Avoiding Jail Pays Off
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Diverting people with mental illnesses out of prison takes commitment from the community along with adequate funding.
By Sarah Steverman and Tara Lubin
April 2007
Community mental health care can be costly, but it is far cheaper for states than incarceration. It costs around $26 a day to treat someone in a community mental health program, but it can cost more than $65 a day to keep them in jail. And states can tap federal resources to help pay for community mental health services. The vast majority of prison costs, however, falls on the state.
Keeping people with serious mental health needs out of criminal justice systems requires a network of community mental health services. Without good treatment, people with serious mental illnesses often end up in difficult and dangerous situations. Those suffering from schizophrenia, bipolar disorder, major depression and other serious mental health disorders, can have delusional thoughts, hallucinations, extreme moods and other debilitating symptoms. These symptoms can cause a person to make decisions he normally wouldn’t. Sometimes it leads to unlawful behavior.
When adults with serious mental illnesses commit low-level misdemeanors like loitering, public intoxication and panhandling, connecting them to mental health services is better than a stay in jail for both them and the community.
Intervening on behalf of an offender with mental illness can take place at different points in justice proceedings. Police programs bring offenders to a mental health agency or crisis center instead of putting them in jail. Some jails have mental health workers from the local community agency onsite, making assessments easier and quicker while avoiding pre-trial expenses. Other programs are based on a court model, which requires a mental health agency to help identify alternative sentencing recommendations.
Despite variations in diversion programs, all have a common factor: A mental health worker performs an assessment and helps develop an individual treatment plan to get the offender on the right track and to help the justice system monitor his or her progress.
The treatment plans outline what community services the individual will participate in, where he will live, how his medications will be monitored, and how often he will report to his mental health agency and the court. The plan sets recovery goals and outlines the steps to take. The plan also outlines the responsibility of the mental health agency and courts to monitor the individual.
Some plans use “assertive community treatment” for people with serious mental illness. ACT team members are available 24 hours a day and usually check in with their patients almost every day.
Participants with less acute needs may work with a mental health professional during regular office hours but must agree to a specific schedule. With an increased emphasis on drug therapy as an effective mental health treatment, almost all plans for people involved in the justice system address medication management. For the large number of jail diversion participants with co-occurring substance abuse needs, drug rehabilitation is part of their plans.
Addressing the needs of people with mental illness coming from the justice system is similar to addressing the needs of people identified in shelters or schools. Throughout the treatment period, the community mental health worker, program participant and court continually refer to the plan to ensure that everyone is upholding the terms of the agreement and working toward keeping the person out of further trouble and on a path toward recovery.
The biggest obstacle to following the treatment plan is finding the right places for clients to live and work. Landlords and potential employers often require background checks, and housing and employment programs are therefore often reluctant to work with people with criminal records. Connecting a jail diversion program participant to appropriate housing and finding funding is much the same as helping someone coming to community mental health services from homelessness or a hospital. It can be a challenge. “The most common problem is housing,” says Megan Goodfield, director of Connecticut’s Community Forensic Services. “Occasionally the court would prefer a more supervised housing situation [than is available in the community].”
Funding for community services for people who have been in trouble with the law is not that different from those who have not come into contact with the justice system. As with general health care services, the primary funding sources for mental health are Medicare, Medicaid or private insurance, augmented by a relatively small amount of state general funds. Therefore, mental health professionals work with their clients to secure public or private insurance coverage as they begin treatment. Because Medicaid is the primary source of community funding, in addition to determining what each individual needs to reach recovery, it is important for the treatment team to be proficient at choosing services that are reimbursable.
Filling in the Gaps
States are realizing that there is a shortage of resources, especially for people without health insurance. Four years ago, Texas lawmakers appropriated $35 million to provide community-based services for juveniles and adults with serious mental illnesses who were either on probation or in diversion programs. The screening process for these clients includes coordination with local mental health agencies to determine if the offender has previously received public mental health treatment.
“You can pay now or you are going to pay later,” says Representative John E. Davis of Texas. “We have to spend money up front for prevention, community services and support for people with mental health needs, or you’ll end up housing them in the prison system.”
Since 2005, local mental health centers in Texas are required to adopt a state-approved jail diversion plan. Community mental health workers form partnerships with justice officials to find ways to help offenders with mental health needs.
Representative Davis says additional funds of up to $82 million are proposed for crisis intervention. Identifying those who qualify should be easy, he says, because “around 15 to 20 percent of folks in our prisons have been in touch with our mental health or mental retardation system” at some point in their lives. He says new money for community support services would allow mental health and justice to work together to identify, treat and keep people with acute needs out of jail, whether they have been in the justice system before or not.
Connecticut has a long record of keeping people with mental illnesses out of prisons. Since 2001, the legislature has funded diversion programs in the Department of Mental Health and Addiction Services that emphasize treatment. A task force created in 2006 is examining the ways the state is addressing the needs of offenders with mental illness. A subcommittee of the task force is looking for gaps in the community mental health service system for people involved in the criminal justice system. Although the state has one of the most comprehensive mental health systems in the country, some are concerned that certain services fall short. Even with all the resources available, Goodfield of Connecticut’s Community Forensic Services says needs are great and programs are stretched to meet all of them. “I think that’s a common obstacle,” she says.
Senator Gwen Margolis is trying to address the money problem in Florida with a proposed grant program that would help counties pay for community services for people in jail diversion programs. Her legislation, if enacted, would fund a Criminal Justice and Mental Health Reinvestment Grant Program to provide community investment grants for planning, changing or starting up diversion programs. Another bill introduced by Senator Margolis would direct the Substance Abuse and Mental Health Corporation to create a task force to identify barriers to providing comprehensive mental health and substance abuse treatment services to children, youths and adults who are in the criminal justice system.
Margolis says that people with mental illnesses often end up in jail for offenses not much more serious than loitering. Once in jail, they lose their rights to Medicaid and the burden for their mental health care switches from the federal government to the state.
“It’s been a disaster in almost every county in Florida, prisons have become mental health hospitals without adequate space or staff,” she says. “It seems logical to divert people with mental health needs to a program where expenses can be shared with the federal government.”
Sarah Steverman and Tara Lubin work on mental health issues in NCSL’s Washington, D.C., office.