Reducing the Number of People with Mental Illnesses in Jail

Six Questions County Leaders Need to Ask
by Risë Haneberg, Dr. Tony Fabelo, Dr. Fred Osher, and Michael Thompson

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Not long ago the observation that the Los Angeles County Jail serves more people with mental illnesses than any single mental health facility in the United States elicited gasps among elected officials. Today, most county leaders are quick to point out that the large number of people with mental illnesses in their jails is nothing short of a public health crisis, and doing something about it is a top priority.

Over the past decade, police, judges, corrections administrators, public defenders, prosecutors, community-based service providers, and advocates have mobilized to better respond to people with mental illnesses. Most large urban counties, and many smaller counties, have created specialized police response programs, established programs to divert people with mental illnesses charged with low-level crimes from the justice system, launched specialized courts to meet the unique needs of defendants with mental illnesses, and embedded mental health professionals in the jail to improve the likelihood that people with mental illnesses are connected to community-based services.

Despite these tremendous efforts, the problem persists. By some measures, it is more acute today than it was ten years ago, as counties report a greater number of people with mental illnesses in local jails than ever before. Why? After reviewing a growing body of research about the characteristics of people with mental illnesses who are in contact with local criminal justice systems; analyzing millions of individual arrest, jail, and behavioral health records in a cross-section of counties across the United States; examining initiatives designed to improve outcomes for this population; and meeting with countless people
who work in local justice and behavioral health systems, as well as people with mental illnesses and their families, the authors of this brief offer four reasons why efforts to date have not had the impact counties are desperate to see:

There are insufficient data to identify the target population and to inform efforts to develop a system-wide response. New initiatives are frequently designed and launched after considerable discussion but without sufficient local data. Data that establish a baseline in a jurisdiction—such as the number of people with mental illnesses currently booked into jail and their length of stay once incarcerated, their connection to treatment, and their rate of rearrest—inform a plan’s design and maximize its impact. Furthermore, eligibility criteria are frequently established for diversion programs without the data that would show how many people actually meet these criteria. As a result, county leaders subsequently find themselves disappointed by the impact of their initiative. Counties that recognize the importance of using this data to plan their effort often find the data they need do not exist. It is rare to find a county that effectively and systematically collects information about the mental health and substance use treatment needs of each person booked into the jail, and records this information so it can be analyzed at a system level.

Program design and implementation is not evidence based. Research that is emerging on the subject of people with mental illnesses in the justice system demonstrates that it is not just a person’s untreated mental illness but also co-occurring substance use disorders and criminogenic risk factors that contribute to his or her involvement in the justice system. Programs that treat only a person’s mental illness and/or substance use disorder but do not address other factors that contribute to the likelihood of a person reoffending are unlikely to have much of an impact. Further, intensive supervision and limited treatment resources are often not targeted to the people who will benefit most from them, and community-based behavioral health care providers are rarely familiar with (or skilled in delivering) the approaches that need to be integrated into their treatment models to reduce the likelihood of someone reoffending.

The initiative is small in scale. Due to scarce resources, diversion programs or improvements to reentry planning are frequently launched as pilots, rarely taken to scale, and as a result unable to serve many of the people who would be eligible for them. And community-based treatment and other supports are frequently stretched so thin that they are only able to reach a small fraction of the people who need them.

The impact of the initiative is not tracked. County leaders making a significant investment in community-based services and supervision for people with mental illnesses should know what impact that investment has had on these four key measures: reducing the number of people with mental illnesses booked into jail, reducing the length of time people with mental illnesses remain in jail, increasing connections to treatment, and reducing recidivism. But few counties have benchmarked these numbers, and capacity to collect and analyze data is so limited that many county leaders are unable to get data on how many people received treatment and other services or how many people completed a program. Without outcome data, however, it is hard for the people who administer programs and services to focus on clear targets. Similarly, it is hard for county leaders to hold program administrators accountable for desired results.

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