“Stepping Up” to Beat the Mental Health Crisis in U.S. Jails

Over the last 40 years, local jails have increasingly become de facto psychiatric treatment facilities for the millions of people with mental illnesses and substance use disorders who become involved with the local criminal justice system. Counties and states are at the breaking point, many without the resources or capacity to address this population’s mental health needs while ensuring an appropriate criminal justice response and protecting public safety. The national Stepping Up movement offers state and local governments a roadmap for navigating the complicated process of addressing this urgent issue.

  Download the Article in PDF / E-Reader Compatible Format

About the Authors

Risë Haneberg is a Senior Policy Advisor for The Council of State Governments Justice Center.

Karen Watts is the Deputy Director of Communications for The Council of State Governments Justice Center.

There was a time when news of there being more people with mental illnesses in local jails than inpatient treatment facilities in the United States would be shocking. Today, it’s no surprise to hear that jails across the nation see an estimated 2 million people with serious mental illnesses each year1—almost three-quarters of whom also have substance use disorders2—or that the prevalence of people with serious mental illnesses in jails is three to six times higher than for the general population.3 Once incarcerated, people with mental illnesses tend to stay longer in jail and upon release are at a higher risk of returning to jail than people without these illnesses.

“The United States has 5 percent of the world’s population, but we have 25 percent of the world’s prison population. In large part, that’s because we have essentially criminalized mental illness,” U.S. Sen. Al Franken (D-MN) has said. “Instead of providing people with adequate access to mental health treatment, we let them fall through the cracks and languish in jail.”

The human toll—and the cost to taxpayers—is staggering. Jails spend two to three times more on adults with mental illnesses that require intervention than on people without those needs,4 yet often do not see improvements in recidivism or recovery. Despite counties’ and states’ tremendous efforts to address this problem, they are often thwarted by significant obstacles, such as coordinating the efforts of multiple systems and operating with minimal resources. Meanwhile, large numbers of people with mental illnesses continue to cycle through the criminal justice system, often resulting in tragic outcomes, missed opportunities to link them to treatment, inefficient use of funding and failure to improve public safety.

Recognizing the critical role local and state officials play in affecting change, in the spring of 2015, The Council of State Governments Justice Center, the National Association of Counties, and the American Psychiatric Association Foundation joined forces to launch Stepping Up, an unprecedented national initiative of county and state leaders to reduce the number of people with mental illnesses and substance use disorders in jails. With support from the U.S. Department of Justice’s Bureau of Justice Assistance, the initiative builds on the many innovative and evidence-based practices being tested and implemented across the country and engages a diverse group of organizations with relevant expertise, including those representing the criminal justice system, such as sheriffs, jail administrators, judges, prosecutors, defense attorneys and community corrections professionals; and the behavioral health system, including mental health agency directors, treatment providers, and substance use experts, as well as people with mental illnesses and their families, and key advocacy groups, such as the National Alliance on Mental Illness.

The initiative challenges counties to “step up” and commit to addressing the factors contributing to the over-representation of people with mental illnesses in jails, and to using research-based strategies to drive those numbers down. It also provides counties with clear, practical direction for developing action plans to facilitate access to treatment and promote appropriate alternatives to jail. As of April 2016, 251 counties across 42 states had signed on to the initiative, and statewide Stepping Up efforts have been launched in California and Ohio.

At a May 2015 national Stepping Up kick-off event in Columbus, Ohio, mental health advocate and former Rhode Island Congressman Patrick Kennedy said, “Stepping Up is perfectly timed with all of these efforts in prevention, all of these efforts in treating the whole person. The only problem is, those efforts aren’t being taken to scale. And that’s why we’re stepping up—to take the things we already know work to scale.”

A growing number of law enforcement professionals—who are on the front lines of contact with people with mental illnesses in their communities—are being trained to interact with this population effectively, but lack the viable treatment options in the community that are necessary to divert many of these people from jail.

“People with mental illnesses who encounter the criminal justice system need treatment so they are put on a path to recovery,” asserts Dr. Saul Levin, CEO and medical director of the American Psychiatric Association Foundation. “We need to improve the availability of community-based behavioral health care services and we, as providers, must take steps to deliver integrated substance abuse and mental health treatment.” 

In the months following the initiative’s launch, participating counties established strategic plans to attack this challenge, specifically to reduce the number of people with mental illnesses in jail, to reduce their length of stay in jail, to increase the  number of people connected to treatment in the community, and to reduce recidivism. At the summit, a draft document—“Reducing the Number of People with Mental Illness in Jail—Six Questions County Leaders Need to Ask”—was released to further guide counties in this work. The six questions are:

  • Is our leadership committed?
  • Do we conduct timely screening and assessments?
  • Do we have baseline data?
  • Have we conducted a comprehensive process analysis and inventory of services?
  • Have we prioritized policy, practice and funding improvements?
  • Do we track progress?

Jurisdictions that have undertaken this effort include Bexar County, Texas, where the jail is now screening everyone for mental illnesses at booking; New York City, where early diversion options have been implemented to provide treatment for people with mental illnesses and reduce their length of stay in jail; Franklin County, Ohio, where a jail liaison team has been established to ensure that people are being connected to treatment on release; and Salt Lake County, Utah, which has reoriented supervision caseloads to provide more intensive supervision to people with serious mental illnesses who are at a higher risk of reoffending. 

At a national Stepping Up summit in April 2016, 50 select county teams from across the country met in Washington, D.C., to share and compare their strategies in this work, as well as to hear from experts in the field about how to better serve this population. The more than 250 summit participants want to radically reform how local criminal justice systems address the largest mental health crisis this country as ever seen. “We have to meet this urgent problem where it lives: in our local jails and in our communities. It’s not about throwing money at the situation, it’s about being smarter about recognizing who belongs in the criminal justice system and who doesn’t, and redirecting resources to alternative responses that will better serve the individual and the community,” said Chief Deputy Allen Jones of the Champaign County (IL) Sheriff’s Office. Champaign, IL is also a current recipient of a Justice and Mental Health Collaboration Program (JMHCP) grant to develop a system-wide plan to reduce the number of people with mental illnesses in its jail.

The Stepping Up initiative has already seen a high level of commitment and effort to bring about real systemic change in counties and states across the country. Much of this work takes time, however, as well as a willingness to adopt new approaches and the ability to garner crucial funding. “We know more now than ever before what types of approaches can advance both recovery and recidivism-reduction goals,” said Denise O’Donnell, director of the U.S. Department of Justice’s Bureau of Justice Assistance. “[This initiative] leverages a broad range of strategies that improve diversion, community-based treatment, crisis intervention by police, specialty courts and supervision caseloads, reentry planning and other approaches that can be taken to the next level.” 

1 Steadman, Henry, et al., “Prevalence of Serious Mental Illness among Jail Inmates.” Psychiatric Services 60, no. 6 (2009): 761–765. Even greater numbers of people have mental illnesses that are not serious mental illnesses, but still require resource-intensive responses. 
2 Abram, Karen M., and Linda A. Teplin, “Co-occurring Disorders Among Mentally Ill Jail Detainees,” American Psychologist 46, no. 10 (1991): 1036–1045.
3 Steadman, Henry, et al., “Prevalence of Serious Mental Illness among Jail Inmates.” 
4 See, e.g., Swanson, Jeffery, et al., Costs of Criminal Justice Involvement in Connecticut: Final Report (Durham: Duke University School of Medicine, 2011).