health ser- vices. According to county judge Steven Leifman, approximately 9.1% of the county’s population (192,000 adults and 50,000 chil- dren) — two to three times the national average — has serious mental illness, but only about 1% receives services in the public mental health system. Moreover, roughly one third of the county’s under-65 population lacks health care coverage.2 In general, indi- gent people receive treatment only when they’re in extreme cri- sis and present an imminent risk of harm to themselves or others,

or when they enter the criminal justice system.

Many communities have devel- oped strategies to redirect people with mental illnesses away from the criminal justice system. Though these approaches reduce inappropriate arrests and incar- cerations, their effect on commu- nities’ public health and safety is often limited because they reside primarily within the legal system. What sets Miami-Dade County apart is its 15-year effort to de- velop a comprehensive, coordinat- ed response to what’s recognized as a shared community problem requiring a shared community solution. This effort leverages di- verse expertise and resources to divert people with mental illness- es from the criminal justice sys- tem to community-based mental health services, aiming to improve community outcomes.

Decriminalizing Mental Illness — The Miami Model John K. Iglehart

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In addition to grappling with inadequate funding, the local mental health system is ham- pered by fragmented service de- livery and poor coordination, which make it difficult to navi- gate. Some additional funding has been secured from govern- mental and private sources, but the initiative’s success is largely attributable to an effort to struc- ture patterns of service delivery and deploy existing resources in ways that are better aligned with the needs of people coming out of the justice system.

These efforts have helped to reduce the size of the county’s jailed population and the number of police officers injured in the

line of duty and to improve pub- lic safety. Now, Miami-Dade plans to open a facility that it says “will expand the capacity to di- vert individuals from the county jail into a seamless continuum of comprehensive, community-based treatment programs that lever- age local, state and federal re- sources.”3

Miami-Dade’s initiative was launched in 2000, when Judge Leifman, frustrated by the fact that people with mental disor- ders were cycling through his court repeatedly, created the Eleventh Judicial Circuit Criminal Mental Health Project (CMHP). As Leifman explained, “When I became a judge . . . I had no

idea I would become the gate- keeper to the largest psychiatric facility in the State of Florida. . . . Of the roughly 100,000 book- ings into the [county] jail every year, nearly 20,000 involve people with serious mental illnesses re- quiring intensive psychiatric treatment while incarcerated. . . . Because community-based deliv- ery systems are often fragment- ed, difficult to navigate, and slow to respond to critical needs, many individuals with the most severe and disabling forms of mental illnesses . . . fall through the cracks and land in the crimi- nal justice or state hospital sys- tems” that emphasize crisis reso- lution rather than “promoting

ongoing stable recovery and com- munity integration.” 4

The CMHP includes pre-book- ing and post-booking jail-diver- sion programs. The pre-booking part follows the Crisis Interven- tion Team model, in which mental- ly ill people who may otherwise be arrested for minor offenses are diverted to crisis units to re- ceive treatment. Law-enforcement officers undergo 40 hours of training in recognizing signs of mental illness in distressed per- sons and deescalating potentially violent situations. Some 4600 of- ficers serving in Miami-Dade’s 36 municipalities and in county public schools have been trained. In 5 years, officers from the two

largest police departments have responded to about 50,000 men- tal health crisis calls that result- ed in 9000 diversions to crisis units and only 109 arrests. The average daily census in the coun- ty jail system has dropped from 7200 to 4000, one jail facility has been closed, and fatal shootings and injuries of mentally ill peo- ple by police officers have been dramatically reduced.

Participation in treatment for persons diverted pre-booking is based on the state’s civil com- mitment laws and the person’s desire to receive treatment. If someone appears to meet crite- ria for civil commitment, the treat- ment provider may petition the court for authorization for invol- untary outpatient or inpatient placement. More often, however, diverted people do not meet these criteria and are simply pro- vided referrals and linkages for follow-up care.

The post-booking program in- volves identifying people in acute psychiatric distress who’ve been booked into the county jail. After screening them for eligibility, judges can approve defendants’ transfer from jail to a crisis unit, where they receive treatment while the court monitors their progress and case managers em- ployed by the courts and the South Florida Behavioral Health Network work with community- based service providers to arrange ongoing treatment and housing. All participants are assessed for criminogenic risk factors and treatment needs using evidence- based tools. Once participants return to the community, case managers continue to monitor them and their treatment provid- ers for 1 year. Participants who are eligible to apply for federal

Over the past decade, the CMHP has facilitated about 4000 diversions

of defendants with mental illness from the county jail into community-based

treatment and support services.

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entitlement benefits are assisted in preparing and submitting ap- plications.

People referred to the post- booking diversion program who appear to meet criteria for exam- ination under Florida’s civil com- mitment laws may initially enter treatment on an involuntary ba- sis. Once stabilized, they are asked for consent to continue participation; 80% of them agree because participation may mean more favorable disposition of their legal cases, and it provides access to resources and supports that may otherwise be out of reach. The cases of those who re- fuse treatment or participation follow the normal criminal jus- tice process.

Initially, the CMHP served only people charged with misde- meanors. In 2008, the post- booking program was expanded to include defendants arrested for less serious, nonviolent felo- nies, who are screened by the state attorney’s office before en- rollment to ensure that they have no significant history of violence and are unlikely to threaten pub- lic safety. Over the past decade, the CMHP has facilitated about 4000 diversions of defendants with mental illness from the county jail into community-based treatment and support services. The annual recidivism rate has been about 20% among partici- pants who committed a misde- meanor, as compared with roughly 75% among defendants not in the program. Participants

charged with minor felonies have 75% fewer jail bookings and jail days after enrollment in the pro- gram than they had beforehand, and their recidivism rate is much lower than that of their counter- parts outside the program.

Like most mental health pro- grams, the CMHP relies on mul- tiple sources of support, and no program is more important than Medicaid. Unfortunately, Florida is one of 19 states that have de- clined to expand their Medicaid programs under the Affordable Care Act, leaving some 3 million adults with incomes at or below 138% of the federal poverty level without insurance coverage. About 567,000 Floridians fall into this coverage gap and remain unin- sured. “Expanding Medicaid would have had a profound impact on keeping people with a serious mental illness out of both the criminal justice system and the acute mental health system,” Leif- man told me. Although Florida provides little funding for com- munity mental health services, it “spends exorbitantly to house people with mental illnesses in criminal-justice settings.”5

Miami-Dade County stakehold- ers actively support the initia- tive’s replication in other com- munities. In 2015, the Council of State Governments Justice Cen- ter, the National Association of Counties, and the American Psy- chiatric Association Foundation launched “Stepping Up: A Nation- al Initiative to Reduce the Num- ber of People with Mental Ill-

nesses in Jails.” Miami-Dade, chosen as one of four launch sites, has been helping with planning and development. More than 240 counties in 41 states have passed resolutions to ad- vance the goal of reducing the prevalence of people with mental illnesses in their jails, and repre- sentatives of 50 jurisdictions in 37 states recently attended a Step- ping Up Summit meant to help them achieve that aim.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Mr. Iglehart is a national correspondent for the Journal.

1. Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. Prevalence of serious mental illness among jail inmates. Psychiatr Serv 2009; 60: 761-5. 2. Robert Wood Johnson Foundation, Uni- versity of Wisconsin Population Health In- stitute. County health rankings & roadmaps (http://www .countyhealthrankings .org/ sites/ default/ files/ 2016CountyHealthRankings Data .xls). 3. Eleventh Judicial Circuit, Miami Dade County, Florida. Eleventh Judicial Criminal Mental Health Project: program summary. 2016 (http://fmhac .net/ Assets/ Documents/ 2015/ Handouts/ Leifman CMHP Program Description 102714 .pdf ). 4. Where have all the patients gone? Exam- ining the psychiatric bed shortage. Testi- mony before the House Energy and Com- merce Subcommittee on Oversight and Investigation, March 26, 2014 (https:/ / energy commerce .house .gov/ hearings-and-votes/ hearings/ where-have-all-patients-gone -examining-psychiatric-bed-shortage). 5. Leifman S. Give people with mental ill- ness treatment, not a jail cell. Miami Herald. May 29, 2014 (http://www .patrickjkennedy .net/ articles/ give-people-mental-illness -treatment-not-jail-cell).

DOI: 10.1056/NEJMp1602959 Copyright © 2016 Massachusetts Medical Society.

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