SPEAKERS CONTENTS INSERTS
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670–345
2000
IMPACT OF MENTALLY ILL OFFENDERS ON THE CRIMINAL JUSTICE SYSTEM
HEARING
BEFORE THE
SUBCOMMITTEE ON CRIME
OF THE
COMMITTEE ON THE JUDICIARY
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTH CONGRESS
SECOND SESSION
SEPTEMBER 21, 2000
Serial No. 143
Printed for the use of the Committee on the Judiciary
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For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 20402
COMMITTEE ON THE JUDICIARY
HENRY J. HYDE, Illinois, Chairman
F. JAMES SENSENBRENNER, Jr., Wisconsin
BILL McCOLLUM, Florida
GEORGE W. GEKAS, Pennsylvania
HOWARD COBLE, North Carolina
LAMAR S. SMITH, Texas
ELTON GALLEGLY, California
CHARLES T. CANADY, Florida
BOB GOODLATTE, Virginia
STEVE CHABOT, Ohio
BOB BARR, Georgia
WILLIAM L. JENKINS, Tennessee
ASA HUTCHINSON, Arkansas
EDWARD A. PEASE, Indiana
CHRIS CANNON, Utah
JAMES E. ROGAN, California
LINDSEY O. GRAHAM, South Carolina
MARY BONO, California
SPENCER BACHUS, Alabama
JOE SCARBOROUGH, Florida
DAVID VITTER, Louisiana
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JOHN CONYERS, Jr., Michigan
BARNEY FRANK, Massachusetts
HOWARD L. BERMAN, California
RICK BOUCHER, Virginia
JERROLD NADLER, New York
ROBERT C. SCOTT, Virginia
MELVIN L. WATT, North Carolina
ZOE LOFGREN, California
SHEILA JACKSON LEE, Texas
MAXINE WATERS, California
MARTIN T. MEEHAN, Massachusetts
WILLIAM D. DELAHUNT, Massachusetts
ROBERT WEXLER, Florida
STEVEN R. ROTHMAN, New Jersey
TAMMY BALDWIN, Wisconsin
ANTHONY D. WEINER, New York
THOMAS E. MOONEY, SR., General Counsel-Chief of Staff
JULIAN EPSTEIN, Minority Chief Counsel and Staff Director
Subcommittee on Crime
BILL McCOLLUM, Florida, Chairman
STEVE CHABOT, Ohio
BOB BARR, Georgia
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GEORGE W. GEKAS, Pennsylvania
HOWARD COBLE, North Carolina
LAMAR S. SMITH, Texas
CHARLES T. CANADY, Florida
ASA HUTCHINSON, Arkansas
ROBERT C. SCOTT, Virginia
MARTIN T. MEEHAN, Massachusetts
STEVEN R. ROTHMAN, New Jersey
ANTHONY D. WEINER, New York
SHEILA JACKSON LEE, Texas
GLENN R. SCHMITT, Chief Counsel
DANIEL J. BRYANT, Chief Counsel
RICK FILKINS, Counsel
CARL THORSEN, Counsel
BOBBY VASSAR, Minority Counsel
C O N T E N T S
HEARING DATE
September 21, 2000
OPENING STATEMENT
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Gekas, Hon. George W., a Representative in Congress From the State of Pennsylvania, and presiding chairman, Subcommittee on Crime
WITNESSES
Arons, Bernard S., M.D., Director, Center for Mental Health Services, Department of Health and Human Services
Cayce, James D., judge, Superior Court of the State of Washington, Seattle, WA
DeWine, Hon. Mike, a U.S. Senator From the State of Ohio
Eslinger, Donald F., sheriff, Seminole County, Florida
Hogan, Michael F., director, Ohio Department of Mental Health, on Behalf of the National Association of State Mental Health Program Directors
Melekian, Bernard K., president, Los Angeles County Police Chiefs Association, and chief, Pasadena Police Department, Pasadena, CA
Schrunk, Michael D., district attorney, Multnomah County, Oregon
Sharfstein, Steven S., M.D., president and medical director, Sheppard Pratt Health System, Baltimore, MD
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Slate, Risdon N., member, board of directors, National Alliance for the Mentally Ill, Lakeland, FL
Strickland, Hon. Ted, a Representative in Congress From the State of Ohio
Thompson, Robert J., chairman, Law and Justice Committee, Pennsylvania State Senate, Harrisburg, PA
Webdale, Kim, New York, NY
Wilkinson, Reginald A., director, Ohio Department of Rehabilitation and Correction, and vice president, Association of State Correctional Administrators, Columbus, OH
LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING
Arons, Bernard S., M.D., Director, Center for Mental Health Services, Department of Health and Human Services: Prepared statment
Cayce, James D., judge, Superior Court of the State of Washington, Seattle, WA: Prepared statment
DeWine, Hon. Mike, a U.S. Senator From the State of Ohio: Prepared statment
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Eslinger, Donald F., sheriff, Seminole County, Florida: Prepared statment
Hogan, Michael F., director, Ohio Department of Mental Health, on Behalf of The National Association of State Mental Health Program Directors: Prepared statment
National Association of Counties (NACo): Prepared statement
Melekian, Bernard K., president, Los Angeles County Police Chiefs Association, and chief, Pasadena Police Department, Pasadena, CA: Prepared statment
McCollum, Hon. Bill, a Representative in Congress From the State of Florida, and chairman, Subcommittee on Crime: Prepared statement
Schrunk, Michael D., district attorney, Multnomah County, Oregon: Prepared statment
Sharfstein, Steven S., M.D., president and medical director, Sheppard Pratt Health System, Baltimore, MD: Prepared statment
Slate, Risdon N., member, board of directors, National Alliance for the Mentally Ill, Lakeland, FL: Prepared statment
Strickland, Hon. Ted, a Representative in Congress From the State of Ohio: Prepared statment
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Thompson, Robert J., chairman, Law and Justice Committee, Pennsylvania State Senate, Harrisburg, PA: Prepared statment
Webdale, Kim, New York, NY: Prepared statment
Wilkinson, Reginald A., director, Ohio Department of Rehabilitation and Correction, and vice president, Association of State Correctional Administrators, Columbus, OH: Prepared statment
APPENDIX
Material submitted for the record
IMPACT OF MENTALLY ILL OFFENDERS ON THE CRIMINAL JUSTICE SYSTEM
THURSDAY, SEPTEMBER 21, 2000
House of Representatives,
Subcommittee on Crime,
Committee on the Judiciary,
Washington, DC.
The subcommittee met, pursuant to notice, at 1:30 p.m., in Room 2226, Rayburn House Office Building.
Present: Representatives George W. Gekas, Steve Chabot, Howard Coble, Robert C. Scott, and Sheila Jackson Lee.
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Staff present: Glenn R. Schmitt, chief counsel, Rick Filkins, counsel; Veronica L. Eligan, staff assistant; and Bobby Vassar, minority counsel.
OPENING STATEMENT OF PRESIDING CHAIRMAN GEKAS
Mr. GEKAS. The hour of 1:30 having arrived, the committee will come to order.
The Committee on Crime as a subcommittee of the full Judiciary Committee has scheduled and is now in the process of beginning the hearing, a special hearing on the mentally ill in our criminal justice system. The chairman of the subcommittee, Bill McCollum, of Florida, has for many years been involved in a series of questions and problems that have arisen out of that very same question, including the question of insanity defense in the death penalty arena and other prosecutions, the homeless and how the mentally ill of that population uniquely affect that urban problem, and continuously on the people in prison who have been or become mentally ill. So it is not a phenomenon that Chairman McCollum has scheduled this hearing but, rather, a continuum of his often expressed interest in this subject.
Without objection, I will enter into the record the opening statement that Bill McCollum has prepared and only from it will I quote some statistics that I think can lay the proper groundwork before we get to the witnesses.
[The prepared statement of Mr. McCollum follows:]
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PREPARED STATEMENT OF HON. BILL MCCOLLUM, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA, AND CHAIRMAN, SUBCOMMITTEE ON CRIME
Today, the Subcommittee on Crime holds a hearing on the impact of mentally ill offenders in the criminal justice system. A recent Bureau of Justice Statistics study reported that 283,000 mentally ill offenders are incarcerated Federal, state, and local prisons and jails. It estimates that 16% of state inmates, 7% of Federal offenders, and 16% of those held in local and county jails are mentally ill. A similar percentage of persons on probation, approximately 547,000 people, also have a history of mental illness.
I doubt that many people knew that these numbers were as high as they are. And they suggest a problem that I know has not been examined by this Subcommittee in some time, if at all, and one which I believe we should begin to consider. That is the purpose of our hearing here today.
Today we will hear from people who have experience in dealing with mentally ill persons at various stages in the criminal justice system, including law enforcement and corrections officials, judges, prosecutors, and mental health experts. They will discuss the impact that these offenders have on society, and the problems that result from not taking the necessary steps to treat them in appropriate ways. They will also discuss the limitations of the criminal justice system, as it is presently structured, in dealing with these types of offenders. And they will discuss the impact that these offenders have on the criminal justice system.
Mentally ill offenders serve, on average, 15% longer prison terms than other offenders. And while incarcerated, they are more likely than other offenders to be involved in fights with other inmates and to be charged with breaking prison rules. If for no other reason than the burden these types of offenders place on the system, we should examine whether we are dealing with them appropriately.
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We are particularly fortunate to be hearing today from Sen. Mike DeWine and Rep. Ted Strickland. Both of these Members have introduced legislation on this issue and while this hearing is not a legislative hearing on their bills, I believe it is appropriate to discuss proposals to address this problem, and I know the Subcommittee will benefit from the testimony of these Members who have devoted time to studying this issue. And so with that, I welcome all of our many witnesses here today, and I look forward to receiving their testimony.
Mr. GEKAS. In his opening statement, Bill McCollum states that one of the figures is 283,000 mentally ill offenders are incarcerated in our Federal, State, and local prisons and jails. It estimates that 16 percent of State inmates, 7 percent of Federal offenders, and 16 percent of those held in local and county jails are mentally ill. A similar percentage of persons on probation, approximately 547,000 people, also have a history of mental illness.
I believe that that opening paragraph on the part of Representative McCollum lays the proper foundation for this massive and pressing problem. So the witnesses, I am sure, will elucidate on how these figures impact on their own institutions, on their own careers, on their own ability to try to solve some of the problems.
When the time comes, we, of course, will subject the witnesses to some examination, Q&A, as is the routine in these hearings, and we will hope to gain from all today a new drive toward solving some of these very distinct problems in our criminal justice system.
With that, I yield to the gentleman from Virginia, the ranking member, Mr. Scott.
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Mr. SCOTT. Thank you, Mr. Chairman, and I am pleased to join you in convening the hearing on the impact of the mentally ill on the criminal justice system. Since the 1960's, State mental health hospitals have increasingly reduced their populations of mentally ill individuals in response to a nationwide call for deinstitutionalization. The move toward deinstitutionalization has been based upon the fact that persons with mental illnesses are constitutionally entitled to refuse treatment or, if they are institutionalized, to have it provided in the least restrictive environment. Unfortunately, community mental health treatment centers have not been created at a rate necessary to meet the needs of those individuals.
In a recent report by the Department of Justice, we find that the criminal justice system has become by default the primary caregiver of the most seriously mentally ill. More specifically, that report stated that last July at least 16 percent of those in local jails, at least 16 percent of those in State prisons, and 7 percent of Federal inmates reported either a mental condition or an overnight stay in a mental hospital and were identified as mentally ill. The highest rate of reported serious mental illness was among white female inmates at 29 percent.
The National Alliance for the Mentally Ill reports that on any given day at least 284,000 schizophrenic and manic-depressive individuals are incarcerated, while only 187,000 seriously mentally ill individuals are in mental health facilities.
It is my hope that this hearing will shed light on the extent to which these individuals with mental illness are falling through the cracks and landing in the criminal justice system, whether corrections administrators are sufficiently equipped to provide appropriate services to offenders with mental illness, and whether providing proper mental health treatment can actually reduce crime.
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Finally, I look forward to the testimony of Senator DeWine from Ohio and Congressman Ted Strickland from Ohio regarding specific suggestions on the role Congress should play. And while I understand that this hearing is not on the bills that they have introduced—that is, H.R. 2594 and its companion S. 1865, America's Law Enforcement and Mental Health Project, and another bill H.R. 5091, the Mental Health Early Intervention Treatment and Prevention Act of 2000—although this is not a hearing on those bills, I hope we will have the opportunity to touch upon what those bills might provide.
In the end, our goal must be to find a better way to address the needs of persons with mental illness and to address those needs to prevent criminal activity.
Mr. Chairman, I thank you for scheduling the hearing and looking forward to the testimony.
Mr. GEKAS. We thank the gentleman.
Let the record indicate that a member of the committee, the gentleman from Ohio, Mr. Chabot, is present and is able and willing, I understand, to present to us the witnesses on the first panel.
Mr. CHABOT. Thank you, Mr. Chairman. I am pleased to have two members of the Ohio delegation here for this panel.
I would first like to welcome the senior Senator from my State of Ohio, Senator Mike DeWine. Senator DeWine was first elected to the Senate in 1994. Prior to serving in the other body, he spent 8 years here in the House and also served as the Lieutenant Governor of Ohio. He was also a prosecutor in the State of Ohio prior to that. He chairs the Senate Subcommittee on Antitrust, Business Rights and Competition of the Judiciary Committee and the Subcommittee on Aging of the Health, Education, Labor and Pensions Committee. Senator DeWine has introduced S. 1865, America's Law Enforcement and Mental Health Project, which would provide grants to establish demonstration mental health courts.
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Senator DeWine is a great advocate for those who need help, especially children and the elderly, and I am looking forward to hearing his testimony on this important issue, and we welcome you this afternoon, Senator DeWine.
I also have the privilege of introducing another member of the Ohio delegation, my friend and colleague, Representative Ted Strickland. Congressman Strickland was first elected in 1992, was gone for one term but came back again in 1996, and was re-elected again in 1998. Prior to serving in the House, he worked as a minister, a psychologist, and a college professor. He was a director of a Methodist children's home, an assistant professor of psychology at Shawnee State University, and a consulting psychologist at the Southern Ohio Correctional Facility in Ohio. He holds a doctoral degree in counseling psychology from the University of Kentucky. He is the founding co-chair of the House Correctional Officers Caucus.
Representative Strickland introduced H.R. 2594, America's Law Enforcement and Mental Health Project, which would provide grants to establish 25 demonstration mental health diversion courts. We welcome you here this afternoon, Ted, and we look forward to your testimony as well.
Mr. GEKAS. Thank you, Mr. Chabot.
We join Steve in welcoming our colleagues in the Senate and the House. When Mike DeWine was elected to the Senate, with that one bold stroke the intelligence quotient of the Senate and the House was amply increased. But notwithstanding that, we start with the order of seniority. We will ask Mike to begin the testimony.
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STATEMENT OF HON. MIKE DeWINE, A U.S. SENATOR FROM THE STATE OF OHIO
Mr. DEWINE. Well, Mr. Chairman, thank you very much. Let me just tell you how nice it is to be back in a subcommittee on which I served. As I recall, Mr. Chairman, you always outranked me by one on the Judiciary Committee, so my leaving did not improve your lot. [Laughter.]
You just have someone else who is right behind you and I see that your progress has continued over the years. Since we came to the Congress together in 1982, it is good to be with you again, Mr. Chairman.
This might seem like sort of the all-Ohio day with myself and my good friend, Ted Strickland. We also have two very important witnesses: Michael Hogan, director of the Ohio Department of Mental Health, and Reggie Wilkinson, who is the director of the Rehabilitation and Correction Services in Ohio. I have worked with both of them, Mr. Chairman, when I was Lieutenant Governor, and so I am glad that they are here. They are both experts, and they both know a lot more about this subject than I do. But I will share a few thoughts with you, if I could.
My experience with this problem goes back to when I was an assistant county prosecutor and then the elected county prosecutor in my home county of Greene County. I can't tell you how often a police officer would come to me for charges and, as he or she was describing the individual who was being charged, would tell me that the suspect had a mental problem. And they would usually say it in much more graphic terms than that.
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That is a problem that continues today. It is a problem that is due to many reasons: deinstitutionalization in the 1960's through the 1970's and later, the homelessness and drug issues. We could go on and on. It is a problem, and it is much more of a problem today for our courts and our penal systems than it has ever been in the past.
What I have tried to do with the legislation that I have introduced in the Senate and what Ted has tried to do with legislation that he has introduced in the House is to say on behalf of the Federal Government this is a problem and we need to try some different approaches. We need to try some pilot projects. We need to try to be of assistance to the local community. Not that we want to tell the local community how to deal with a criminal justice problem, but every community is dealing with this problem.
When you talk to Reggie Wilkinson, who heads our prison system in Ohio, who will testify, he will tell you the percentage of people in our prison system today who have a mental health problem. And he will tell you that they are trying to do a good job with these folks, but they lack the resources, candidly, to do it.
If you were to talk to a county sheriff in Greene County or Clark County or, Mr. Chairman, in one of your counties in Pennsylvania, they would tell you the same thing. They deal with people all the time who have mental health problems, and they don't have the resources to deal with them.
We need to do a better job taking what resources we do have in the community and meshing them with our criminal justice system. We have come a long way since I was a county prosecutor in the 1970's when there used to be a huge wall between any social services and the correction system and the criminal justice system. We are breaking that wall down, taking it down brick by brick. But an area where we still frankly don't have the merger that we need is in the area of mental health. And so we need to break those barriers down to get the mental health assistance to people in our system.
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As I explain to people, they say, well, you know, we have a lot of people who have mental health problems. Yes, we do. But if you had to pick a segment of the population that is likely to cause you and me and our families problems in the future because of their mental health problems, you could probably start with looking in our prisons and in our jails. These folks, we are already paying to house them and to feed them and to clothe them. It just makes sense to try to get some mental health assistance to them, and to provide some alternative that is what our respective bills do.
I am not here to advocate for our bill today, but what I am here to say is this is a problem that we as a country really have to begin to deal with. So I appreciate the opportunity to be with you. This legislation that both Ted and I are promoting is an attempt really to mesh mental health and other social services, and to get their assistance into court, where there needs to be a lot of expertise in this area.
I thank you for taking the time to look at this very, very important issue.
[The prepared statement of Senator DeWine follows:]
PREPARED STATEMENT OF HON. MIKE, DEWINE, A U.S. SENATOR FROM THE STATE OF OHIO
Chairman McCollum, thank you for the opportunity to testify about the impact of the mentally ill in the criminal justice system. I also appreciate the opportunity to share this panel with my colleague from Ohio, Representative Ted Strickland, who is a leader on this important issue.
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My interest in and experience with the criminal justice system began more than 25 years ago, when I was working as a prosecutor in my home of Greene County, Ohio. I have continued that interest throughout my career in public service. What I learned, though, early on is that our state and local penal facilities have become way stations for far too many of our nation's mentally ill.
A recent Justice Department study revealed that 16 percent of all inmates in America's state prisons and jails are mentally ill. In Ohio last year, 18 percent of all prison inmates received some type of mental health services. Further, the Justice Department estimates that nationwide some 238,000 mentally ill offenders were incarcerated in 1998, alone.
Most local jails have been struggling for decades to deal with overcrowding. As the mentally ill inmate population continues to grow rapidly, local jails are becoming overwhelmed by the need to care for larger and larger numbers of mentally ill persons.
There seem to be several notable causes for the increase over the last thirty years of the mentally ill in our penal system, such as the crisis in community mental health care, the drug epidemic, and increases in homelessness. The deinstitutionalization of thousands of America's mentally ill has had dramatic effects on our criminal justice system. The situation we have today in our prisons and jails is essentially the result of a vast assault on involuntary commitment laws and over thirty years of budget cuts of mental health institutions. Unfortunately, community mental health providers have been unable to fill the void of mental health care.
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As a result, some mentally ill persons, by default, have landed in our prisons and jails. It is unacceptable that Los Angeles County and New York jails have essentially become the largest mental health care institutions in our country—these are jails, after all, not mental health facilities. Even in my home state of Ohio, nearly 1 in 5 prisoners need psychiatric services or special accommodations.
Throughout this destructive cycle, law enforcement agencies and corrections institutions designed to fight crime have had to spend valuable time and scarce resources providing mental health services to prisoners. Certainly, some mentally ill offenders must be incarcerated because of the severity of their crimes. But, many others could receive appropriate care early on, reducing recidivism and unnecessary burdens on our police and corrections officials, as well as the mentally ill offender.
That's why Representative Strickland and I have introduced America's Law Enforcement and Mental Health Project (LAMP) in both the House and Senate. This legislation would help states and local communities to create mental health court programs. It is my hope that this will help to address more effectively the problems our criminal justice system is facing currently. This bill also would help community services and support structures coordinate programs and services for mentally ill persons before their contact with the penal system. I am convinced that the plight of the mentally ill in our justice system is a sleeping giant, just as domestic violence was a decade ago. Mental health courts are a good method to begin revealing and addressing the problems of the mentally ill who are arrested.
These courts would be specialized courts with separate dockets and dedicated knowledgeable personnel. Courts would only be required to hear cases involving non-violent offenses. Under my bill, each court would have the flexibility to develop a program to meet its own specific needs. Thus, mental health courts would provide state and local courts with alternative sentences or alternatives to prosecution for those offenders who can best be served by mental health treatment and other community services.
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Mental health courts would expedite early intervention by the timely identification, screening, and referral of potential candidates. A core group of specialized professionals would staff the mental health court, including a dedicated judge, prosecutor, public defender and court liaison to the service providers in the community.
One of the most critical aspects of this program is the coordination of services between the justice system, mental health providers, and support systems. I believe the absence of this coordination between the systems is one of the causes for the increased presence of the mentally ill offenders in the penal system. Each court, moreover, would provide supervision of participants that is more intensive than might otherwise be available, with an emphasis on accountability and monitoring the participant performance.
As you know, Mr. Chairman, the first Mental Health Court was established in Broward [brow-erd] County, Florida, almost two years ago. This court has been a remarkable success. This court hears an average of 69 cases per month and has linked over one-third of all its defendants with community health care providers or private psychiatric help. Notably, less than ten percent of all defendants were deemed inappropriate for their mental health court program, and only eight percent refused community health services. Broward County has found that many mentally ill defendants did not always know what treatment options were even available to them before they fell into the hands of the criminal justice system.
I am pleased that efforts are already underway to create a mental health type-court in my home state in Hamilton County, Ohio. The county courts are experimenting with a process to separate and move cases involving mentally ill defendants from the regular morning docket to what is being called the ''one o'clock p.m.'' docket. Moving these special cases from the busy morning docket permits more time for all relevant court and social service players to intervene. This small time changes has had big impacts in helping to provide get defendants quick and appropriate mental health treatment when needed.
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I urge my colleagues to join us in support of this legislation. I believe that mental health courts will be a dynamic step forward both for the criminal justice system and for the mentally ill caught in that system.
Again, Mr. Chairman, thank you for the opportunity to discuss this important issue.
Mr. GEKAS. We thank the Senator, and we turn to his and our colleague, Representative Strickland.
STATEMENT OF HON. TED STRICKLAND, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO
Mr. STRICKLAND. Mr. Chairman, thank you, and I would like to begin my statement by saying how very deeply I appreciate the work of Senator Mike DeWine. He and his staff have been absolutely wonderful in working with us, and I really appreciate it, Mike, so much.
Senator DeWine. I enjoyed working with you.
Mr. STRICKLAND. As a psychologist, and perhaps the only Member of Congress who has ever worked in a maximum security prison, I have personally treated individuals who will live out the rest of their lives behind bars because they have committed crimes that they most likely would not have committed had they received adequate mental health treatment. I have seen the ravaging effect that a prison environment has on the mentally ill and the destabilizing effect that the mentally ill have on the prison environment. Inmates, families, correctional officers, judges, prosecutors, and police are in unique agreement that our broken system of punting the most seriously mentally ill to the criminal justice system must be fixed.
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But as we consider the effects of this system, this broken system, I hope we remember how it became broken in the first place. By 1963, we realized that State mental hospitals were too often institutions for quarantining the mentally ill. So the Congress passed the Community Mental Health Centers Act to move the mentally ill out of prolonged confinement in overcrowded custodial institutions into voluntary treatment at community mental health centers. And in October of 1963, President Kennedy signed the Community Mental Health Centers Act.
Unfortunately, the Congress, those of us in Congress seem to have played a trick upon the most vulnerable population in America by refusing to adequately fund community mental health centers. And to make matters worse, we imposed restrictions on Medicaid that kept Medicaid dollars from going into State mental hospitals. We effectively set in a motion a public health tragedy that resulted in thousands of mentally ill patients winding up on the streets of communities that do not have adequate services to treat them.
It should not surprise us, then, that jails are becoming America's new mental asylums. Our current court systems, prisons, and jails are being clogged with mentally ill individuals who should be taking part in mental health treatment. Law enforcement and correctional officers who are charged with apprehending and incarcerating the most dangerous criminals in our society cannot always do their jobs because they are forced to provide makeshift mental health services to hundreds of thousands of mentally ill individuals. Squad cars, jail cells, and courtrooms are filled with the mentally ill, taking up resources that should be directed toward catching real criminals.
Mental illness does not discriminate between Republicans and Democrats, rich or poor, black or white, man or woman—none of the dividing lines that so often create partisan politics. And that is why I am especially gratified to be working on this legislation with distinguished members from both sides of the aisle and from both sides of the Hill. We are trying to create mechanisms that will bridge the gap between the mental health and the criminal justice systems.
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I would like to thank not only Senator DeWine but Senators Domenici, Kennedy, and Wellstone, as well as Representatives Wilson, Waxman, Horn, Capps, Roukema, and Kaptur for taking the lead on sponsoring legislation to provide criminal justice and mental health professionals the resources they need to work together in order to keep mentally ill defendants in treatment rather than jail.
I would like to quickly and briefly summarize the current legislation.
H.R. 2594, America's Law Enforcement and Mental Health Act, which I introduced last July, seeks to help local communities close the revolving door of recidivism among the mentally ill population by providing modest Federal grants to establish these mental health courts in order to direct non-violent mentally ill offenders out of jail into long-term treatment.
Secondly, the Mental Health Early Intervention, Treatment and Prevention Act of 2000, which was first introduced last May in the Senate by Senators Kennedy, Domenici, Wellstone, and I believe Senator DeWine was heavily involved in that, is an attempt to finally fulfill the unkept promise that was provided through the Community Mental Health Act of 1963. It would do that by making grants to communities for mental health treatment centers, as well as the training of non-traditional front-line mental health workers like teachers, law enforcement, and fire fighters. Additionally, this bill seeks to lessen the burden of the mentally ill on the criminal justice system by providing grants that train police on how to identify the mentally ill and direct them into available treatment, to fund jail and prison programs that screen, evaluate, and treat mentally ill inmates, and to create these mental health courts to direct non-violent mentally ill defendants out of this revolving door of recidivism.
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Last July, Members of Congress, including Congresswoman Wilson, Congressmen Waxman and Horn, Congresswoman Capps, Congresswoman Roukema, Congresswoman Kaptur, and myself introduced H.R. 5091, a mirror companion to the Senate bill.
As the co-chair of the Congressional Corrections Caucus, I hope that this Congress will seize upon these legislative opportunities with the same courage and compassion with which law enforcement and correctional officers deal with the mentally ill every day.
In conclusion, I want to thank this subcommittee for being willing to closely look at this problem from which so many turn away. I believe that there is a welcome consensus among a broad spectrum of stakeholders and political ideologies that there are very practical steps we can take to stop the criminal justice system from being this country's primary caretaker of the seriously mentally ill. The truth is that law enforcement and correctional officers are not and should not be psychiatrists, psychologists, social workers, and nurses with guns.
I thank you for giving the good Senator and myself the opportunity to share our thoughts and our feelings with you this afternoon.
[The prepared statement of Mr. Strickland follows:]
PREPARED STATEMENT OF HON. TED STRICKLAND, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO
Chairman McCollum, Ranking Member Scott, and distinguished members of the Subcommittee, thank you for inviting me to testify today about the very serious problem of mentally ill people recycling through our criminal justice systems. As a psychologist, and perhaps the only member of Congress who has worked in a maximum security prison, I have personally treated individuals who will live out the rest of their lives behind bars because they have committed crimes that they most likely would not have committed had they been able to receive adequate mental health treatment. I have seen the ravaging effect that a prison environment has on the mentally ill, and the destabilizing effect that the mentally ill have on a prison environment. Inmates, families, guards, judges, prosecutors and police are in unique agreement that our broken system of punting the most seriously mentally ill to the criminal justice system must be fixed.
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Background of the Problem
As we consider the effects of this broken system, we should remember how it became broken in the first place. In 1963, Health, Education and Welfare Secretary Anthony Celebrezze said, ''The facts regarding mental illness and mental retardation reveal national health problems of tragic proportions compounded by years of neglect.'' He said that large state mental hospitals were primarily institutions for quarantining the mentally ill, not for treating them and that ''all levels of government, as well as private individuals and groups, must share the responsibilities of a 20th century approach to this outstanding national health problem.''
We in Congress responded to this ''outstanding national mental health problem'' by passing the Community Mental Health Centers Act which sought to move as many of the mentally ill as possible out of prolonged confinement in overcrowded state custodial institutions into voluntary treatment at community mental health centers. On Oct. 31, 1963, President Kennedy signed the Community Mental Health Centers Act into law.
Unfortunately, we in Congress failed to keep this Act's promise by failing to fund it. We refused to provide the money needed to help states build adequate community mental health infrastructures. To make matters worse, we imposed restrictions on Medicaid that kept Medicaid dollars from going into state mental hospitals. Thus, we set in motion a public health tragedy that resulted in thousands of mentally ill patients being dumped out of state hospitals into communities that did not have the adequate services to receive them.
Do not misunderstand me. I know that reform efforts were well intended. However, those same reform efforts that were meant to protect people with mental illness resulted in many of the most severely ill going without needed treatment and, in too many cases, becoming homeless, incarcerated, suicidal, and victimized. Ironically, those efforts are euphemistically referred to as ''the deinstitutionalization movement.'' In my opinion, the huge numbers of mentally ill individuals in jails, prisons, homeless shelters, and flop houses demand we call this movement what it has become: transinstitutionalization.
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Impact of the Mentally Ill on the Criminal Justice System
Law enforcement and corrections officers will tell you that they are at ground zero of our country's mental health crisis, 24/7. Here are just a few of the grizzly statistics:
25% to 40% of mentally ill individuals become involved in the criminal justice system;
In July 1999, the Department of Justice issued a Special Report announcing that at least 16% of state jails and prisons, or 260,000 people, are individuals with severe mental illness. That is more than four times the number of people currently in state mental hospitals;
The American Jail Association estimates that 600,000 to 700,000 bookings each year involve individuals with mental illness;
On any given day, at least 284,000 schizophrenic and manic depressive individuals are incarcerated, and 547, 800 are on probation;
By default, L.A. County Jail is now the largest mental institution in the United States, holding an estimated 3,300 mentally ill inmates on any given night.
These statistics represent countless backwards steps that have been made in the name of progress. They remind me of what the governor of Virginia said when he expressed dismay that he was ''forced to authorize the confinement of persons with mental illnesses in the Williamsburg jail, against both his conscience and the law,'' because of lack of appropriate services. That was in 1773.
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More than two hundred years later, we have unfortunately come to accept incarceration and homelessness as part of life for the most vulnerable population among us. Unfortunately, our expectation of what life has to offer the most seriously mentally ill is tragically low. I believe that our low expectations result at least in part from the backdrop of hopelessness that is created by the 200,000 individuals with schizophrenia or manic-depressive illness who are now living out their symptoms on the streets. In many cities, including our nation's capitol, seriously mentally ill people are now an accepted part of the urban landscape, sleeping on sidewalks, shuffling through the streets, talking to people only they can see. Unlike the rest of us, law enforcement officers don't have the luxury of looking away.
Reasons for Hope
Ironically, in the midst of this tragedy comes unprecedented reasons for hope for the mentally ill. The U.S. Congress declared the 1990s The Decade of the Brain. During the last decade, an explosion of information about mental illness has occurred. New technologies opened windows onto the human mind, revealing for the first time how the molecules of our brains coordinate thought, feeling and emotion. MRIs showed us what schizophrenia looks like. Brain imaging showed us how behavioral therapy actually changes the brain's physical make-up. Research helped us not only gain a better understanding of what mental illness looks like but how we can better treat it.
Just last year, Surgeon General Satcher released the first-ever Surgeon General Report on Mental Health. Though the Report deals extensively with the neuroscience of mental health, it emphatically stands for the proposition that neuroscience alone cannot treat the human mind. The Surgeon General makes clear that neuroscience and behavioral science are necessary partners in understanding and treating mental illness.
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This seminal report alerted the nation and the world about the prevalence of mental illness, how it effects children differently than adults, how delivery systems currently work, and how they might change to work better in the future. But perhaps most importantly of all, the Surgeon General's Report refutes any effort to moralize mental health, officially ending the distinction we have too long made between mental and physical health.
Strategies for Change
Mental illness does not discriminate between Democrats or Republicans, rich or poor, black or white, man or woman'' none of the dividing lines that so often create partisan politics. That is why I am especially gratified to be working on legislation with distinguished members from both sides of the aisle, and both sides of the hill, to create mechanisms that will bridge the gap between the mental health and criminal justice systems' the gap through which so many mentally ill defendants currently fall. I would like to take this opportunity to personally thank Senators DeWine, Domenici, Kennedy, and Wellstone, as well as Congresspeople Wilson, Waxman, Horn, Capps, Roukema and Kaptur for taking the lead on sponsoring legislation to provide criminal justice and mental health professionals the resources they need to work together to keep mentally ill defendants in treatment rather than jail.
I would like to briefly summarize the current legislation that seeks to lessen the burden of the mentally ill on the criminal justice system:
1. H.R. 2594, America's Law Enforcement and Mental Health Act, which I introduced last July, seeks to help local communities to close the revolving door of recidivism among the mentally ill population by providing federal grants of up to $400,000 to 25 local jurisdictions to establish mental health courts in order to direct nonviolent mentally ill offenders out of jail, into long term treatment. Mental health courts are uniquely effective at reducing the recidivism of seriously mentally ill offenders because they use the power of the criminal justice court to ensure that the defendants receive long term mental health treatment. Misdemeanor defendants who are determined to be seriously mentally ill are offered treatment in lieu of jail, subject to their continued compliance.
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2. S. 1865, a companion to H.R. 2594, was introduced last November by Senators DeWine and Domenici. Substantively the same as H.R. 2594, S.1865 calls for the creation of 125 pilot mental health courts.
3. S. 2639, the Mental Health Early Intervention, Treatment and Prevention Act of 2000, was introduced last May by Senators Kennedy, Domenici and Wellstone to help finally fulfill the unkept promise of the Community Mental Health Act of 1963 by providing, among other things, grants to communities for mental health treatment centers, as well as the training of non-traditional front line mental health workers, like teachers, law enforcement and fire fighters. Additionally, S. 2639 seeks to lessen the burden of the mentally ill on the criminal justice system by providing grants that (1) train police on how to identify the mentally ill and direct them into available treatment; (2) fund jail and prison programs that screen, evaluate and treat mentally ill inmates; and (3) create mental health courts to direct non-violent mentally ill defendants out of the revolving door of recidivism into long term, wrap-around treatment.
4. H.R. 5091, a mirror companion to S. 2639, was introduced last July by myself and Congresspeople Wilson, Waxman, Horn, Capps, Roukema and Kaptur.
As Co-Chair of the Congressional Corrections Caucus, I hope that this Congress will seize upon these legislative opportunities with the same courage and compassion with which law enforcement and corrections officers deal with the mentally ill every day.
Conclusion
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I want to thank this sub-committee for being willing to look closely at a problem from which too many of us turn away. I believe that there is a surprising consensus among a broad spectrum of stakeholders and political ideologies that there are very practical steps we can take to stop the criminal justice system from being this country's primary caretaker of the seriously mentally ill . The truth is that by helping the seriously mentally ill we help ourselves.
Mr. GEKAS. The committee expresses its gratitude to the witnesses, and extending the normal courtesy to them, we will not subject them to bristling cross-examination. [Laughter.]
We now excuse you with our further gratitude. Your statements will be, without objection, entered into the record.
Mr. STRICKLAND. Thank you, Mr. Chairman. And could I ask unanimous consent to place into the record a statement from the National Association of Counties in which they offer their support for this kind of diversion effort.
Mr. GEKAS. Without objection, it will be so included.
Mr. STRICKLAND. Thank you.
[The prepared statement of NACo follows:]
PREPARED STATEMENT OF NATIONAL ASSOCIATION OF COUNTIES (NACO)
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RESOLUTION ON THE MENTALLY ILL IN JAIL
Issue: Diversion of mentally ill in jails to intervention options.
Adopted Policy: NACo supports legislation that would facilitate the diversion of non-violent offenders from county jails and the criminal justice system into appropriate community intervention options, if the county chooses flus. option. Also, that any such legislation provide sufficient funding to assure appropriate community treatment NACo opposes the termination of the Medicaid entitlement whenever clients are incarcerated in county facilities.
Background: The confinement of the mentally ill in county jails represents a major health and liability problem for county governments. It is also a financial burden on county budgets because federal and state mental health funding streets usually shut down when a mentally ill individual enters the jail. NACo recognizes the need for federal demonstration projects to divert mentally ill persons who are non-violent from the county jail.
The nation's local jails are increasingly becoming the dumping grounds for the mentally ill. Of the 10 million admissions to county jails each year, it is estimated that as many as 16 percent are individuals suffering from mental illness. Most of these individuals have committed only ''nor infractions, more often, the manifestation of their illness than the result of criminal intent.
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Jail cells and court dockets throughout the United States are crowded with a growing mentally ill population, many of whom are released without a treatment plan. Out on the street and out of the mental health treatment system mentally ill probationers too often become repeat offenders whose recycled incarceration ill serves themselves, their communities, and the law enforcement, criminal justice, and correctional professionals who are charged with their care.
A few pioneering community, most notably Broward County, Florida and King County, Washington have developed Mental Health Diversion Courts, which are special dockets dedicated to enhancing public safety by diverting Elie mentally ill misdemeanant out of jail and into treatment. The Mental Health Diversion Court is a collaborative effort of the criminal justice and mental health treatment system to use case managers to improve case processing tinte, access to public mental health treatment service, and rates of recidivism. It is a grassroots effort to bridge the gap where so many fall, between the criminal justice and mental health systems.
Fiscal/Urban/Rural Impacts: Promoting demonstration programs will in the long term reduce the financial burden on both rural and urban counties since federal and state funding streams usually shut down when a mentally ill individual enters the jail.
Adopted July 18, 2000 at the National Association of Counties Annual Conference in Charlotte, NC.
Mr. DEWINE. Mr. Chairman, thank you very much.
Mr. GEKAS. By all means. Thank you.
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We are ready to invite and we do invite the next panel of witnesses to approach the witness table, which is all of one witness. Panel number two consists of Dr. Bernard S. Arons, the Director of the Center for Mental Health Services, Department of Health and Human Services.
Dr. Arons was appointed to this position in 1993, the same year he was selected as an adviser on mental health issues to Tipper Gore in the Office of the Vice President. That year he also became Chair of the Mental Health and Substance Abuse Working Group Cluster of the President's Task Force on National Health Care Reform. He also works as a clinical professor of psychiatry at the Georgetown University School of Medicine and continues his private practice in psychiatry. He is a graduate of Oberlin College and the Case Western Reserve University School of Medicine.
As is customary, again, we will ask the witness first to present his written statement, which will be accepted for the record, without objection, and ask him to restrict an oral review of that testimony to 5 minutes, more or less, because we have a great number of witnesses from whom we have to hear more testimony.
Thank you. You may proceed.
STATEMENT OF BERNARD S. ARONS, M.D., DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Mr. ARONS. Thank you, Mr. Chairman, members of the subcommittee. I would like to submit my written testimony for the record and use my allotted time to present some oral comments and summary.
Mr. GEKAS. Without objection.
Mr. ARONS. Thank you.
Let me just say how pleased I am at this opportunity to address this very important issue with members of the subcommittee and with you, Mr. Chairman. I would like to spend a few minutes talking about this issue from a somewhat different perspective. You already have heard very useful information from Senator DeWine and Congressman Strickland. I would like to talk a bit about what we can do about this issue at five points along the way: we must begin before the front door of our jails and prisons. And we must work out a plan of activities while they are inside the doors of our jails and prisons, and then when leaving, when going out those doors and re-entry. I will very briefly summarize my thoughts about those activities.
I am director of the Center for Mental Health Services, which was established by Congress 8 years ago with the responsibility of improving treatment and the quality of services for individuals with mental illness throughout our country. An important point that I would like to make is that the situation we find ourselves in is not inevitable. We know that effective treatment is available throughout the country to provide services to individuals with mental illness. And, yet individuals with mental illness are not receiving those effective treatments.
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It is not inevitable that individuals with mental illness are in trouble with the law, find their ways into jails or prisons, or become violent or dangerous. People with mental illness who are in treatment are working, they are in our schools, they are volunteering, they are being good parents, and we know that we can do something about this. So my first message is to put prevention first, to provide services and treatment in the community for individuals with mental illness.
But we know that these days the services are not always available, that access to treatment is sometimes limited, and that other major barriers include economics, the supply of services, stigma and discrimination. The real issue is that individuals with mental illness do not receive treatment. And then we stand by and watch as they respond to the difficulties that their illness creates, often ending up in difficulty with other members of the community. Sometimes the police are called. The next step where we can intervene is working in partnership between the mental health community and police in the training of individuals from the police force.
We have some very successful programs that we have been sponsoring with grants from the Center for Mental Health Services. One is in the State of Pennsylvania, in Philadelphia, where we are using consumers, recipients, people with mental illness, to work in training police on how best to intervene and how best to respond to situations in the community that involve individuals with mental illness. We are finding that this is a very successful program and extremely well received by the police who are being trained.
We know that once someone does get in difficulty with the law there are opportunities for diversion at prebooking, even before charges are made. There are opportunities for courts or in jains and prisions to divert individuals who are in need of treatment ot the treatment which is needed.
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We are privileged to be sponsoring, as part of the responsibility that Congress placed on us to explore and to publicize model programs for the country. Right now, we are evaluating nine sites across the country in our jail diversion program, looking to evaluate the best opportunities for pre-booking and post-booking diversion, including such strategies as mental health courts. And we are very pleased about this work.
We also have produced a summary of these issues in 1995 called ''Double Jeopardy,'' addressing issues of people with mental illness in the criminal justice system, using this catchy title ''Double Jeopardy'' from the law to note that people with mental illness and who end up with a criminal justice record often end up with dual stigma and have a more difficult time.
Now let me talk a bit about re-entry. When individuals with mental illness are in prison or jail, they sometimes receive treatment in jails and prisons, and then we have developed an unfortunate situation where, when they leave, there is a lack of follow-up, a lack of linkage, a lack of a re-entry process into the community where that treatment can be continued. Unfortunately, we see a tremendous amount of recidivism and of people dropping out of treatment. In a certain sense, we have created what I like to view as a trap door. As that person is being brought to the door of the exit of the jail or prison, right then a trap door opens and they fall back into the system as well.
My last point is that I want to make sure that we don't create an incentive, if you will, to criminal activity. Persons with mental illness and their families are often very innovative, very creative. They have struggled for many years to find effective treatment. We need to be sure that we don't create a situation where the only opportunity for effective treatment is through a process of criminal activity.
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And, finally, partnerships are essential. We know that we must build a close linkage between the mental health community and the criminal justice community to accomplish this. That partnership is most important.
Thank you.
[The prepared statement of Dr. Arons follows:]
PREPARED STATEMENT OF BERNARD S. ARONS, M.D., DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
The number of persons with mental illness in U.S. jails continues to grow. Currently the prevalence of active serious mental illness among inmates admitted to U.S. jails is about 7 percent, which means that nearly 700,000 persons with active symptoms of severe mental illness are admitted to jails annually. For those persons in prison, recent Bureau of Justice Statistics reports approximately 16% or about 233,000 are also similarly diagnosed. About 75 percent of these people have a co-occurring alcohol or drug use disorder. Criminal justice and mental health professionals and advocates have called for diversion efforts to link offenders with mental illness to community-based services to break their continued cycling through the criminal justice, mental health, and substance abuse treatment systems and to reduce the number of people with mental illness in jails.
In order to help address this problem, the SAMHSA Center for Mental Health Services has supported a large scale study of the effectiveness of pre- and post- booking diversion models. While nowhere near a comprehensive approach to all the issues involved in providing care and treatment to persons with mental illness who become involved with the criminal justice system, this is the area that appeared to offer the best promising program models that could be evaluated for their differential impacts.
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For this reason, I will focus my background information on our diversion program while only briefly referencing other aspects of the issue which will, I expect, be addressed by other witnesses. The second part of my testimony will offer an approach to problem solving that could be useful to members of Congress as well as local communities struggling to deal with this growing crisis.
What is Jail Diversion?
Jail diversion generally refers to specific programs that screen detainees in contact with the criminal justice system for the presence of mental disorder; they employ mental health professionals to evaluate the detainees and negotiate with prosecutors, defense attorney, community-based mental health providers, and the courts to develop community-based mental health dispositions for mentally ill detainees. The mental health disposition is sought as an alternative to prosecution, as a condition of a reduction in charges, or as satisfaction for the charges, for example, as a condition of probation. Once such a disposition is decided upon, the diversion program links the client to community-based mental health services.
It is important to note that jail diversion services consist of two broad interlocking areas of intervention. First is the diversion mechanisms, or the means by which an individual is identified at some point in the arrest process and diverted into mental health services. Second is the system of integrated mental health and substance abuse services to which the client is diverted.
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Broadly defined, diversion leads individuals with mental illness or substance use problems away from criminal incarceration. Diversion services may either prevent incarceration or cut it short. Conceptually, then, the definition of diversion could include many crisis services that are used to intervene after the onset of acute symptoms but before an individual has engaged in any criminal behavior, thus removing a basis for arrest. Such a broad definition would make it very difficult to differentiate crisis services from jail diversion because one could never be sure that an arrest would otherwise have occurred. Diversion could also be any planning for release from jail, because a plan for community services after release often facilitates a faster release, thus preventing extended incarceration. Diversion programs can be operated by police, pre-trial service agencies, courts (as part of a Mental Health Court or otherwise), and from several parts of the jail system.
What makes jail diversion unique is that this service positions itself within the criminal justice system as an immediate alternative to incarceration. Individuals with mental illnesses may be identified for diversion from the criminal justice system at any point, including pre-booking interventions (before formal charges are brought) and post-booking interventions (after the individual has been arrested and jailed.
Pre-booking diversion occurs at the point of contact with law enforcement officers and relies heavily on effective interactions between police and community mental health services. Most diversion efforts in the United States are post-booking programs, which can take place upon arraignment in the courts or in the jail.
A post-booking diversion program at either the arraignment court or the jail is one that screens individuals potentially eligible for diversion for the presence of mental illnesses; evaluates their eligibility for diversion; negotiates with prosecutors, defense attorneys, community-based mental health providers, and the courts to produce a disposition outside the jail in lieu of prosecution or as a condition of a reduction in charges (whether or not a formal conviction occurs); and links individuals to the array of community-based services they require.
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In a 1994 national survey, 34 percent of U.S. jails indicated that they had some type of formal diversion program for mentally ill detainees. However, in a follow-up telephone survey, only 18 percent of the jails that claimed to have such interventions actually had programs that fit the definition provided above. After researchers visited these sites, their final estimate was that only about 50–55 true jail diversion programs for mentally ill detainees exist nationwide.
When the major diversion programs were examined, five key elements were associated with the programs that were perceived to be most successful.
1. All relevant mental health, substance abuse and criminal justice agencies were involved from the start.
2. Regular meetings between key personnel from the various agencies were held.
3. Integration of services was encouraged through the efforts of a liaison person, or ''boundary spanner,'' between the corrections, mental health, and judicial staff.
4. The programs had a strong leadership.
5. Non-traditional case management approaches were used. These approaches relied on staff that were hired less for their academic credentials and more for their experience across criminal justice, mental health, and substance abuse systems.
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The bottom line was that program effectiveness depended on building new system linkages, viewing detainees as citizens, and holding the community responsible for the full array of services needed by the detainees.
Outcomes
Although jail diversion programs appear to have widespread support, few outcome studies have systematically examined the effectiveness of diversion programs using client outcome data. The literature offers little information on whether current programs benefit the targeted recipients in terms of symptom stabilization, reduced jail time, higher level community adjustment, and stable participation in community mental health services. Torrey and colleagues noted that there was not enough evidence about the comparative effectiveness of alternative approaches to jail diversion to recommend one approach over another.
Three modest outcome studies have been published. Lamb and colleagues' study of a pre-booking diversion program in Los Angeles sought to determine whether emergency outreach teams composed of police officers and mental health professionals could assess and make appropriate disposition decisions for psychiatric crisis cases in the community, including situations involving a threat of violence or actual violence. The study included a six-month follow-up of all referrals to the specialized outreach teams. Sixty-nine subjects encountered by the teams were placed on involuntary 72-hour holds, 80 were transported to hospitals, and 73 were actually hospitalized. Only two subjects were taken to jail.
The researchers concluded that the team benefitted from shared access to mental health and criminal justice records in making disposition decisions. The trained police officers provided security, transportation, law enforcement field resources, and the knowledge about handling violence. The mental health specialists provided knowledge about mental illness and experience in diagnosis, crisis evaluation, and interacting with psychiatric patients. Overall, the teams increased the percentage of mentally ill persons who had access to the mental health system.
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The study of the pre-booking diversion program by Steadman and associates included two diversion sites—the community service officer program in Birmingham, Alabama, and the crisis intervention team in Memphis, Tennessee. The Birmingham community service officer program is a police department-based program staffed with in-house social workers. The Memphis crisis intervention team is a police-department-based cadre of specially trained officers who handle mental health crisis calls when the police are the first line of response. For comparison, the study included a traditional mental health emergency team—a mobile crisis unit in Knoxville, Tennessee—which is based in the county's mental health department and works with the Knoxville police department.
The three programs had notable differences, partly due to the program structure and staffing patterns. However, all three showed great promise for diverting mentally ill people from jail, keeping them in the community, and facilitating access to treatment. Across all three sites, only 6.7 percent of the ''mental disturbance'' calls resulted in arrest. The Memphis crisis intervention team had an arrest rate of two percent, which was comparable to that reported by Lamb and colleagues for the pre-booking diversion program they studied. These proportions compare to an 18 percent rate in a Chicago study, where no specialized police mental health team was available.
In more than half of the encounters examined in all three programs, mentally ill subjects were either transported or referred to treatment; in a third of the encounters, program staff used specialized response procedures to provide crisis intervention or resolve the incident on the scene. Of the three programs, the Memphis crisis intervention team appeared to make the management of crisis incidents easiest on police by offering a no-refusal, 24-hour crisis drop-off center.
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Lamb and colleagues examined outcomes from a post-booking diversion program in Los Angeles County that provided mental health consultation to a municipal court. Clinical and forensic records of 96 individuals charged with misdemeanors and referred to a clinical psychologist court consultant for evaluation were studied. Follow-up information was collected one year after arrest on each subject. Poor outcomes were defined as psychiatric hospitalization, arrest, significant physical violence against persons, or homelessness during the follow-up year. Although 54 percent of the sample had a poor outcome, a significantly larger proportion of subjects who were diverted to receive judicially monitored treatment had a good outcome compared with subjects who were not mandated to receive monitored treatment. Also, subjects mandated to receive judicially monitored treatment had significantly better outcomes than subjects referred for treatment, but without court monitoring.
The three outcome studies described here offer some useful information. However, they do not provide adequate data to help answer the questions of a county executive, a sheriff, or some other elected official who asks a diversion program proponent to show how the proposed program will save the county money or keep the streets safer. In the absence of more comprehensive client outcome data and some cost-effectiveness information, the creation of innovative programs to prevent the unnecessary and often harmful incarceration of persons with serious mental illness is severely compromised.
To produce such data is extremely difficult. In real-world settings, random clinical trials are usually ethically impossible or, if possible, are impractical given local politics and the public's fears. Nonetheless, our current initiative holds great promise for filling these empirical gaps with information that will help communities in the design, implementation, and operation of both pre-booking, police-department-based diversion programs and post-booking, arraignment-court and jail-based diversion programs.
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The SAMHSA Jail Diversion Initiative
In September, 1997, The Substance Abuse and Mental Health Services Administration (SAMHSA) funded a three-year Knowledge and Development Application on jail diversion. The goal of the Knowledge and Development Application program is to develop new knowledge about ways to improve the prevention and treatment os substance abuse and mental illness, and to work with state and local governments as well as providers, families, and consumers to apply that knowledge effectively in everyday practice. Knowledge Development and Application grants do not provide operating funds for service programs, except as required by the knowledge development activity.
The jail diversion initiative moves beyond the three outcome studies described above in four ways. First, it includes several sites. Second, it is collecting extensive background and outcome data on subjects who are diverted from jail and on comparison subjects. Third, the study subjects constitute a diverse group. About 70 percent of the subjects are expected to be men in their mid 30s, most of whom have a mood disorder or schizophrenia. Their charges are expected to be primarily nonviolent misdemeanors, although a few are expected to have committed nonviolent felonies. Fourth, the jail diversion initiative will gather some cost data. The result will allow more sophisticated answers to the core questions for diversion—what works, for whom, and under what circumstances.
SAMHSA selected nine sites with established diversion programs to assess the effectiveness of the three major types of jail diversion programs—pre-booking programs, court-based post-booking programs; and jail-based post-booking programs. The sites qualified for funding by submitting proposals describing strategies to evaluate the relative effectiveness of fully-functioning diversion models for individuals with co-occurring serious mental illnesses and alcohol or other drug use disorders.
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A total of four pre-booking programs are included in the research initiative. Pre-booking programs in Memphis, Multnomah County (Portland), Oregon, and Montgomery County, Pennsylvania, intensively train members of the police force to handle calls that involve an individual with mental health or substance abuse problems. Each site has a 24-hour crisis center with a no-refusal policy that is available to receive persons brought in by the police. A pre-booking program in Wicomico County, Maryland, targets women.
A total of 11 post-booking programs are being studied. Most of the post-booking programs are jail based, although five of the Connecticut programs are court based. In the court-based programs, mental health workers situated in the courthouse identify clients while they are awaiting their hearing and negotiate with the court to develop community-based alternatives to jail.
The jail-based post-booking programs involved in the research initiative include New York City's NYC–LINK program, which uses linkages between planners at the jail and transitional mangers in the community to create community-based treatment arrangements for offenders with mental illness. The two post-booking programs at the Arizona sites identify offenders in jail and can refer them to three tiers of diversion alternatives: release from jail with conditions, deferred prosecution, and summary probation.
Lane County, Oregon, has a unique program that involves a psychiatric hospital located near the jail that offers detoxification services. Diversion options in Montgomery County, Pennsylvania, also include condition release with mental health services or dropping of charges once the offender is identified as a current mental health client. A third alternative in Montgomery County is ''coterminous diversion,'' in which police take the offender into custody, then deliver the offender straight to psychiatric treatment and also file charges. This arrangement can result in a variety of dispositions, ranging from dropping the charges to having the offender respond to the charges.
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The post-booking program in Honolulu begins when detainees are transported from holding cells in the local precincts to the courthouse in the early morning, where they are seen by a case coordinator who determines before arraignment whether diversion is appropriate.
Each of the sites will conduct a process and outcome evaluation of its jail diversion programs. The process evaluation focuses on a detailed description of the pre- or post-booking interventions at each site, a description of each subject's exposure to the intervention, and a description of the community context of the interventions and how it changes over time. Both self-report and record-based data will be used.
The general hypothesis that will be tested in the cross-site study is that diversion from jail to community mental health and substance abuse services will reduce negative outcomes such as recidivism, poor psycho social functioning, and psychiatric hospitalizations while increasing the quality of life of mentally ill detainees. The relative effectiveness of pre-versus post-booking diversion will also be assessed.
A cost-effectiveness analysis will be carried out to determine the cost savings to the criminal justice system; the benefits to the individuals who are diverted, in the form of improved individual outcomes; and the benefits to society as a whole, in the form of decreased costs due to a reduction in criminal victimization and property crimes and increased employment of diverted subjects. Comparisons of costs and effects will be made for pre- versus post-booking programs as well as for both types of diversion programs versus incarceration.
Additional avenues to be explored that may well enhance the role of standard treatment approaches are the adjunctive use of self-help groups by consumers who are in jails and prisons, specialized treatment groups within jails and prisons that are integrated to address co-occurring problems of mental illness and substance abuse, and focused group treatment approaches for women in jails and prisons that address the co-occurring issues in the context of histories of physical and sexual abuse, need for improved parenting skills, etc. Some preliminary study is underway in these areas to help define these issues for careful exploration, and it appears that the use of group treatment approaches is a viable and useful addition to more traditional one-on-one services approaches.
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The role of family members in the planning, implementation, and support of services for a son or daughter or other family member has also been an approach to building diversion programs that are vitally related to communities. Families have been vocal advocates for improved services for the mentally ill in the criminal justice system. They are eager to assist in building a more accessible and treatment—friendly system both in the jail or prisons and in the community. Family members as resources in this process are carving out responsibilities that can relieve the overall burden on all concerned.
Diversion programs are thought to be the most effective approach to integrate, at a community level, an array of mental health, substance abuse, and other support services, including group approaches, to break the cycle of repeated entry into the criminal justice and mental health and substance abuse treatment systems by persons with mental disorders. However, very few systematic outcomes studies that address the effectiveness of jail diversion programs have been conducted. Thus far no research has systematically examined which types of programs work best for whom. We do not know which are the most effective programs and which are the most appropriate for certain communities and for certain groups of detainees.
Available research findings suggest that at least two core elements are necessary for diversion programs: aggressive linkage to an array of community services, especially those for co-occurring mental health and substance use disorders, and nontraditional case managers. However, we have not determined whether diversion programs are more effective than high-quality jail-based programs at accomplishing the goals discussed above.
At present, no single definitive model for organizing a criminal justice-mental health diversion program exists. In addition, little is known about which types of programs are effective for detainees with co-occurring disorders or whether programs actually benefit the targeted recipients, especially in terms of symptom stabilization, reduced jail time, higher levels of community adjustment, and stable participation in community mental health and substance abuse services. The SAMHSA jail diversion Knowledge and Development Application is expected to provide data that can be used to answer these pressing policy and clinical questions.
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Other Key Challenges
Diversion is not the only key interface between the mental health and criminal justice systems. There are persons with mental illness who will become incarcerated who require treatment in jail or prison. Other persons will be referred to treatment by their probation or parole officer. Still others will complete their jail or prison term and need to be reconnected to their community mental health system. All of these crossroads between criminal and justice and mental health present additional challenges and opportunities for improving outcomes for people with mental illness. Much is known about how to best provide treatment in jail and prison; how to supervise conditions of parole and probation, and how to facilitate community reentry. I need not add to the important information and insights available to the Committee from other sources in this testimony. Suffice it to say that there will be many parts to a solution of the problem we are addressing; we will want to take advantage of the learning and insights available to us from all sectors of both field.
Looking for Solutions
The mental health and criminal justice systems have a big, common problem: persons with mental illness are increasingly involved in the criminal justice system, resulting in greater burden on criminal justice and less effective treatment for persons with mental illness. While study is not yet complete, we have invested in programs with a track record. We need to learn from their experience, even as we await more complete outcome data. Several of the programs already discussed make it clear that joint partnership between both systems is required.
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We need to emphasize that as a society we have created this situation. Inadequate treatment and services leaves people unprotected from the force of their illness, and we wait and watch until they do something, often a non-violent misdemeanor, to put them in trouble with the law. Jails and prisons are not set up to help ameliorate the force of these illnesses, and a vicious cycle is often set in place creating high rates of recidivism for these people.
But, the existence of a common problem can be part of its solution. I assume the issue comes down to creating the right balance between providing treatment for illness and deterrence from dangerous behavior. The more the balance tips away from risk to public safety toward treatment goals, the sooner a treatment alternative to Criminal justice system involvement is indicated; the more there exists a serious public safety concern, the more emphasis would be placed on protection, at the expense of the most effective treatment. We can only identify the proper balance if the two systems—criminal justice and mental health—do it together. If we can agree on common interests, we can seek common solutions.
Where does this take us? First, it seems clear that all our interests can be at least partially addressed if more people with serious mental illness get effective treatment. Engagement in treatment represents achievement of the mental health system's basic treatment mission while at the same time it reduces the prospects of further demands on public resources by persons with active illness who are unable to work and maintain themselves independently. At the same time, there is good evidence that decreased reliance on the criminal justice system to handle persons with active mental illness frees up critical resources for pursuing the criminal justice system's basic mission to prevent societal harm caused by criminal activity. It follows, therefore, that diversion of non-dangerous persons with mental illness to effective treatment would be one component of a common goal.
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There is a growing body of knowledge about how successful pre and post booking diversion programs work. SAMHSA'S multi-site study of jail diversion is teaching us much about both the ingredients necessary for an efficient diversion mechanism and the treatment programming that is needed to yield improved outcomes. Coupled with experience in many jurisdictions around the country, including places where a variety of mechanisms such as mental health courts, are being implemented, we have a solid foundations for using diversion mechanisms everywhere in the country.
There are, however, persons with mental illness who engage in serious criminal activity that merits prosecution and imprisonment. Just like any other group of people, there are some persons with mental illness who are dangerous. In these circumstances, a joint goal of protecting society and providing humane care must be formulated if mental health and criminal justice are to work together. While incarcerated, dangerous persons should receive treatment for their mental illness. This goal, that of humane deterrence, can be legitimized in both systems.
As a result, one can envision a two-pronged goal statement for mental health and criminal justice vis-a-vis persons with mental illness. It might be stated as follows:
In order to minimize involvement of persons with mental illness in the criminal justice system while protecting the public, the degree of criminal justice involvement should be directly proportional to the extent to which an individual poses a danger to society. Therefore, two compatible goals can be stated:
for persons with mental illness who are non-dangerous, they should be diverted to effective treatment at the earliest practical stage of the criminal justice process;
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for persons with mental illness who are dangerous, provide humane care and treatment during incarceration and explicit linkage to community-based treatment on release.
Several strategies can be deduced from this goal statement:
1. criteria defining dangerous or non-dangerous persons need to be formulated and adopted by consensus of both the mental health and criminal justice systems and applied fairly;
2. persons involved in the criminal justice system should be screened for mental illness.
3. an efficient diversion mechanism should be available;
4. availability of effective community-based and humane jail/prison-based treatment should be assured; and
5. provision for necessary supervision should be arranged through the criminal justice system.
Whether we agree on this particular approach or not, the critical concern is that we seek a solution together. In my view, the formation of local joint ventures between the criminal justice and mental health systems holds the most promise for a solution to the current dilemma. The idea as well as the concrete characteristics of a joint venture make sense as an overall approach.
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The idea of a joint venture is slightly different and much more concrete than the often repeated call for increased coordination, collaboration or partnership. A joint venture is a entity distinct from its component members. The entity has separate governance and is chartered for a specific purpose, in this case achievement of the common criminal justice system/mental health goal referenced above. The entity has no other purpose or responsibilities. It can be abolished without changing the character of its components.
There are several advantages to this approach. First, the entities entering into the joint venture must agree on the purpose or goal of the venture and make specific commitments with respect to achieving the goal. While most often financial, these commitments can also include adoption of specific practices and agreements to behave in specific ways under certain circumstances. The joint venturers make their commitments at the beginning of the venture before investments are made or any specific tasks are performed. Joint mental health and criminal justice ventures make up-front commitments to pool specific resources and to employ the screening, diversion, treatment, supervision, and reporting practices that are necessary to assure treatment and provide security.
Second, since the joint venture is a discrete entity, the role played by the criminal justice and mental health systems can be defined independently of traditional roles and responsibilities without abrogating those roles and responsibilities in the underlying systems. The new entity is, therefore, released from the bonds of history and precedent and given opportunity to forge new relationships and rules of conduct. Power and leadership rules can be radically redefined without compromising the underlying systems. Joint mental health and criminal justice ventures disregard historical differences, take advantage of each system's strengths, make rules that are tailored to the goals of the venture and create a direct link between investments of resources and specific outcomes that benefit both systems. The management style to create win-win conditions for both systems. At the same time, the traditional systems remain in place without the need for changes it would be naive to expect.
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The nature of the joint venture would help define its business practices. Rather than institutionalizing a traditional bureaucracy, a joint venture can, and should, adopt selected business practices that can yield more focus on specific outcomes and improved quality assurance and utilization review mechanisms. In addition, the joint venture can adopt accounting procedures better tailored to accommodating pooled funding and the corresponding tracking requirements imposed by multiple categorical funding streams. Finally, expectations change with respect to the accountability mechanism that would be adopted by a joint venture, with a premium placed on watching the bottom line, which in this case would be specific targets related to engagement in treatment and prevention of recidivism among the targeted populations.
Regardless of the organizational vehicle, reducing the numbers and percentages of persons with mental illness in the criminal justice system will depend to a large extent on the willingness of providers and managers in both systems to understand one another. Those people who have experience in both systems understand the strengths and weaknesses of each. There is plenty of evidence that when the strengths of the fields are exploited all aspects of the service systems improved. So, police departments that have learned the advantages of mental health crisis intervention techniques when forming Crisis Intervention Teams have consistently improved both engagement in treatment and prevention of criminal recidivism among persons with serious mental illness. Mental health professionals who understand how courts work and how judges use their authority have been able to expand the availability of services to persons with mental illness by taking advantage of the judicious use of that power. The emerging principles of therapeutic jurisprudence underscore the value of sharing learning and experience across the two fields. There is no doubt that the principles underlying Assertive Community Treatment and enlightened community supervision practices within probation and parole share many similarities and a common ancestry. Taking a strengths-based approach to problem solving will be a key element of a success system of care for persons with mental illness involved in the criminal justice system.
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More and more people with serious mental illness are entering the criminal justice system. The criminal justice system is being overwhelmed by the burden of providing humane care and management for persons with mental illness. This could be an historic opportunity to change by improving the efficiency and effectiveness of both systems. By agreeing upon a common goal and forming joint ventures to solve problems traditionally viewed as competing, the two systems can make a difference in the lives of hundreds of thousands of persons who suffer mental illness and associated criminal justice involvement. It cannot happen too soon.
References
Torrey EF, Steiber J, Ezekiel J., Wolfe SM, Sharfstein J., Noble JH, Flynn LM: Criminalizing the Mentally Ill. Washington, DC: Public Citizen's Health Research Group and the National Alliance for the Mentally Ill, 1992
Steadman HJ, Barbera S, Dennis D. A national survey of jail diversion programs for mentally ill detainees. Hospital and Community Psychiatry 45:1109–1113, 1994
Teplin, L. Psychiatric and substance abuse disorders among male urban jail detainees. American Journal of Public Health 84:290–293, 1994
Bureau of Justice Statistics. Jails and jail inmates 1993–1994. Washington, DC: US Department of Justice, 1995
Steadman HJ, Morris SM, Dennis DL. The diversion of mentally ill persons from jails to community-based services: A profile of programs. American Journal of Public Health 85:1630–1635, 1995
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Morris SM, Steadman HJ, Veysey, BM. Mental health services in United States jails: A survey of innovative practices. Criminal Justice and Behavior 24:3–19, 1997
Teplin, L. The prevalence of severe mental disorder among urban jail detainees: Comparisons with the epidemiological catchment area program. American Journal of Public Health, 80:663–669, 1990
Abram KM, Teplin LA. Co-occurring disorders among mentally ill jail detainees. American Psychologist 46:1036–1045, 1991
Rogers R, Bagby M. Diversion of Mentally disordered offenders: a legitimate role for clinicians. Behavioral Science and the Law. 10:407–418, 1992
Lamb RH, Shaner R, Elliot DM, DeCuir W, Foltz J. Outcome for psychiatric emergency patients seen by an outreach police-mental health team. Psychiatric Services. 46:1267–1271, 1995
Lamb RH, Weinberger LE, Reston-Parham C. Court Intervention to address the mental health needs of mentally ill offenders. Psychiatric Services 47:275–281, 1996
Deane MW, Steadman HJ, Borum R, Veysey BM, Morrissey JP. Emerging partnerships between mental health and law enforcement. Psychiatric Services. In press, 1999
Borum R, Deane MW, Steadman H, Morrissey J. Police perspectives on responding to mentally ill people in crisis. Behavioral Sciences and the Law In press, 1999
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Mr. GEKAS. We thank the gentleman. The Chair will allot itself 5 minutes to pose some questions to the witness.
You mentioned the problem of re-entry, which goes hand in hand with the term recidivism and return to custody that many of our prisoners encounter. In my recollection of our local law enforcement procedures and in court, when there is a recognized mentally ill person left out of prison by way of probation, et cetera, the follow-up is built into it through court demands that there be regular mental illness check-ups or other conditions placed upon that probationed criminal, as it were, the convicted person, to try to prevent that very same thing.
Are those still in use across the country, those methodologies?
Mr. ARONS. Ideally after fulfilling one's term in jail or prison, there would be a process of setting up services and making certain that certain obligations are met, such as follow-up and treatment. Probation may be one example, and I think that you will hear later that Ohio has made some great strides in making certain that that happens.
Unfortunately, there still are many communities across the country where, once a person has completed their jail sentence, they may, in fact, be released without follow-up. Many times families will tell us that their loved one was given a bus token and some clothes on the day they were due to be released. And at midnight on that day their sentence is over. They are released into the community, and there may not be a follow-up requirement to assure that treatment continues.
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We need to really put a system in place so that the treatment that a person was receiving, if it was effective in jail or prison, continues in the community and in the mental health center when they leave. I think there are still communities where we need to work on that.
Mr. GEKAS. You stated that in the hypothetical that you—not hypothetical but actual episode in Philadelphia where a crime in progress or shortly afterwards resulted in immediate referral to the mental health system. Are you talking about local law enforcement there in Philadelphia?
Mr. ARONS. Yes, and that was just one example, but certainly there are other examples that we find in other locations. And very often a call is made to the police about someone with a mental illness where there may not have been a crime actually committed or there may not have been an action for which the policeman would typically arrest someone. But without other alternatives available, I think the police often are confronted with a situation where someone does need help, and yet there are no alternatives to arrest and confinement.
Mr. GEKAS. The Chair reserves the balance of its time and now yields to the gentleman from Virginia for a period of 5 minutes.
Mr. SCOTT. Thank you, Mr. Chairman.
Dr. Arons, do you have studies that show that mental health treatment will actually reduce the incidence of crime?
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Mr. ARONS. Yes, there have been a number of studies and, also, I think some very interesting studies about diversion programs. When the police have no alternatives except either arrest or to let someone free, we find that in about 18 percent of time, when they get called around an incident involving someone with a mental illness, about 18 percent of the time arrest will occur.
When there is a program for diversion where the police have alternatives that are available to bring a person for treatment, that number falls to between 2 and 6 percent. So we know that there are effective programs that are being used across the country. We need to expand those.
Mr. SCOTT. Do you have evidenc that the diversion actually works to reduce crime? When they are diverted, are they less likely to commit crimes in the future?
Mr. ARONS. We have some initial findings to that effect. Part of the purpose of our nine-site study is to develop some very solid evidence of that. We are looking at three issues. We are looking at the effect on the individual. Is there improvement in their condition? Is there improvement in their situation? Is there less recidivism? Do they follow up in treatment? We are also looking at the effect on the criminal justice system. We are also looking, third, at the effect on the community. Are we able to reduce crime and reduce the cost of crime in the community through these programs? And we hope to have very solid information that we can use as a result of this program within the next year or so.
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Mr. SCOTT. You indicated that once you are arrested, you are entitled to mental health treatment. Who pays for that treatment when they are in the criminal justice system? And if you are trying to get follow-up after they are released, who pays for that?
Mr. ARONS. Typically, an individual involved in the criminal justice system has their health care needs met as part of the criminal justice system. So, typically, there will be the attempt made to provide general health care as well as health care for mental illnesses.
As you probably are aware, in many situations there are inadequate services available. There are not the specialists, the psychiatrists, psychologists, psychiatric nurses, and social workers available in the criminal justice system. And so sometimes that treatment may not be at the quality that it should be.
After leaving——
Mr. SCOTT. If I may, if it is not up to the quality that it should be, is that person more likely to commit a crime in the future? Or are we going to wait for the results of your study to get that answer?
Mr. ARONS. No, I think we have some evidence already. We need more evidence, but there is some evidence that there will be more likelihood of committing crimes in the future. And, in addition, that person is often more difficult to treat in the criminal justice system. Often that individual, without adequate treatment, creates concern for the criminal justice provider as well.
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Mr. SCOTT. If a person has medical health insurance with mental health coverage, are they treated differently in the criminal justice system than those that do not have insurance?
Mr. ARONS. Well, the insurance coverage for mental health is a dismal situation in this country, at best. Even when people do have coverage, the coverage for mental illnesses is often far less than that available for the rest of health care, and that is why States and communities throughout the country have been attempting to pass what we call parity legislation to try to enhance and expand the provision of mental health services.
Typically, in a jail or prison, whether one has insurance or not may make less difference than when the person is released, where the availability of insurance coverage does enhance the opportunity to obtain treatment.
Mr. SCOTT. Are those with insurance more likely to get diverted from the criminal justice system?
Mr. ARONS. I am not sure we have an exact answer to that at this point.
Mr. SCOTT. Thank you, Mr. Chairman.
Mr. GEKAS. We thank the gentleman. The Chair relinquishes the balance of its time, and we excuse the witness with our gratitude.
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Mr. ARONS. Thank you very much.
Mr. GEKAS. We are ready to empanel the next group of individuals who will testify, panel number three, which is made up of:
Bernard Melekian is the chief of police in Pasadena, California, and president of the Los Angeles County Police Chiefs Association. Mr. Melekian has also served with the Santa Monica Police Department for 23 years and was awarded the Medal of Valor in 1978 and the Medal of Courage in 1980. He holds a bachelor's degree and a master's degree from the California State University in Northridge and is also a graduate of the FBI National Academy.
He is joined at the witness table, directly to his right, by Michael Hogan, director of the Ohio Department of Mental Health, to whom reference was made by Senator DeWine, a position that this gentleman has held since March 1991. Prior to that, Dr. Hogan served as commissioner of mental health in Connecticut. From 1994 until 1998, he served on the National Advisory Mental Health Council and is president of the board of the National Association of State Mental Health Program Directors Research Institute. Dr. Hogan received his bachelor's degree from Cornell University and his doctorate from Syracuse University.
To his right is the next witness, Kim Webdale, spokesperson for mental health care and victims' rights issues. She became involved in these issues after her sister Kendra was thrown into the path of a subway train by a mentally ill man and killed as a result of that in January of 1999. She currently serves as a committee member for the Council on State Governments Mental Health Advisory Board. She received her master's degree in exercise physiology from Adelphi University and is employed by MetLife as program coordinator for its corporate wellness and fitness services.
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And, lastly, Dr. Sharfstein. Steven Sharfstein is the medical director and CEO of the Sheppard Pratt Health System. Dr. Sharfstein is a former clinical professor and vice chairman of the University of Maryland's Department of Psychiatry and served as the deputy medical director of the American Psychiatric Association from 1983 until 1986. He received his undergraduate degree from Dartmouth College, his M.D. from Albert Einstein College of Medicine, and his MPA from the John F. Kennedy School of Government at Harvard.
At the outset, as in all our panels, we invite you to render your written statement for the record, which will be accepted without objection for the record, and we ask that your oral review be restricted to 5 minutes, more or less, preferably less, and then to be prepared to answer some of the questions by members of the committee. We will proceed in the order in which they were introduced, so we will start to my right with Chief Melekian.
STATEMENT OF BERNARD K. MELEKIAN, PRESIDENT, LOS ANGELES COUNTY POLICE CHIEFS ASSOCIATION, AND CHIEF, PASADENA POLICE DEPARTMENT, PASADENA, CA
Mr. MELEKIAN. Thank you, Mr. Chairman and members of the committee. I don't know what the protocol is, if I have to ask if you have my written statement, and I would ask that it be entered into the record.
I suspect that for you this is another day of business, but this is my first appearance before a congressional committee, and it is the experience of a lifetime, and I thank you for the privilege of being here.
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I have been a police officer for 28 years. I am the chief of police for the city of Pasadena, a city of 135,000 that hosts the Rose Parade and the Rose Bowl every year. My officers would tell you that being chief means that I don't do any real work anymore. And, to some degree, they might be right. The young men and women who answer the phones and answer the public's calls for service and sail in harm's way every day do the real work of law enforcement in this country. And five to seven hundred times a year in the city of 135,000 people, that means that they deal with issues surrounding the mentally ill, a role for which they are both ill-prepared and ill-trained.
I came into this business for a variety of reasons, not the least of which was to help people. And I find that with regards to this issue, I am unable to do my job. I cannot help the woman who comes into my police station in fear for her life, for the life of her children, because her husband hears voices and views her as some sort of demonic creature. I cannot help the person who is afraid of their coworker whose desk may be wrapped in tin foil or who hears voices that no one else can hear. I cannot help the people who are afraid of their neighbors or the homeless person walking down the street. And I cannot help elderly parents who are trying to take care of their middle-aged mentally ill children. And I cannot help the mentally ill themselves who struggle and often request help, as did Buford Furrow prior to the shooting at the Granada Hills Day Care Center.
This issue has been, in my opinion, improperly framed to be one of as to whether one is for or against civil liberties. There is nothing civil about jail. There is nothing civil about living under a bridge in the Arroyo Seco or in an alley in any major city in this country. There is nothing civil about people's fear and uncertainty with regards to the mentally ill. And there is nothing civil about dying alone on a street, whether in the heat of Pasadena in July or in the cold of the District of Columbia in February.
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There are many high-profile stories. I have tried to tell you in my written remarks about my friend Dan, who I went to high school with. He went on to college to get a dual degree in math and physics, was a member of the first United States table tennis team to visit China, and who in the end lived alone in his parents' garage, often threatening to shoot them or to burn down the garage or to burn down the house. He terrorized his parents, he terrorized the people in his neighborhood, and he scared the heck out of the cops, including myself, who responded to the one, two, three calls a month that came from Dan's house.
At one time I could talk to him because he knew who I was, but at the end he did not. And ultimately he died alone, terrified himself, and no one, certainly not me and certainly not the system, had adequate resources to help him.
I guess if I had more than 5 minutes, I would have questions for the committee. Why is the issue of mental illness before the Subcommittee on Crime? Why have police officers in this country become the first responders and, in effect, placed in the position of becoming armed social workers? Why does the Los Angeles County jail system house the most mental patients of any facility in the United States? In some ways, we have changed mental illness into being mental crime.
I believe wholeheartedly in the good intentions of this committee. I believe that this issue is impacting law enforcement. It is impacting our entire system. It is certainly placing those young men and women who sail in harm's way and who have to make deadly force decisions that they should never be faced with. These folks need treatment, these folks need help, and we need some assistance to do that.
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I am very excited to be part of the Council of State Governments' effort to bring together all the people that are impacted on this, and I really thank you. I have a list of suggestions and solutions, but I don't have a long list of time, and I really appreciate your listening.
Thank you.
Mr. GEKAS. You have additional time left on the clock, maybe 40 seconds. [Laughter.]
Seventeen seconds.
Mr. MELEKIAN. I think I will relinquish my time. Thank you, Mr. Chairman.
[The prepared statement of Chief Melekian follows:]
PREPARED STATEMENT OF BERNARD K. MELEKIAN, PRESIDENT, LOS ANGELES COUNTY POLICE CHIEFS ASSOCIATION, AND CHIEF, PASADENA POLICE DEPARTMENT, PASADENA, CA
Good afternoon and thank you for allowing me to appear before you today. My name is Bernard K. Melekian. I am the Chief of Police for the city of Pasadena, California. I am also the current president of the Los Angeles County Police Chief's Association and a member of the Police Executive Research Forum (PERF). The importance of advancing the debate on how the criminal justice system can improve its response to people with mental illness cannot be overstated. I want to sincerely thank you for taking on this difficult issue.
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For the last year I have been involved in an interesting effort that is being spearheaded by the Council of State Governments (CSG). They have brought together leaders from law enforcement, the courts, corrections and other disciplines including mental health consumers and victim advocates. I have had the honor of representing PERF in this process. PERF is committed to finding measures that will better meet the needs of people with mental illness while ensuring the safety of our officers and the communities they serve.
The discussion of mental illness and particularly its impact on the criminal justice system is particularly critical. It is tempting and would be easy to spend my allotted time throwing numbers and statistics at you. I suspect that others have already done that. If I had to summarize this issue in thirty seconds, I would point out to you that the largest facility in this country housing mentally ill patients is the Los Angeles County Jail. The Sheriff's department estimates that nearly 1/3 of the inmates currently in custody belong in a mental institution.
I bring that to your attention, not for the purpose of pointing out the problem of warehousing, but rather to ask you to consider how these people arrived there. Specifically, they were brought there, not by mental health professionals, but by police officers.
For the officer on the street, dealing with the mentally ill is both frightening and frustrating. From the comfort of the conference room or the classroom, it is easy to point out that less than 10% of the mentally ill will become violent. However, our local police officers must respond to citizen's requests for assistance. They have no means of evaluating the threat potential of the person they encounter prior to reaching the location. Their response to a person with a weapon is the same, regardless of the state of that person's mental health. The solutions that I believe must be developed center around interventions that take place prior to the officer ever arriving at a crisis location.
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State governments across the country dismantled their mental hospitals, but did not provide the promised community centers and professional outreach. This resulted in thousands of people being dumped on the streets with little thought as to their ultimate welfare or the welfare of the local communities who received them. The resulting level of social unease and fear has placed a tremendous burden on local law enforcement.
While several officer-involved shootings in recent memory have generated controversy, the surprising thing is not the number of deadly force incidents, but the fact that there aren't more of them. All too often, police officers confront the mentally ill equipped with little more than their verbal skills and the means to employ deadly force. The results are often disastrous. It is the officer, the department, and the jurisdiction that employs that officer who is ultimately held accountable.
Our local police forces have become armed social workers. This is a mission that we are both ill equipped and ill-trained to carry out. For the local police officer, the mentally ill fall into two categories, the homeless and the marginally housed. Both present a unique set of problems.
Law enforcement officers often come into contact with people who are engaged in wildly bizarre behaviors. The community demands that the officer ''do something''. All too often, there is no mental health facility or counseling available. The only treatment option is jail. While in jail, they will certainly not be in a therapeutic environment designed to assist them with whatever their problem might be.
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The issue of the marginally housed is equally significant and often more dangerous. Everyone knows someone who is trying to take care of a relative or loved one who is mentally ill.
I would like to tell you about my friend Dan. He and I went to high school together and were good friends. Dan went on to obtain a dual degree in mathematics and physics from Cal Berkeley. He was on the first U.S. table tennis team to go to China in the early 1970's.
Dan began to hear voices, gradually deteriorated, and ended up living in his parent's garage. Here were two people in their 80's trying to live a life that always included the uncertainty of not knowing if their son was going to burn down their house.
We used to get called to Dan's house about once or twice a week. Sometimes he had a gun; sometimes he had gasoline and road flares. Always he was irrational. In the beginning, he would recognize me and I could talk him out of whatever he was set on doing. At the end, I was merely another blue uniform. Often Dan didn't meet the criteria for even a 72-hour hold for evaluation. There were often no options other than arrest and jail.
I don't know how many people there are like Dan in this country, but I know that there are a huge number in Los Angeles County. They are often cared for by relatives at home, with few, if any, community resources to assist them. Every day police officers are sent to these residences. Sometimes they are sent to intervene in a violent dispute, more often to simply try and keep the peace where none is possible.
There are some specific steps that need to be taken if we are to deal effectively with this issue:
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There is a critical need for the promised community treatment centers to ensure adequate resources, for the benefit of both the community and the clients
It is imperative that greater commitment authority be granted to mental health professionals and emergency room doctors for short-term evaluations. In particular, the definition of gravely disabled needs to be reworked to allow for the treatment of those persons who are unable to care for themselves
Additionally, some means of dealing with persons who make specific threats either in the community or the workplace needs to be implemented. For example, Buford Furrow, the day-care gunman made numerous threats against Jews and minorities, but there was no legal method of evaluating his threats
In many states, a condition of probation for heroin addicts is that they take methadone under direct supervision. Some similar methodology to ensure the ingestion of prescribed medication needs to be in place for the mentally ill
Funding for programs featuring partnerships between law enforcement and mental health outreach workers need to be expanded. Such programs are in place in Los Angeles, Ithica, NY and Memphis. The preliminary results are very encouraging.
Current law impedes the development of an effective mental health system that would permit seriously mentally ill people to get the help they need and avoid the criminal justice system. I agree categorically that the patient's rights must be protected. I believe just as strongly that one of their basic rights is the right to treatment and to live free from the fear that the demons of mental illness often visit upon their victims. We also need to ensure that the communities in which they live are safe from violent acts and the reasonable fear of such acts from persons who are suffering from untreated mental illness.
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I urge you to resist the pressure to pass laws as a result of high-visibility incidents and to consider supporting multidisciplinary measures that will help us meet the public safety needs of our communities and the specific needs of those with serious mental illnesses.
Thank you for your attention and consideration.
67345a.eps
67345b.eps
Newspaper: Los Angeles Times
Date: December 22, 1999
Section: Metro; Part B; Page 9; Op Ed Desk
Headline: Commentary: It takes more than cops to handle the anguished loose on the streets; Society: Police training is not enough to handle the unpredictability of dealing with the mentally ill.
Byline: Bernard K. Melekian
The interaction between law enforcement personnel and the mentally ill has received a great deal of attention in recent weeks. A number of encounters culminating in the use of deadly force have become, rightly, the subject of intense public discussion.
While the problem is very real, it is troubling to see the focus continue to be placed on law enforcement.
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Awareness and training can and should be improved. This training has been going on for a number of years. Academy classes teach young officers the theory of dealing with people whose perception of reality is distorted by imagined demons. The Mental Illness & Law Enforcement Seminar has been attended by police officers and mental health professionals for nearly 10 years.
Yet awareness and training do very little to prepare officers for encounters with people exhibiting bizarre behaviors in nonclinical situations. The biggest challenge in dealing with the mentally ill on the street is that the outcomes are predictable only in hindsight.
The mentally ill with whom the police come into contact generally fall into two categories. There are the functionally homeless who spend most of their time living on the street and very often do not have even a rudimentary grasp of how to access social services. Then there are those people who have some family structure, which is to say that they have a place to sleep, but are not helped in any meaningful way beyond the basic survival needs. Often they evoke fear and anxiety in the very people who are trying to care for them.
In both instances, when the mentally ill person begins to act out, the police are seen as the only resource. Our police training correctly emphasizes that 90% of mentally ill people, regardless of their exhibited behavior, are not a threat to the officer. Yet training does not answer the only questions of importance to the officer at the scene: Does this person fall into that other 10%? Is he a threat to the immediate public or me? The anxiety produced by the inability to answer these questions is coupled with a very limited number of options available to the officer: a loud voice and instruments of force. These are neither desirable nor effective.
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The most significant causal factor in encounters between police and the mentally ill is patients' failure to take their prescribed medications. The ability of mental health professionals to ensure that medications are being taken is very limited. Appropriate legislation needs to be passed to create a setting in which qualified professionals can oversee the distribution and ingestion of medication.
A model currently exists for such a system in the form of methadone clinics. Heroin addicts who wish to avoid jail time must take methadone under direct supervision and in a controlled environment. There is no reason that a similar system could not be created to assist mentally ill people in taking the medication that stabilizes their inner anguish.
There is also a critical need to increase the number of mental health outreach workers in Los Angeles County. Law enforcement officers, no matter how well trained, are not mental health professionals. They are not qualified to diagnose the behavior of a person in crisis.
The Los Angeles County Sheriff's Department has established a very effective program that pairs a deputy sheriff with a mental health worker. This program needs to be expanded to serve all the law enforcement agencies in the county. The availability of such teams throughout the county on a 24-hour per day basis would help provide street officers with adequate resources for dealing with potentially dangerous individuals.
While these programs would greatly assist law enforcement in dealing with the mentally ill, neither is long-term. Society must provide funding for community mental health centers and adequate bed space. In addition, the ability of trained medical personnel to make involuntary commitments for treatment and observation must be enhanced.
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I suppose there is something appealing about defining the problem in terms of demanding better training for street officers. It gives the appearance of providing a simple solution to a complex problem. But not only is it intellectually dishonest, it is morally wrong.
MENTALLY ILL OFFENDERS IN THE CRIMINAL JUSTICE SYSTEM
The average proportion of mentally ill inmates in the California state prison system at any one time is about 8 percent. (California Research Bureau; Mentally Ill Offenders in California's Criminal Justice System, February 1999).
10 to 15% of California county jail inmates are mentally ill on any given day (8,000–12,000 people) (California Research Bureau, Calif. State Library 2/1999)
16% of State prisoners identified as mentally ill. (Bureau of Justice Statistics, Special Report, July 1999)
283,800 mentally ill in prison or jail, 547,800 on probation.. (Bureau of Justice Statistics, Special Report, July 1999)
Half of mentally ill inmates reported 3 or more prior sentences. (Bureau of Justice Statistics, Special Report, July 1999)
Annual cost to police and sheriff's departments is estimated to be $445million and $160, million respectively, $605 million in total. (California Research Bureau, Calif. State Library 2/1999)
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Mentally ill offenders are generally repeat offenders, incarcerated 10 times or more for minor crimes and misdemeanors. (California Research Bureau, Calif. State Library 2/1999)
Disciplinary problems common among mentally ill inmates. (Bureau of Justice Statistics, Special Report, July 1999)
Mentally ill offenders in many cases being homeless most often commit minor crimes or ''crimes of survival'' ie: shoplifting, loitering, trespassing, intoxication, petty theft, vandalism, disturbing the peace. (California Research Bureau, Calif. State Library 2/1999)
Homeless more prevalent among mentally ill offenders. (Bureau of Justice Statistics, Special Report, July 1999)
Mentally ill offenders display aggressive violent behavior, have long histories of institutionalization, and/or exhibit a diminished ability to function independently in jail or other detention settings. (California Research Bureau, Calif. State Library 2/1999)
The range of jail detainees with co-occurring Mental Illness and substance abuse disorders is 3—11 percent. (1997 U.S. Department of Justice report). (California Research Bureau, Calif. State Library 2/1999)
Mentally ill inmates were more likely than others to be in prison for a violent offense. (Bureau of Justice Statistics, Special Report, July 1999)
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California spends $1.2 to $1.8 billion a year in criminal justice costs related to untreated mental illness. (The LPS (Lanterman, Petris, Short) Task force report; February 1999).
PASADENA PD STATS (1998 & 1999)
Note: the following stats deal specifically with calls from the point of initiation that involved some sort of mental illness, ie: 918, 918V, Attempt suicide, suicide. The mentally ill offenders stats do not include calls where it was discovered after the fact that the suspect was mentally ill. Nor does this include the number of calls that were IRO'd.
1998 PPD dispatched 73,706 calls, 307 reportedly involved mentally ill subjects.
January—October 1999 PPD dispatched 62,591 calls, 278 involved mentally ill subjects
It is estimated that approximately 50% of the mentally ill that PPD encounters are homeless. (There is no official record kept).
In 1998 the longest time spent on a detail was 969 minutes, or 16 hours
Four calls took 800 minutes, or 13 hours.
In 1999 the longest time spent on a call was 529 minutes or 8+ hours. 13 calls that took over 300 minutes, or 5 hours to handle.
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On average PPD officers spend 2+ hours on cases dealing with the mentally ill.
Mr. GEKAS. Thank you.
We turn to the next witness, Dr. Hogan.
STATEMENT OF MICHAEL F. HOGAN, DIRECTOR, OHIO DEPARTMENT OF MENTAL HEALTH, ON BEHALF OF THE NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS
Mr. HOGAN. Thank you, Mr. Chairman, Ranking Member Scott, and I appreciate the opportunity to enter my written testimony also and to try to summarize it succinctly.
We appreciate your attention in focusing our Nation's concentration on problems in mental health and their impact on crime and criminal justice. I believe that the record of this hearing will establish the undeniable scope of this problem in dollars and cents and statistics, but more significantly in human tragedies, like the death of Ms. Webdale's sister.
What may not be apparent and in a way is beyond the scope of the subcommittee's focus is that this mental illness problem has such an impact across society. And without detracting from the committee's appropriate and laser focus on this connection with crime, I want to mention a couple of these dimensions.
We know that mental illness is a factor in 30,000 suicides nationally every year. We know that children with mental illness have the worst grade point averages and the worst outcomes of any group of children in school; two-thirds of them almost never graduate from high school; that disability related to mental illness is the single fastest-growing category in both short-term disability programs and in Social Security. And somehow our focus in addressing those mental illness problems that you have got us attending to must be carried out within the context of these larger issues and problems.
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I do believe a consensus is emerging that you will hear from members of the different panels that non-violent mentally ill offenders should be diverted to supervised mental health treatment programs. This is what we are trying to do in Ohio, as an attachment——
Mr. SCOTT. Could you say that again? What kind of——
Mr. HOGAN. That non-violent mentally ill offenders should be diverted to treatment. We are making efforts in Ohio, as an attachment to my testimony will indicate. We believe that diversion to supervised treatment would be more effective, it would be more appropriate, and it would appropriately reduce the burden on corrections. The mental health model to be outlined by Judge Cayce is, we believe, a very promising approach, and we applaud the leadership of Congressman Strickland and Senator DeWine in sponsoring legislation to expand mental health courts.
Although diversion is the right thing to do, in many communities across America the question is diversion to what. The mental health safety net in too many of our communities is stretched too thin. In the past decade, mental health spending declined compared with health spending in general, and private mental health spending in health insurance plans declined against public spending.
From 1990 to 1997, the budget of State mental health agencies declined 6.5 percent against inflation. Now, there is no doubt in my mind that States must reprioritize mental health and also that mental health leaders must be galvanized to better collaboration with their law enforcement counterparts at the State and local levels. But the problem will also not be fully solved without correcting deep flaws in Federal programs that don't work for mental health care in States and communities, for example, Medicaid's failure to cover psychiatric hospitalization and, thus, by implication community care; HUD's withdrawal from low-income and disability housing production. These things have contributed to the community instability of many people with the most serious and unpredictable illnesses.
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Almost 150 years ago, Mr. Chairman, the Congress enacted land-grant legislation to help States build mental hospitals, but it was vetoed by President Pierce as an area that the Federal Government should not get into. In 1977, the Comptroller General issued a sharply critical report entitled ''Returning the Mentally Disabled to the Community: Government Needs to Do More.'' With 20/20 hindsight, we can now say that Government has not done enough.
Because of this, I thank the subcommittee for its leadership in bringing these problems to the Nation's attention in such clear focus. It is a critical first step in developing solutions for better mental health care and better public safety.
Thank you.
[The prepared statement of Mr. Hogan follows:]
PREPARED STATEMENT OF MICHAEL F. HOGAN, DIRECTOR, OHIO DEPARTMENT OF MENTAL HEALTH, ON BEHALF OF THE NATIONAL ASSOCIATION OF STATE MENTAL HEALTH PROGRAM DIRECTORS
The ''mental illness problem'' is severe in criminal justice, and in society.
There are clear problems at the interface between the mental health and criminal justice systems. Although four of the five most common offenses charged to persons with mental illness are not violent crimes, persons with mental illness are over-represented in jails and prisons. Among the general population in the United States, only 2.8 percent of adults have a serious and persistent mental illness. Nationally, best estimates are that between 6 and 15 percent of the adults in jails and prisons have a serious mental illness. However, the scope of this problem extends beyond numbers and costs. More must be done.
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At the same time, the ''mental illness problem'' in criminal justice is not an isolated issue. In part, this problem reflects the growing impact of mental illness across society. Disability due to mental illness is the fastest growing category of disability. Children with emotional disturbance have the lowest grade point averages of any category of disabled students. More persons with mental illness enter the vocational rehabilitation system—and leave with worse outcomes'than any other disability group. And mentally ill persons are over-represented among the homeless. So, although our focus today is on an overburdened criminal justice system, we must be mindful of the broad problems in our Nation's approach to mental health.
Mental health care is primarily a state responsibility.
Since Colonial times, primary responsibility for mental health care has rested with state and local governments. Almost 150 years ago, the Congress passed Land Grant legislation to assist the states in constructing asylums for mental health care. In a harbinger of continued federal ambivalence about this problem, President Pierce vetoed the legislation, indicating that this was not a proper area for federal involvement.
Mental health care is greatly complicated by two major factors. First, unlike any other category of illness—where primary responsibility rests with health insurance—government funds and directly manages a separate ''safety net'' system for the seriously mentally ill. This safety net is wearing thin. In recent years, overall spending on mental health care has declined as a percentage of overall health care spending, and the proportion of costs borne by government is increasing. Including state matching funds in the Medicaid program, state governments spent over $20b on mental health care in 1997, and were the largest source of mental health spending. However, state mental health expenditures have slipped in the past decade as rising Medicaid, education and corrections spending ate up most state revenues. Nationally, the budgets of the State Mental Health Authorities (SMHAs) declined 6.5% in inflation-adjusted dollars between 1990 and 1997. In Ohio, Medicaid and education costs both increased over 50% in inflation- adjusted dollars during the 1990's; corrections spending increased by over 100%, and mental health spending declined by about 1%.
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Federal programs impede state efforts to deliver mental health care
A second basic challenge in mental health is that although basic responsibility rests at the state and local level, many federal programs impact mental health care, and most of them are problematic. A good example is Medicaid. Although Medicaid fully covers institutional and residential care for mentally retarded individuals in Intermediate Care Facilities (ICF–MR), equivalent care for mentally ill persons is excluded from coverage. As a result, Medicaid Home and Community Based Services waivers providing community care as an alternative to institutions now provide over $7b in quality community care are essentially not available to mentally ill persons. Problems in federal programs that must be remedied to prevent further deterioration in the mental health safety net are summarized in Attachment 1.
Nonviolent mentally ill persons should be diverted from the criminal justice system to supervised treatment
I believe, with my fellow state mental health directors, that the problems associated with mental illness in criminal justice require an urgent focus. This requires better mental health care, and a priority on partnerships with the criminal justice and corrections systems. Further, we believe special attention must be given to the mental health issues in courts, corrections and within law enforcement entities. Without better mental health care, better partnerships and an improved focus in criminal justice, we can expect unacceptable outcomes to continue. These will include inappropriate police encounters; unnecessary arrests and incarcerations; delayed release from jails and prisons; increased recidivism of persons with mental illnesses to the criminal justice system; and delayed or lack of needed mental health treatment.
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Against this backdrop, while the Ohio Department of Mental Health (ODMH) is working on all fronts to improve the quality of mental health care in Ohio, we have made mental health diversion programs a top priority. Diversion places non-violent people with mental illnesses in supervised community treatment instead of jails. Diversion interventions can occur prior to arrest or at the pre-booking and post-booking stages of the criminal justice process. ODMH recently awarded thirteen diversion grants to counties to provide mental health linkage and treatment as an alternative to incarceration in local jails for certain non-violent offenders. (A description of these programs is attached as Attachment 2.)
The core challenge facing SMHAs and local mental health officials is ''Diversion to what?'' While improvements in mental health's focus on criminal justice are sorely needed, the mental health safety net in many communities is thin and frayed. Capacity is not adequate for many core treatment services such as the effective Program for Assertive Community Treatment (PACT) model. Additionally, declining availability of truly low-income housing impacts persons with serious mental illness—almost all of whom live in extreme poverty—very severely.
Is deinstitutionalization the problem—is ''reinstitutionalization'' a solution?
There is a persistent impression that deinstitutionalization—originally framed as a preference for community care, but often interpreted as mere emptying of state mental hospitals—is a major ''driver'' of the mental illness problem in our criminal justice system. However, the problem is more complex, and does not suggest easy answers. The period of intense reductions in the Nation's state hospitals ended by about 1980. From a peak of about 559,000 patients in state hospitals in 1955, state hospital use was reduced to about 139,000 patients by 1980, according to researcher Dr. Joe Morrissey. Furthermore, most of this reduction was actually due to the transfer of elderly mentally ill persons from state hospitals to nursing homes. According to the National Institute of Mental Health, by 1977 there were 250,000 seriously mentally ill individuals in nursing homes. Given that most of the decline in state hospital utilization is attributable to discharge or transfer of long-stay patients, in Ohio we conducted a simple study to see if our discharged long-stay patients (those hospitalized over a year) had ended up in the state correctional system. We discovered that only about 2% of the discharged patients were incarcerated in state prisons.
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Yet the large and unacceptable numbers of mentally ill persons in prisons, jails and courts is an undeniable truth. Whether the cause correlates better with changes in sentencing—especially drug sentencing'than with deinstitutionalization is perhaps a moot point. What is undeniable is that the mental health safety net is thin and frayed, and that the results are evident in the criminal justice system.
The perception—right or wrong'that deinstitutionalization is the culprit suggests to some that ''reinstitutionalization'' is a simple cure. However, this approach would be inappropriate, unaffordable and ineffective. A quick calculation of the costs of reopening mental hospitals in Ohio—considering that custodial care is no longer acceptable and that we are mandated by the General Assembly to meet national accreditation standards in all of our hospitals—indicates that we would need to spend well over $2b annually. It won't happen. Furthermore, there is no research evidence that long term hospitalization or residential treatment is effective for adults with serious mental illness.
A more thorough response is needed. In 1977, the Comptroller General issued a sharply critical review of the government's mental health programs, aptly entitled Returning the Mentally Disabled to the Community: Government Needs to do More. With the benefit of hindsight, we can now say that government has not done enough.
Several bills before the Congress take significant steps in the right direction. The Mental Health Early Intervention, Treatment and Prevention Act (S. 2639, HR 5091) sponsored by Senators Domenici and Kennedy and Representative Strickland respectively, is the broadest and most responsive piece of proposed legislation that the Congress has considered in several decades. More focussed legislation that would promote development of Mental Health Courts has been proposed by Rep. Strickland (HR 2594) and Senator DeWine (S. 1865). This legislation is beneficial because it would focus attention on mentally ill individuals specifically as they enter the criminal justice system.
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If the mental illness problem in criminal justice is to be addressed, the mental health safety net in communities must be rebuilt. For this to happen, the deficiencies in federal programs must be addressed, and state and local mental health, corrections and law enforcement must work more collaboratively. It is time for these steps to be taken.
ATTACHMENT 1: PROBLEMS IN FEDERAL PROGRAMS IMPACTING MENTAL HEALTH CARE
Given the continuing crisis in services for people with serious mental illness, it is time to focus on the major federal programs relevant to the task of community mental health care. These include housing programs and subsidies, vocational rehabilitation and Medicaid, Medicare, special education, and Social Security programs. On the one hand, recent federal mental health leadership is extraordinary (e.g. White House conference, Surgeon General's Report, ''parity'' for federal employees). On the other, the core federal programs that states rely on to serve those with serious mental illness have generally not improved. In each of these programs, federal program design factors greatly limit states' abilities to provide comprehensive community based care. This is crucial because care for those with the most serious mental disorders has always been a state responsibility. However, states must rely on these federal programs to provide adequate care.
In the case of housing, we have seen recent progress in HUD administration. However, a reduced federal role in production of low-income housing, inadequate levels of Section 8 housing subsidies, and the dramatic conversion of existing low-income to market rate housing have reduced the availability of safe, decent, and affordable housing for persons with mental illness, who often live in extreme poverty. Persons with serious mental illness have not uniformly fared well under welfare reform, exacerbating this problem. In the case of vocational rehabilitation, ongoing design limitations in the federal program (e.g. a bias toward short term training and placement) mean that the rehabilitation success rate for individuals with serious mental illness is lower than for any other disability group, while the need is higher. The combination of limited access to affordable housing and poor vocational assistance puts vulnerable people with mental illness at risk, and cannot wholly be compensated for at the state and local levels.
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Limitations in Medicaid are complex. The two major problems are: 1) the fact of a limited (and still optional) mental health benefit, further constrained by the historic ''IMD exclusion'' that is integral to Medicaid's coverage of mental health care and 2) the problems inherent in either fee-for-service or managed care reimbursement for mental health treatment. The IMD exclusion (which prevents reimbursement of care in mental health facilities) is rooted in the well-intended decision to not federally reimburse and thus encourage psychiatric hospital care. However, one consequence of this policy is states' inability to reallocate Medicaid funds from institutional to community settings (and to utilize Home and Community Based Waiver resources) to build and sustain community services. Both of these mechanisms have been used very successfully in the developmental disabilities field (where, ironically state institutions are reimbursed as Intermediate Care Facilities) to build better funded community care systems. This is frank federal discrimination against the mentally ill population.
The problems inherent in fee-for-service (unmanaged) Medicaid mental health reimbursement include the fact that only some mental health clients are eligible for Medicaid and that only some of the services they require are covered, and that fee-for-service billing is very expensive. Managed care approaches under Medicaid waivers can help with some of these problems, but have other serious limitations. The fact that Medicaid only covers some consumers and a portion of mental health services means that managed care arrangements tend to create gaps in care. Additionally, benefit design limitations and the ''IMD exclusion'' which prohibits payment to psychiatric hospitals and congregate mental health residential facilities' tend to lead to low and potentially inadequate mental health capitation rates.
Medicare is problematic for people with mental illness because of the absence of a medications benefit (since medications are often the first line of treatment for mental disorders). Additionally, Medicare's coverage of inpatient and outpatient mental health treatment is not on a par with coverage for treatment of other illnesses.
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Regarding children and youth who are in need of Special Education, the national graduation rate for Serious Emotionally Disturbed (SED) Students is only 41%, and these students—usually of average or above average intelligence—have the lowest grades of any group of students with disabilities. Federal mandates to provide for special need students have not translated to adequate services at the local level where these students attend classes—in part because the federal government has not picked up anywhere near its promised share of special education costs.
Improving access to insurance-financed health and behavioral health care for people with mental illness remains a challenge. Only in the case of mental illness do we have an explicitly two-tiered care system, with state managed public systems serving as a safety net for ''shallow'' commercial coverage of mental illness treatment. Recent evidence suggests that health coverage for those with a mental illness is worsening, that state level ''parity'' laws have not been very effective, and that mental illness treatment is increasingly being shifted to governments. The federal government's preemption of state insurance regulation of self-insured plans under ERISA must therefore be considered another problematic piece in the mental illness puzzle.
For those persons with SMI who receive benefits through Social Security programs, the work disincentives have been immense. Now that we better understand the importance of a job for many consumers in their recovery process, the missed opportunities and damage for many are painfully obvious. This is one area where federal leadership in reforming a broad federal program—that impacts those with mental illness significantly—has been exemplary. There is a strong recognition in SSA that mental disorder related disability is costly. Recent steps are very positive. For example, the Ticket to Work legislation should help enormously. This example of Social Security Administration reform should be used as an example in reviewing the other federal programs.
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ATTACHMENT 2: OHIO MENTAL HEALTH JAIL DIVERSION PROGRAMS
COLUMBUS—Michael F. Hogan, Ph.D., Director of the Ohio Department of Mental Health, announced the award of $874,268 in grants to improve care for people with a mental illness who are involved with local criminal justice systems. The 15-month grants will provide treatment instead of expensive incarceration for certain non-violent offenders, and link persons with a mental illness who are in jail to the appropriate support and treatment upon their release. The hope is that treatment services will help individuals recover and avoid future problems with the law.
''I am proud to announce that ODMH is making a significant investment in programs to meet the needs of people with a mental illness who too-often cycle through the criminal justice system,'' said Dr. Hogan. ''Most people with a history of mental illness who have been arrested or jailed have committed minor and nonviolent offenses. Incarceration is not usually an effective intervention for these individuals. The programs funded through these grants will benefit these offenders and the community at large.''
Diversion programs intervene at the time of arrest, or during pre-booking or post-booking, to deliver appropriate community mental health and substance abuse services instead of incarceration. Linkage programs help improve coordination between the criminal justice and mental health systems in providing services to the offender. Examples of successful programs include joint law enforcement and mental health diversion teams; mental health courts; forensic residential services; monitoring and wrap-around services; and community mental health linkage services from local jails.
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''Ongoing community treatment through diversion and linkage programs is proven to reduce recidivism to the criminal justice system and decrease lengths of expensive inpatient stays,'' said Sandra Cannon, ODMH Chief of Forensic Services. ''A key component of this effort is improved coordination between the criminal justice and mental health systems.''
Collaborative efforts to divert misdemeanor and nonviolent mentally ill persons from the criminal justice system have become increasingly popular with local officials and mental health advocates in recent years. ODMH has previously worked with the Departments of Alcohol and Drug Addiction Services, Youth Services, Rehabilitation and Correction and Criminal Justice Services to divert offenders with mental illness and substance abuse problems from jails and provide alternative treatment options within the community.
Entities that submitted grant applications included alcohol, drug addiction and mental health services (ADAMHS) and community mental health (CMH) boards; partnerships and collaboratives between local criminal justice and mental health systems, including families and consumers; and county-wide and regional partnerships. All funds will be awarded to the ADAMHS or CMH Board for distribution to the participating partners, except as noted. The fourteen grant amounts and program components are listed by ADAMHS or CMH Board area below.
The Athens-Hocking-Vinton ADAMHS Board will use $16,837 in FY 2000 and $67,347 in FY 2001 to replicate in Athens County the Memphis Police Crisis Intervention Team model. Utilizing collaboration between mental health professionals, law enforcement personnel, consumers and families of consumers, this program provides intensive sensitivity training to front-line law enforcement personnel about the unique symptoms and needs of people with a severe mental illness, and establishes direct access to a mental health facility where persons with a mental illness can be taken instead of jail. The Memphis Police Department has utilized this program to increase satisfaction of consumers and families regarding their interventions, decrease incidents of injuries to officers and consumers and decrease jail use and recidivism rates for people with a mental illness.
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The Clermont County ADAMHS Board will receive $6,910 in FY 2000 and $37,370 in FY 2001 to implement a diversion team made up of a case manager and a probation officer dedicated to serving persons with mental illness and co-occurring substance abuse who are involved with the local court system. The staff will act as liaisons with, and provide linkages between, the mental health and criminal justice systems. The staff will work in conjunction with the local Treatment Alternatives to Street Crime (TASC) agency, a Department of Alcohol and Drug Addiction Services-funded program that provides case management, education groups and linkages to substance abuse treatment.
The Columbiana County Mental Health and Recovery Services (MHRS) Board will use $9,856 in FY 2000 and $45,888 in FY 2001 to fund a program developed by three county court judges, the judge of the East Liverpool Municipal Court, the President of the National Alliance for the Mentally Ill (NAMI)-Columbiana County and the Director of Adult Services for the MHRS Board. The program will encourage additional outreach, engagement and monitoring services through the use of two court liaison/community support program workers, facilitate recovery through peer consumer outreach and support, and provide support and education to families of individuals in the target populations through education and outreach provided by NAMI-Columbiana County.
The Eastern Miami Valley ADAMHS Board (Clark, Madison and Green Counties) will receive $11,530 in FY 2000 and $49,750 in FY 2001 to build on existing efforts in Clark County to improve assessments, in-jail services, community linkages and diversion alternatives. The collaborative program will provide education and training for law enforcement officers and establish a social worker position that will provide solid and timely linkages for people with severe mental disabilities with community resources and interventions, including judicial, probation and mental health agency staff.
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The Fairfield County ADAMHS Board will receive $12,400 in FY 2000 and $49,600 in FY 2001 to fund jail diversion services that will coordinate the interventions of the local behavioral health network and law enforcement. The board will hire a court liaison to work closely with the courts and service providers, develop specialized case management services for clients on probation or at risk of incarceration and provide peer support and educational services to this population. Grant funds will also be used to expand specialized community support programs and evaluate the outcomes of project services.
The ADAMHS Board of Franklin County, in conjunction with the Franklin County Sheriff's Office, Netcare Corporation and Southeast, Inc., will use $12,187 in the first year and $39,738 in the second to expand the capacity of the county's ongoing diversion and linkage programs. The primary program objectives are to increase awareness within the criminal justice system about diversion options available for severely mentally disabled offenders; strengthen the diversion linkages between the criminal justice system and Netcare, the contract agency responsible for mental health assessments, and between Netcare and Southeast's criminal justice system community treatment team (CJS CTT); and expand the capacity of Southeast's specialized CJS CTT to serve persons who are at the greatest risk of committing repeat offenses.
The Gallia-Jackson-Meigs Board of Alcohol, Drug Addiction and Mental Health Services will receive $13,374 for the remainder of FY 2000 and $47,296 for FY 2001 to develop a formal jail linkage and diversion program for adults with a severe mental disability or co-occurring diagnosis of substance abuse and mental illness. The grantee agency is Woodland Centers, Inc., in cooperation with the Gallipolis Municipal Court, the City Solicitor, and the Galia County Adult TASC Program. It is anticipated that the funds will be used to develop a model that can be eventually used in Meigs and Jackson Counties.
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The Lake County ADAMHS Board will use $9,875 in FY 2000 and $53,875 in FY 2001 to fund a mental health diversion team that will provide early intervention and alternative treatment options to individuals with severe mental disorders. This program is committed to focusing resources, training and expertise on the individual needs of each offender as they begin their recovery process. A mental health diversion specialist will bridge the gap between the courts and community mental health services, and the diversion team will be a resource for correction professionals. The diversion team represents a collaborative effort between the Lake County Commissioners, the sheriff's department, community police departments, the Lake County Adult Probation Department, municipal and common pleas courts and the Lake County ADAMHS Board and its contract provider agencies.
The ADAMHS Board of Licking and Knox Counties will use grant funds to increase staff and support for existing diversion and linkage programs. Portions of the overall allocation of $10,050 in FY 2000 and $40,000 in 2001 will be used to create a community forensic liaison position in Knox County. In Licking County, grant funds will be used to establish more efficient and reliable methods of diversion and linkage from local jails. The grant will be used to fund a new mental health court liaison at both Knox and Licking Counties' Municipal Courts.
The Lucas County CMH Board will receive $28,620 in FY 2000 and $100,000 in FY 2001 to aggressively link or re-link people with a serious mental illness who are arrested with community mental health services. The Toledo Municipal Court, Lucas County Court of Common Pleas, Lucas County Sheriff, University of Toledo and the mental health board will work collaboratively to create a new criminal justice process and a mental health team that will operate out of the municipal court. During the 15-month grant period, the partners will collect and analyze data to evaluate the effectiveness of the program.
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The ADAMHS Board of Montgomery County, in partnership with the sheriff's office, the county adult probation and pre-trial services departments, DayMont Behavioral Healthcare, Inc., Good Samaritan Hospital's Samaritan CrisisCare, and New Dimensions, will provide identification of and linkage to treatment services for adults involved with the criminal justice system who have been identified with a mental illness or co-occurring disorder of substance abuse and mental illness. The ''Access Project'' will expand the availability of case management and community support, treatment, medical and somatic, vocational, educational and employment services and correctional programming to identified adult offenders. The board will receive $20,000 in FY 2000 and $80,000 in FY 2001 to administer the program.
The ADAMHS Board of Tuscarawas and Carroll Counties, in cooperation with Cornerstone Support Services, developed a proposal for an assertive community treatment team that will be funded with $10,834 in FY 2000 and $42,666 in FY 2001. All of the services funded through this grant will be new services that were developed and will be overseen by an advisory council consisting of mental health and substance abuse providers, law enforcement, parole, probation and jail staff, courts and families of mental health consumers. The ODMH grant amount represents a percentage of the total commitment to the program, with the balance coming from third party sources and agency-generated revenue.
The Washington County Mental Health and Addiction Recovery Board will receive $9,683 in FY 2000 and $38,582 in FY 2001 to develop a formal diversion program for severely mentally disabled adults who have ongoing contact with courts and law enforcement. The main elements of the proposal are enhanced access to screening and assessment to identify people with mental illness, a diversion group to get support for individuals in the community, and intensive case management. Developed in collaboration with the mental health board, the Washington County Sheriff's Department, the Marietta Police Department, the Marietta Municipal Court and Washington County's community mental health agency, this program will be a major step toward improving the availability of services for the people it serves.
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In addition to the mental health and ADAMH boards named above, the National Alliance for the Mentally Ill-Ohio (NAMI–Ohio) will receive a $10,000 grant to develop a comprehensive manual and curriculum for training jail and court staff and other criminal justice professionals around the state about techniques for the safe and effective management of persons who manifest behaviors symptomatic of major brain disorders.
Mr. GEKAS. We thank the gentleman, and we turn to Ms. Webdale.
STATEMENT OF KIM WEBDALE, NEW YORK, NY
Ms. WEBDALE. Good afternoon, Mr. Chairman and subcommittee members. It is indeed a privilege and a pleasure to be here to testify before you today.
Less than 2 years ago, I was unaware of the problems that plagued the mental health care system and how those problems would ultimately impact my life in the most unexpected and tragic of ways. I recognized that the mentally ill were becoming an increasingly prevalent sight on our streets and subways. But I was oblivious to the fact that they were infiltrating our criminal justice system and our jails at an equally alarming rate. As a long-time New Yorker, I had become as immune to people eating out of garbage cans and displaying bizarre sorts of behavior as I was to the homeless people inhabiting the streets. Like homelessness, mental illness was something I found disturbing, something I pitied from afar, and something I frequently ignored, but it was never something I feared. In fact, when my sister Kendra moved to New York City, I even gave her some advice regarding the mentally ill population. I said, ''Just ignore them and they won't bother you.''
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My words came back to haunt me on January 3, 1999. I received a phone call that evening from a reporter informing me that Kendra was dead. A mentally ill man had thrown my 32-year-old sister from the platform into the path of a 400-ton subway train entering the station. She was killed instantly. I cannot begin to describe the heartache that followed: having to tell my parents that their cherished daughter was dead, hearing the despair in Kendra's four other siblings' voices, and identifying Kendra's lifeless body was just the beginning. Despite the belief to the contrary, the passage of time only serves as a painful reminder of the time separating us from the life once spent with Kendra.
After Kendra's death, my family became dedicated to learning as much as possible about violence and the mentally ill. We vowed that we would do whatever we could to ensure that an equally devastating tragedy would not destroy the lives of another family. We learned that Andrew Goldstein, the mentally ill man who had killed Kendra, had been in and out of mental institutions for 10 years. Despite 13 prior violent incidents, he was repeatedly released from hospitals. A distinct pattern emerged known as the ''revolving-door syndrome.'' Goldstein would become violent, be admitted to a hospital, and then released on his own recognizance within approximately 3 weeks, most often with only a few days' worth of medication. Inevitably, he became violent again and the cycle would be repeated.
In fact, the more difficult and violent he became, the more likely the hospital would be to discharge him. And because he was always treated as an emotionally disturbed person, as opposed to going through the criminal justice system, there was no record at all of his criminal, violent past.
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This cycle would continue until he was released 2 weeks prior to killing Kendra. At that time, despite his full knowledge of Goldstein's propensity toward violence, his doctor released him with the words: ''Hit furniture instead of a person the next time you have violent impulses.'' But the next time Goldstein ''got the urge'' to strike out, Kendra would be dead, her beautiful body torn and broken on the subway tracks.
Unfortunately, our search for answers would ultimately lead us to even more questions about how society treats the mentally ill. We questioned how a non-compliant mentally ill man, who was a known danger to others, was allowed on the streets, non-medicated and unmonitored.
Why didn't Goldstein have an intensive case manager? Why, despite 13 prior incidents, wasn't Goldstein ever held accountable for his actions? Why wasn't a hospital bed provided when it was so obvious that inpatient treatment was needed? Why was there no continuity of care between mental health care facilities that treated Goldstein? How could a system that was supposedly designed to protect us fail us so miserably? And, most importantly, what could be done to prevent a future tragedy?
All too soon we found that nothing stood in the way of another mentally ill man striking out at yet another innocent individual. I was on the Number 6 train when almost the exact scenario played out in the 51st Street subway station a few months later. Only this time the victim, Edgar Rivera, would lose his legs, changing his life forever.
Other horror stories began to emerge on a continual basis: a lawyer who stabbed his pregnant girlfriend to death; a case manager who was bludgeoned to death by her mentally ill patient; and a man who stabbed his son to death, was found not guilty by reason of insanity, and then murdered his wife upon his release were only a few of these preventable tragedies.
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We heard of mentally ill people being released from jail who were back onto the streets with no follow-up care whatsoever, no housing, no caseworkers, no medication.
When I discovered that mentally ill inmates were dropped off in the middle of the night with two subway tokens and a few days' worth of medication, I thought it was a sick joke. After all, what kind of system could be that apathetic to the needs of the mentally ill and society alike?
We discovered, as you will hear today, that the problems permeated through the entire mental health care system, from initial police contact, through the criminal justice system, to the jails that contain more seriously mentally ill people than all our mental hospitals combined. We were disheartened by the dissension within the mental health care community itself, who disagreed on solutions to the mental health care problems despite working on similar agendas.
But perhaps the most disturbing question for me that will never be answered is: Why Kendra? Kendra was beautiful, talented, loving, giving, and happy. Kendra loved living in New York City. She was a huge fan of the Yankees, running in Central Park, and taking photographs of New York City. On January 3rd, however, Kendra became a statistic, one of the estimated 1,000 people killed by the untreated mentally ill each year. Kendra was looking forward to visiting a friend on a rainy Sunday afternoon. She was an everyday commuter just waiting for a train until she became the unsuspecting victim of a sick man and an equally sick system. Kendra was taking the advice that now haunts me: ''Ignore the mentally ill and they won't bother you.''
Now that we know the opposite is true, I urge you not to ignore the disaster the mental health care system has become, for ignoring the situation will surely guarantee that more innocent lives are lost. Fortunately, the remarkable effort of the Council on State Governments' Mental Health Advisory Board has helped identify the proverbial ''cracks'' that have overwhelmed the mental health care system. It is time to repair those cracks before they claim their next innocent and unsuspecting victim.
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I know I am over my time, but I would like to take this opportunity to thank the chairman and all of the subcommittee members for their humanity, compassion, and support, and for their progressive approach to finding solutions to our mental health care crisis. I am optimistic and hopeful that change is on the horizon.
Thank you.
[The prepared statement of Ms. Webdale follows:]
PREPARED STATEMENT OF KIM WEBDALE, NEW YORK, NY
Less than two years ago I was unaware of the problems that plagued the mental health care system and how those problems would ultimately impact my life in the most unexpected and tragic of ways. I recognized that the mentally ill were becoming an increasingly prevalent sight on our streets and subways. But I was oblivious to the fact that they were infiltrating our criminal justice system and our jails at an equally alarming rate. As a long-time New Yorker, I had become as immune to people eating out of garbage cans, engaging in volatile conversations with nobody in particular, and displaying bizarre sorts of behavior, as I was to the homeless people inhabiting the streets. Like homelessness, mental illness was something I found disturbing, something I pitied from afar, and something I frequently ignored, but it was never something I feared. When my younger sister Kendra moved into NYC, I even gave her some advice regarding the mentally ill population: ''Just ignore them,'' I said, ''and they won't bother you''.
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My words came back to haunt me on January 3, 1999. I received a phone call that evening from a reporter, informing me that Kendra was dead. A mentally ill man had thrown my 32-year old sister from the platform into the path of a 400-ton subway train entering the station. She was killed instantly. I cannot begin to describe the heartache that followed: having to tell my parents that their cherished daughter was dead, hearing the despair in the voices of Kendra's four other siblings, and identifying Kendra lifeless body was just the beginning. Despite the belief to the contrary, the passage of time only serves as a painful reminder of the time separating us from the life we once shared with Kendra.
After Kendra's death, my family became dedicated to learning as much as possible about violence and the mentally ill. We vowed that we would do whatever we could to ensure that an equally devastating tragedy would not destroy the lives of another family in the future. We learned that Andrew Goldstein, the mentally ill man who had killed Kendra had been in and out of mental institutions for ten years. Despite thirteen prior violent incidents, he was repeatedly released from hospitals. A distinct pattern emerged known as the ''revolving-door syndrome''. Goldstein would become violent, be admitted to a hospital, and then released on his own recognizance within approximately three weeks, most often with only a few days supply of an anti-psychotic medication. In fact, the more difficult and violent he became, the more likely the hospital would be to discharge him. And because he was always treated as an emotionally disturbed person, as opposed to going through the criminal justice system, he did not have a criminal record that indicated his prior, violent past. This cycle would continue until he was released 2 weeks prior to killing Kendra. At that time, Goldstein's doctor released him with these final instructions: ''When you feel a violent urge coming on'', his Dr. advised, ''hit furniture instead of a person''. But the next time Goldstein, ''got the urge'' to strike out, Kendra would be dead. Her body torn and broken on the subway tracks.
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Unfortunately our search for answers would ultimately lead us to even more questions about how our society treats the mentally ill. We questioned how a non-compliant mentally ill man, who was known a danger to others, was allowed on the streets, non-medicated and unmonitored.
Why didn't Goldstein have an intensive case manager?
Why, despite 13 violent incidents, wasn't Goldstein ever held accountable for his actions?
Why wasn't a hospital bed available when it was so obvious that inpatient treatment was needed?
Why was there no continuity of care between mental health care facilities that treated Goldstein?
How could a system that was supposedly designed to protect us, fail so miserably?
And most importantly, what would prevent this tragedy from happening again?
All to soon we found that nothing stood in the way of another mentally ill man striking out at yet another innocent individual. Almost the exact scenario played out on the 51st street subway station a few months later. Only this time, the victim, Edgar Rivera would tragically lose his legs, changing his life forever.
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Other horror stories began to emerge on a continual basis:
A lawyer who stabbed his pregnant girlfriend to death;
a case manager who was bludgeoned to death by her mentally ill patient;
and a man who stabbed his son to death, was found NGRI, and then murdered his wife upon his release, were only a few of the preventable tragedies.
We heard of mentally ill people being released from jail who were back onto the streets with no follow-up care whatsoever'' no housing, no caseworkers, no medications.
When I discovered that mentally ill inmates were dropped off in the middle of the night with 2 subway tokens and a few days worth of medication, I thought it was a joke. After all, what kind of system could be that apathetic to the needs of the mentally ill and society alike?
We discovered, as you will hear today, that the problems permeated through the entire mental health care system, from initial police contact, through the criminal justice system, to the jails that contain more severely mentally ill people than all of our mental hospitals combined. We were disheartened by the dissention within the mental health care community itself, who disagreed on solutions to the mental health care problems despite working on similar agendas. The issue of whether limited resources were best spent on more research, educational initiatives, outpatient commitment, better medications, or more inpatient beds was frequently debated with no clear consensus.
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But perhaps the most disturbing question that will never be answered is: Why Kendra? Kendra was beautiful, talented, loving, giving, and happy. Kendra and I had just returned from a memorable Christmas holiday upstate with our family and she was looking forward to the opportunities of a New Year. Kendra loved living in NYC. She was a huge fan of the Yankees, running in the Central Park, and taking photographs of NYC landmarks. On January 3rd however, Kendra became a statistic: one of the estimated 1,000 people killed by the untreated mentally ill each year. Kendra was looking forward to visiting a friend on a rainy Sunday afternoon. She was an everyday commuter just waiting for a train, until she became the unsuspecting victim of a sick man and an equally sick system. Kendra was taking the advice that now haunts me: ''Ignore the mentally ill and they won't bother you''.
Now that we know that the opposite is true, I urge you not to ignore the disaster the mental health care system has become. For ignoring the situation will surely guarantee that more innocent lives will be lost. Fortunately, the remarkable effort of the Council on State Government's advisory board has identified the proverbial ''cracks'' that have overwhelmed the mental health care system. It is time to repair those cracks before they claim their next innocent and unsuspecting victim.
I'd like to take this opportunity to thank all of the Subcommittee members for their humanity, compassion, and support and for their progressive approach to finding solutions to our mental health care crisis. I am optimistic and hopeful that change is on the horizon.
Mr. GEKAS. We thank the witness.
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Let the record indicate that the lady from Texas, Ms. Jackson Lee, is present as a member of the committee.
We now turn to the final witness of this panel, Dr. Sharfstein.
STATEMENT STEVEN S. SHARFSTEIN, M.D., PRESIDENT AND MEDICAL DIRECTOR, SHEPPARD PRATT HEALTH SYSTEM, BALTIMORE, MD
Mr. SHARFSTEIN. Thank you, Mr. Chairman, Mr. Scott, Ms. Lee. It is a pleasure to be here, and I enter my written comments into the record without objection, and I will summarize my testimony.
I am a psychiatrist, and I am the clinician on this panel, and so I am going to focus my comments on certain clinical issues.
The first thing that I want to underscore is that today in psychiatry, treatment works. We are able to manage and stabilize some of the most disturbing psychotic symptoms of the severely ill in a short period of time. And, in fact, it is the effectiveness of our medications and some of our psychosocial treatments that led to, in large part, the discharge of many patients from State hospitals in the 1970's and 1980's so that people were now living in the community.
Unfortunately, as you have heard, resources were not transferred from the closure of these units and hospitals into community-based programs, and many people began to fall through the cracks.
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I want to make a comment on violence in the mentally ill. You heard some very eloquent testimony from Ms. Webdale, and that tragedy certainly could have been prevented. But it is important to know that the mentally ill, when in treatment, are no more violent than anybody else. It is the folks that have stopped treatment, who have dropped out of treatment, who are not in treatment who are certainly at risk for committing crimes and for being more violent. And it is that population that we are concerned with today because these are the folks that end up getting arrested and end up inappropriately in our jails and prisons.
What we need is access to care. What we need is an approach that assures that when people are discharged from the hospital, that they are supervised, that they are in treatment, that they are taking their medications and coming for appointments, that they have case managers, that they have housing—a very critical piece of the overall puzzle, because homelessness, crime, and mental illness go hand in hand—that they have other benefits, and that they have support from various other systems of care, especially the criminal justice and the police; that when they do come to the attention of the police, that there is a way that the criminal justice system and the mental health system work together to provide treatment and services to these people and not put them in jail. That is what is absolutely critical, I think, at this point in time.
You know, there are five times as many individuals in jails and prisons today as there are in State hospitals, and that is an incredible revolution that has taken place.
I want to finish my testimony with a quote. ''Great injustice is done to the insane by confining them in jails and houses of correction. This state of things unquestionably retards the recovery of the few who do recover their reason under such circumstances and may render those permanently insane who, under other circumstances, might have been restored to their right mind. The confinement of the criminal and the insane in the same building is subversive of that good order and discipline which should be observed in every well-regulated prison.''
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The person who made this statement to, in fact, the Congress of the United States was Dorothea Dix and the year was 1843. One of the great ironies of the 20th century is how, when we have come up with effective treatment, we have thrown the mentally ill back into the 19th century. And I think that we can do better.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Sharfstein follows:]
PREPARED STATEMENT OF STEVEN S. SHARFSTEIN, M.D., PRESIDENT AND MEDICAL DIRECTOR, SHEPPARD PRATT HEALTH SYSTEM, BALTIMORE, MD
Thank you very much for the opportunity to appear before you today to discuss one of the most important public health crises in our country: the criminalization of the mentally ill.
I especially appreciate the initiatives undertaken by Representative Ted Strickland and Senator Mike Dewine and their staff to provide significant new federal leadership to solve this crisis. Their interest and commitment gives a mental health professional such as myself great hope.
My name is Dr. Steve Sharfstein and I am a psychiatrist who has practiced for over 25 years in hospital and community settings in both the public and private sectors. Currently, I am the President of one of the oldest nonprofit hospitals and behavioral care systems in the United States. Last year, Sheppard Pratt provided treatment to over 50,000 individuals throughout the state of Maryland in 20 different locations. The Sheppard asylum was originally founded in 1853 by members of the Friend's Meeting to provide an alternative to jails and other unacceptable settings for the treatment of t he ''insane.'' Our mission today differs little from when we were founded 150 years ago.
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I am here to present to you a clinical perspective on mental illness and the criminal justice system. First, I will describe to you the scope of criminalization of the mentally ill which I believe is a public health tragedy. Second, I will provide some of my own ideas on the source of this crisis of criminalization. Finally, I will try to provide some ideas on clinical solutions which require collaborative criminal justice and mental health system reform.
Criminalization of the Mentally Ill: A Public Health Disaster
In 1999 the Department of Justice reported that as much as 16 percent of the population of state jails and prisons, that is more than 250,000 individuals, suffer from severe mental illnesses. With 3,500 and 2,800 mentally ill inmates respectively, the Los Angeles County jail and New York Riker's Island jail are currently the two largest psychiatric inpatient treatment facilities in the country. Many if not most of these individuals could and should have been treated in hospitals and community based mental health treatment if these services were available and accessible. The warehousing of the mentally ill in jails and prisons is an unacceptable throwback to the deplorable conditions in the 19th century which prompted Dorothea Dix and the Quakers, who founded Sheppard Pratt in Baltimore, to develop asylum care.
Police are often the front line mental health workers when a person with mental illness is in crisis. In New York from 1976 to 1986 the number of ''emotionally disturbed persons'' the New York City police department took to hospitals for psychiatric evaluation increased from approximately 1,000 to 18,500 and by 1998 that number has increased to 24,787. Too often these encounters with police end up as deadly ones. From 1994 to 1999 Los Angeles police shot 37 emotionally disturbed persons killing 25 of them. In 1999 alone, police in New York, Houston and Tampa shot and killed three individuals with mental illnesses in each city.
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The Source of the Crisis of Criminalization
The massive deinstitutionalization of patients from state hospitals into the community beginning in the 1960s is a prime factor in the criminalization of the mentally ill today. Deinstitutionalization derived from clinical, legal and most importantly economic forces so that now there are fewer then 60,000 individuals in public hospitals compared to well over 500,000 forty years ago. There are today nearly five times more mentally ill people in jails and prisons as there are in state psychiatric hospitals.
The clinical reasons for initial discharge include a more effective medication strategy with the discovery of the antipsychotic medications beginning in the 1950s. These medications which have improved over the years enable most patients to be ''better but not well.'' For many individuals with long term mental illness, remaining on these medications for years is essential if their condition is to remain stable. The most common cause for relapse for severe mental illness is non-adherence to treatment and, as I will discuss later, individuals who are not in treatment or who have dropped out of treatment are the ones that we must worry about in terms of the potential for violence.
In addition to the increased clinical efficacy, legal decisions in the 1960s and 1970s guaranteed a right to treatment in the least restrictive setting, the right to refuse treatment under certain circumstances, judicial oversight of involuntary commitment and other protections that established the civil and constitutional rights of the mentally ill.
The most significant cause of deinstitutionalization was economics. Federal financing policy established in 1965 led to the discharge of many thousands of patients from state supported facilities who were ineligible for Medicaid and Medicare funding. Such discharge within community based settings made them eligible for Medicaid reimbursement with at least a 50 percent federal payment.
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State hospitals have closed and continue to close without adequate resources to care for these patients in community based settings. Despite promises to redirect hospital resources after sizing down or closure to the community, states failed to fulfill these promises. For example, when New Jersey closed its largest psychiatric hospital it promised to create 324 new community placements and to study the success of these placements. The study revealed that the state failed to create 47 of the promised new placements and at the end of the study only 167 individual placements, that is half of the promised 324, could be evaluated. In Oklahoma seven months after downsizing Eastern State Hospital 10 percent of its patients spent an average of 32 days in jail.
So with deinstitutionalization, there are many patients untreated or inadequately treated in community settings and predictably many of these individuals became intimately involved with the criminally justice system. In the 1960s and 1970s, the standard for state psychiatric hospitalization changed to require that an individual be an imminent danger to self or others. When Pennsylvania changed its law, Philadelphia's police chief issued a directive that non-dangerous people who could no longer be taken into custody under the Mental Health Act could be arrested for disorderly conduct. Pennsylvania 's prisons experienced a sharp increase in admission of inmates with severe mental illnesses a few months after the change of the law. In many if not most areas across the country, mentally ill individuals who have committed non-violent property crimes or are arrested for vagrancy have found their way inappropriately into jails or prisons.
I would like to make one comment on violence from a public health and clinical perspective. The vast majority of people with mentally illness who are incarcerated are arrested for non-violent crimes, and mentally ill individuals generally who are being treated are no more violent than the general public. Individuals who are not being treated or have dropped out of treatment have the greater potential for violent episodes. One study revealed that individuals who were not taking their medications were 63 percent more likely to be violent than individuals who complied with medication regiments. The New York Times recently studied 100 ''rampage killers.'' More than half of these had histories of serious ''mental health problems.'' The violence of a few individuals with mental illness unfortunately stigmatizes the majority of the mentally ill who are non-violent and are much more often the victims of violence.
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Clinical Options for Solving the Crisis of Criminalization
Treatment works. Medications are increasingly effective with fewer side effects and the combination of psycho-social and psycho-pharmacologic treatment allow the great majority of people with schizophrenia, major depression and bipolar illness and other serious and persistent mental disorders to reside in the community, to work and to live with their families or in non-hospital settings. Unfortunately, there is a great lack of such treatment opportunities in community systems of care such as newer approaches like Assertive Community Treatment which has been shown to be effective for early intervention for people at risk for relapse. Adequate housing and other social welfare supports are other important components of a community-based system. These are also lacking in many communities. Homelessness leads to criminalization. Adequate hospital capacity is necessary in the era of managed care when such hospital stays are very short with the potential for premature discharge.
Another option for solving the criminalization of the mentally ill is court ordered treatment. Need for treatment, grave disability, chronic course, lack of insight into illness and previous noncompliance with treatment are all criteria that should be used in court ordered treatment. Court ordered treatment will only work as long as there is treatment available in the appropriate settings. Some patients may benefit from assisted outpatient treatment that ensures treatment compliance in the community to a court ordered treatment plan. Not only does the court commit the patient to the treatment system but also commits the treatment system to the patient. More study and evaluation of assisted outpatient treatment should be undertaken to assess its impact on the criminalization of the mentally ill.
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Mental Health Courts are another promising opportunity for providing alternative community based services to the non-violent mentally ill offender. Inevitably, some individuals will end up in jail and they should be provided with treatment while incarcerated which is up to date and safe. At release such individuals should be referred to community based treatment. Too often, release from prison leaves the mentally ill individuals with no alternative for appropriate intensive community treatment that is essential in making a success of their lives in the community and preventing reincarceration.
One area the Committee could help with now, is to support innovative programs within corrections departments to help people with reentry linkages once released from jail. For instance, SSI and SSDI benefits are currently ''suspended'' for individuals who are incarcerated under one year. When released, they are expected to go to a local Social Security office to fill out a reinstatement application. There is no review of the individual's medial condition as the SSA assumes they remain disabled but there is the need to document financial status. There is at least a 10-day wait before reinstatement occurs. In some states, the medical application must be made separately at the local welfare office requiring a second visit.
I am very heartened by today's hearing as it may lead to a new era of collaboration and cooperation between the criminal justice and mental health treatment systems. Individuals who experience the tragedy of mental illness must be treated and not punished. Communities should be safe from unpredictable violence committed by a few individuals with serious mental health problems. The criminal justice system should not be over burdened with inappropriate numbers of mentally ill inmates. We can do better and we will.
Mr. GEKAS. We thank the witness. The Chair will indulge in 5 minutes of questioning, after repeating that the witnesses will have their written statements entered into the record without objection.
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The first question I have is to Ms. Webdale. It seemed to me that from the account that you rendered about the culprit who threw your sister into harm's way, that there were 13 previous file violations of law or incidents of violence, which?
Ms. WEBDALE. There were 13 incidents of violence. The police would typically be called to the site of violence and then Goldstein would tell them that he was sick, or he was schizophrenic. He would tell them to take him to a hospital, and they would immediately transport him to a hospital, circumventing the whole criminal justice system. So with the exception of one incident, he didn't have a criminal record at all. In fact, 6 months before he pushed Kendra, he attempted to push another woman onto the tracks, but there is no criminal record of that incident because he was treated as an EDP, or an emotionally disturbed person, as opposed to being charged and going to jail.
Mr. GEKAS. Dr. Sharfstein, isn't this individual, this Goldstein—is that what his name was? Wasn't he a prime candidate for institutionalization without the ability to go into the community?
Mr. SHARFSTEIN. I think that if he was unable to take his medication and be supervised closely in the community, I completely agree with you that he should have been institutionalized somewhere for his life because of that problem.
Mr. GEKAS. Haven't we all found instances, when the deinstitutionalization started to occur, that those very same things were happening, that the individuals were out on the street not taking their medication, not being supervised? Even though the intentions were there, the reality was that the deinstitutionalization helped create the atmosphere for some of the incidents like we have heard here today. Does anyone care to——
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Mr. MELEKIAN. Mr. Chairman, if I might, one of the real ironies, when you compare the mental health system and criminal justice system, is that heroin addicts who are arrested and convicted for burglary and theft and the like, as a condition of probation, can be compelled to take methadone as a condition for remaining free in the community. But there are no similar provisions for the mentally ill with regards to medication that—Dr. Sharfstein is absolutely correct—can demonstrably control their condition.
Mr. GEKAS. Mr. Hogan, you differentiated, it seems to me, in your testimony between the non-violent prison inmate who is mentally ill. Does that mean to imply that the violent ones still have to remain in the criminal justice system and treated by that system as well as the mental health system? Or were you implying that the non-violent should not be in the criminal system at all?
Mr. HOGAN. Good question, Mr. Chairman, and I think that ultimately obviously you pose a question that has to be decided in the context of particular facts. But as a general matter, I would say that if they have done something dangerous and violent and if they are dangerous and violent, they should be locked up. And then they should get care in that prison. It is their right to get care. You will hear from Director Wilkinson, my colleague in Ohio, who has done a wonderful job of improving care in Ohio's State prison system.
But as a non-lawyer, I would tend to make that distinction. If they are going to put other people in harm's way and they committed a crime, they should be found guilty and locked up.
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Mr. GEKAS. The Chair reserves the balance of its time and yields to the gentleman from Virginia for a round of questioning. But before we do that, we want the record to reflect the attendance of the gentleman from North Carolina, Mr. Coble, a member of the committee.
Mr. Scott?
Mr. SCOTT. Thank you. I want to respond to a question posed by Chief Melekian about why it is before this Crime Subcommittee rather than another subcommittee. I guess because we care. Maybe it should be somewhere else, and hopefully we will consider this elsewhere.
You indicated that you ran out of time before you could give us your suggestions. Why don't you take a minute or so to tell us what we ought to be doing.
Mr. MELEKIAN. Thank you, Mr. Scott.
I think from the perspective there are several things. One is that when the mental hospitals across this country were dismantled, one of the solutions was particularly in California, a series of community treatment centers, and for a brief period of time, those centers were there. It was a place where the mentally ill could get counseling and treatment, and it was a resource for law enforcement officers as an alternative for jail. By the early 1980's, those had disappeared.
Clearly, another problem, particularly in California, is the authority for emergency room doctors and other psychiatric professionals to commit people for evaluation. Currently, the standards are so tight that if the person is not acting violently either toward themselves or other people in the immediate presence of the evaluator, it is highly unlikely that that person will be committed for observation.
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I already discussed the issue of Buford Furrow and others who made generalized threats, either against particular groups of people or against specific individuals, but very often absent a specific crime, there is no State or local authority to deal with those people.
I already talked about the issue of medication and compared it with the fact that heroin addicts can be compelled to take methadone, but the mentally ill cannot be compelled to take their medication.
There are a number of successful programs, including ones in Ithaca, New York, the Memphis Police Department in Tennessee, and Los Angeles County Sheriff's Department that pair law enforcement officers with psychiatric social workers and respond to incidents involving the mentally ill, and this has proven to greatly reduce deadly force incidents between law enforcement and mentally ill people on the street. I think clearly that some movement in this direction needs to occur.
And on the Federal level, there are two things I would point out. One is the increased role that the Veterans Administration could play, particularly among those individuals who have served in the military previously. And the other is there is a real problem in terms of funding because of the distinction that is made between mental illness and substance abuse, when, in fact, very often those issues are overlapped, particularly among the homeless.
So those are just a few things I would suggest.
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Mr. SCOTT. Thank you very much.
You indicated that some people had made actually some threats. How often do threats from mentally ill individuals actually turn into violence?
Mr. MELEKIAN. I don't have hard numbers in front of me. My guess would be somewhere around 5 to 10 percent of the time, and that is really one of the challenges for law enforcement, is trying to figure out which of those 1 in 10 is real.
Mr. SCOTT. Do you think some kind of—is that something that can be improved by training or research?
Mr. MELEKIAN. I think both training and research clearly would go a long way, but I think ultimately it may be that if someone is going—if we are going to err perhaps slightly, we need to err on the side of being able to take people—in California it is 72 hours—to place them under 72-hour observation so that a professional can make a determination as to whether the threat is viable or not as opposed to asking a police officer to do it.
Mr. SCOTT. Thank you. My time is just about up, but I wanted to ask Dr. Sharfstein a question. You indicated that those who are under treatment are no more violent than anyone else. If treatment were, in fact, available, would those who are mentally ill actually access it?
Mr. SHARFSTEIN. I think that most, in fact, do access themselves to treatment. There is a small number but significant number that resist treatment, that don't want to be in treatment, who deny that they are ill, which is actually a part of their illness, their denial of being ill. And that is the group that we are concerned with today.
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There are people who would avail themselves of treatment but can't get treatment because there are barriers to treatment. And then there are people who, where there is treatment available, won't avail themselves of treatment unless somehow forced or where the expectation is that they will be in treatment or there is some consequence.
Mr. SCOTT. Thank you, and, Mr. Chairman, I would like to thank Ms. Webdale for her compelling testimony. It is extremely helpful because it puts a real-life image to the problem that we are dealing with. I want to thank you.
Mr. GEKAS. We thank the gentleman.
We turn to the lady from Texas, who is allotted 5 minutes for a round of questions.
Ms. JACKSON LEE. Thank you very much, Mr. Chairman, and thank you for the hearing, and as well, let me acknowledge the ranking member, Mr. Scott, who every time I have offered an amendment in this committee dealing with the issue of mental health, I have enjoyed his support and commitment to the issue.
We would hope that the 21st century connotes progress, but let me cite some numbers for you that may have already been recited, but allow me to do so again.
Studies show that in State mental hospitals in 1955 there were 560,000. In 1989, the number went down to 100,000, and in 1994, 71,000. Yet the American Jail Association estimates that 600,000 to 700,000 people suffering from serious mental illness are being booked into jail each and every year.
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Dr. Sharfstein, forgive me, are you a psychiatrist?
Mr. SHARFSTEIN. Yes.
Ms. JACKSON LEE. My question is, far better than I, what was this whole issue about deinstitutionalizing individuals and look where we are today. Would you just respond to that theory?
Mr. SHARFSTEIN. Well, the State hospitals——
Ms. JACKSON LEE. And let me just say I am quite aware of snake pit, and so I fully appreciate some of the tragedies that went on. But let me understand why we couldn't improve the conditions of treatment as opposed to embrace the institutionalizing, and now we have them incarcerated in jails.
Mr. SHARFSTEIN. Right.
Ms. JACKSON LEE. And I am sorry for interrupting you.
Mr. SHARFSTEIN. Well, many of these State hospitals were snake pits and were not places where anybody would want to be. They were an example of tremendous neglect of the mentally ill. That was one issue.
But I think that there was an increasing recognition and there were studies to show that most people could have their symptoms stabilized with these newer medications and the psychosocial treatments and they could leave the hospital. The issue then was: Could we put together community-based services that met their needs?
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Now, I can give you many examples where, in fact, that has occurred, and today, if somebody develops a serious mental illness, there is much more opportunity for good treatment, for active follow-up, and for a decent quality of life than there was 30, 40 years ago. There are many hundreds of thousands of people who are not in the criminal justice system who have experienced a mental illness, who have received treatment, and are doing well today; whereas, 50 years ago they would have been hospitalized in the State hospital and would have been there for months, if not years in the hospital. So there are two sides to this.
There is a group of individuals, many of whom, by the way, are dually diagnosed—in other words, they have serious mental illness and substance abuse problems, who have difficulty remaining in treatment. They are often discharged into communities that don't have the services that they need. They are not well served by the services that are there, and so that is the group that we are talking about. And that is the group that get put into jails a number of times, not just, you know, for non-violent problems, as well as the few people who I think give the great majority of the mentally ill a very bad name and a lot of stigma to mental illness, who, in fact, are violent in the context almost always of not being in treatment.
Ms. JACKSON LEE. Might I glean from your testimony then—and I do want to thank my colleague, the Congressman from Ohio, Congressman Strickland, for this legislation dealing with diversion courts, and my work has been focused on the impact of mental illness on children and the utilization of juvenile justice courts for children, when, in fact, I think they need 100 percent mental health services. But do I hear you saying that we failed ourselves when we deinstitutionalized and did not provide sufficient number of these community mental health services and resources?
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And, Ms. Webdale, might I thank you. Obviously your case is both enormous and national and tragic for your family. You see a problem with the individual having had an aggressive personality and behavior and not being found in a system that he could have been kept off the streets to protect others and as well get treatment. Is that what I am hearing you saying, that you would not have been opposed to him having treatment, it is just that he was out?
Ms. WEBDALE. He was treated many times. He was in and out of mental institutions for 10 years.
Ms. JACKSON LEE. When I say ''treated,'' kept in the institution and treated.
Ms. WEBDALE. Right. Actually, he was in Creedmore, a high-security facility, for several years. And, in fact, about a year before he killed Kendra, the short-term care facility that he was in recommended to Creedmore that he be hospitalized as an inpatient. However, they didn't have a bed available, so they put him on a waiting list, and they actually did all the paperwork, and he was prepared to be transferred to Creedmore.
Unfortunately, his insurance ran out, and so when he wanted to leave his short-term care facility, he basically had to just walk out the door. He voluntarily signed himself in, so despite the fact that he was violent and non-compliant, he could voluntarily sign himself out of that facility.
The hospital had the option of keeping him in by going to court. However, they decided not to do that, and, therefore, he was back on the streets with absolutely no case manager, no medication, and no care whatsoever.
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Ms. JACKSON LEE. Thank you very much. I am sorry for your tragedy. Thank you.
Mr. GEKAS. We express our gratitude to this panel as well for the excellent testimony which they have offered and which will remain in the record for further examination by the committee. We excuse you with our thanks.
We invite the final panel to present themselves at the witness table. The final panel will examine the impact of the mentally ill on the criminal justice system.
Donald F. Eslinger, the sheriff of Seminole County, Florida, and president of the Florida Sheriffs' Association. Mr. Eslinger has 22 years of service with the Seminole County Sheriff's Office. He is a consultant and instructor for the National Sheriffs' Association regarding community policing and related topics. Mr. Eslinger received his bachelor's degree from National-Louis University and is also a graduate of the FBI National Academy and the National Academy of Corrections.
Michael D. Schrunk is the district attorney for the county of Multnomah, Oregon. Is that correct, Multnomah?
Mr. SCHRUNK. Yes, sir. Portland.
Mr. GEKAS. Mr. Schrunk has served in this capacity since 1981, and he currently chairs the regional Organized Crime Narcotics Task Force and is a member of Multnomah County's Public Safety Coordinating Council. He received extensive experience in prosecution of criminal cases, and while in private practice represented plaintiffs and defendants in civil litigation and defended criminal cases. Mr. Schrunk is a graduate of the University of Oregon Law School.
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With them at the witness table is Dr. Risdon Slate, a member of the Florida Board of Directors of the National Alliance for the Mentally Ill and president of the Polk County chapter of the National Alliance for the Mentally Ill. Dr. Slate is an associate professor of criminology of Florida Southern College, and he is a current task force member of the Polk County, Florida, Public Safety Coordinating Council, where he is involved in monitoring a mental health grant aimed at diverting the mentally ill from jail. Dr. Slate received his bachelor's degree from the University of North Carolina, his master's degree from the University of South Carolina, and his doctorate from the Claremont Graduate School.
The Honorable Jim Cayce, who is now part of this panel, is a superior court judge in King County, Washington. Judge Cayce spent 9 years as a partner in the private practice of law prior to his appointment to the district court bench in 1989. He chaired a community planning task force to explore the feasibility of creating a mental health court in King County, which would later be implemented in February of 1999, only the second kind of its genre in the United States. He presided over the daily mental health court calendars until his appointment by the Governor to the superior court in July of 2000. Judge Cayce received his bachelor's degree from the University of Washington and his law degree from the University of Puget Sound.
Reginald Wilkinson joins the panel, director of the Ohio Department of Rehabilitation and Correction, and vice president of the Association of State Correctional Administrators. Dr. Wilkinson has served in many capacities since joining the department in 1973, including superintendent of the corrections training academy and deputy director of prisons. He is the past president of the American Correctional Association. He received his bachelor's and master's degrees from the Ohio State University and his doctor of education degree from the University of Cincinnati.
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Our final witness is of special interest to the Chair since he is a Pennsylvania State Senator, a post which I held prior to my coming to the Congress of the United States, and I note that the gentleman, Senator Thompson, serves as chairman of the Law and Justice Committee of that body, a body commensurate with the Judiciary Committee, on which I served when I was in the Senate of Pennsylvania. But he has gained greater distinction in his present capacity because he serves on a committee—he is vice chairman of a committee that is dedicated to the subject matter at hand for the eastern portion of the National Council on Governments. So he has delved into this topic for a long time now, and I am proud that as a colleague in and of Pennsylvania and the senate that he graces our panel for the testimony that he is about to give.
We will begin in the order in which the witnesses were introduced with the same routine of offering each of the written statements to be accepted without objection for the record and to ask each to limit the time to about 5 minutes, and we will proceed with the chief.
STATEMENT OF DONALD F. ESLINGER, SHERIFF, SEMINOLE COUNTY, FLORIDA
Mr. ESLINGER. Thank you very much, Mr. Chairman, members of the subcommittee. It is a real pleasure to be here.
Congressman Scott as well as the chairman mentioned some numbers when we first began, mentioned that about 96,000 local inmates are suffering from some type of mental illness. I suggest to you those numbers are staggering, but it is even more staggering to understand that over 10 million defendants are booked into local jails throughout the country, and this truly creates an additional burden on the system.
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For a variety of reasons, our local jails have become the mental health treatment centers of last resort, more often than not housing and, in some instances, treating more mental health consumers than the local community service providers itself. This transference of responsibility for treatment of mentally ill to the criminal justice system is not only ineffective and burdensome to an already overburdened justice system, it is also costly.
On average, mental health offenders cost more to manage in jail, stay longer, and recidivate at a higher rate than any other inmate. The criminal justice system lacks the necessary facilities and resources to effectively treat the mentally ill. Further complicating an already difficult task is the lack of coordination and integration of the mental health services in our communities.
Some of the problems in the system are, for example: Number one, at the point of contact in the field. Most law enforcement officers are not trained to recognize and identify mental health factors. The lack of training combined with the lack of alternatives for disposition of an incident involving the mentally ill person often results in unnecessary entry into the criminal justice system.
Number two, most jails lack the resources to adequately and timely screen for mental health problems of the defendants. Lack of training, insufficient access to mental health histories, and limited or no diversion options create difficult management issues for jail personnel. More often than not, inmates with mental health problems are released from jail without proper planning for discharge. The lack of planning is usually due to lack of formal linkage between the criminal justice system and the community mental health providers.
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As stated here today, there have been many acts of violence relating to mental health, and Seminole County has its own story as well. On July 8, 1998, the Seminole County Sheriff's Office Deputy Gene Gregory responded to a disturbance call in the rural area of Geneva. Deputy Gregory, a 55-year-old husband, father of three, and a 7-year veteran of our organization, was shot and killed as he approached the residence of Alan Singletary, a 44-year-old mentally disturbed individual whose family had sought help for years. After a 13-hour standoff, Singletary was also killed by members of our organization, and two other deputies were wounded during this incident. This tragic incident highlights many of the deficiencies of the mental health delivery systems common in many communities: lack of coordination of services, lack of resources, lack of information for the officer in the field, as well as at the scene of a crisis. However, an adequately funded, integrated mentally ill delivery system with the appropriate treatment and case management for the mentally ill could have made a difference in this situation.
As a result, we have formed a Mental Health and Substance Abuse Task Force. Membership on this task force includes Deputy Gregory's widow, Linda Gregory, and Alan Singletary's sister, Alice Petree.
We also established a crisis intervention team, a comprehensive in-jail mental health service delivery system, post-booking diversion pilot program, which is a post-booking diversion program. And, by the way, Congressman Scott, the inmates pay for this. It is not a burden of the taxpayers of Seminole County. We have also started a medical security program.
While we have made great progress in addressing mental health issues in our community, I truly believe that working together—and I ask this subcommittee to look at the data collection process. The larger scope of data collection on the mentally ill in local jails is needed to take into account the bookings. In other words, in our facility, our population averages about 1,000 a day, but we book 18,000 to 19,000 annually. That has an impact on our system. A national study is needed to assess the impact of deinstitutionalization of the mentally ill.
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Pre-booking diversion pilot programs throughout the country could really have an impact, a positive impact, and mental health courts, but I think one of the most important elements, what I am asking for here, is the coordination of community-based and in-jail services is necessary to ensure seamless continuity of care for the mental health offender, systems integration. And I ask the Government to truly look at methods and funding to encourage local and State governments to get more involved in system integration.
I would ask the subcommittee to give consideration to how the Federal Government can, in fact, assess the magnitude of this problem from a national perspective, and I truly appreciate the opportunity to address this subcommittee. While these endeavors may seem overwhelming, I believe that working together at all levels of government we can make a positive impact and truly enhance the quality of life of all Americans as a result.
Thank you.
[The prepared statement of Mr. Eslinger follows:]
PREPARED STATEMENT OF DONALD F. ESLINGER, SHERIFF, SEMINOLE COUNTY, FLORIDA
In 1880, the first survey of mental health issues in jails revealed that less than 1% of our nation's jail inmates were mentally ill. According to a 1999 U.S. Department of Justice report, 16% (96,000) of the nation's local jail inmates in 1998 were mentally ill. This number was based on an average daily jail population of 583,000. As staggering as this data seems, the 10 million offenders processed in and out of local jails annually indicate an even larger burden on the system. For a variety of reasons, our local jails have become the mental health treatment centers of last resort, more often than not housing (and, in some instances, treating) more mental health consumers than the local community providers. This transference of responsibility for treatment of the mentally ill to the criminal justice system is not only ineffective and burdensome to an already overburdened justice system, it is also costly. On average, mental health offenders cost more to manage in jail, stay longer, and recidivate at a higher rate than other inmates.
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The criminal justice system lacks the necessary facilities and resources to effectively treat the mentally ill. Further complicating an already difficult task is the lack of coordination and integration of mental health services in our communities. Some of the problems of the system are:
Point of contact in the field
Most law enforcement officers are not trained to recognize and identify mental health factors. This lack of training combined with a lack of alternatives for disposition of an incident involving a mentally ill person often result in unnecessary entry into the criminal justice system.
Admission and housing in the jail
Most jails lack the resources to do adequate and timely screening for mental health problems. Lack of training, insufficient access to mental health histories, and limited or no diversion options create difficult management issues for jail personnel. Inadequate housing and limited in-jail mental health services usually equate to decompensation in the inmate's mental condition.
Discharge from the jail
More often than not, inmates with mental health problems are released from jail without proper discharge planning. This lack of planning is usually due to the lack of a formal linkage with the community mental health providers and results in a lack of continuity in care.
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There are many notorious incidents of violence related to mental illness that I could cite to demonstrate a need for change. We read about them all too often. The November, 1999 killing of seven co-workers in Hawaii by a 15 year Xerox employee with mental problems. The August ,1999 shooting of three children, a teen, and a senior citizen at the North Valley Jewish Community Daycare Center by a man who had tried to commit himself to a psychiatric hospital. What often appears to the public as a random act of unexplained violence is more often than not associated with mental illness and a community's lack of resources to deal with the problem. These incidents occur all over this nation, sometimes in our own back yard. I want to tell you, briefly, our community's very personal story of violence related to mental illness.
On July 8, 1998, Seminole County Sheriff's Deputy Gene Gregory responded to a disturbance call in the rural community of Geneva. Deputy Gregory, 55 years old, a husband and father of three sons, and a seven year veteran of the force, was shot and killed as he approached the residence of Alan Singletary, a 44 year old mentally disturbed individual whose family had sought help for years. After a 13 hour stand-off, Singletary was also killed. Two other deputies were wounded during the incident.
This tragic incident highlights many of the deficiencies of mental health delivery systems common in many communities—lack of coordination of services, lack of resources, lack of information for the officer in the field and at the scene of a crisis. An adequately funded, integrated mental health delivery system with appropriate treatment and case management for the mentally ill may have made a difference in this case.
In the aftermath of Deputy Gregory and Alan Singletary's deaths, a number of initiatives have been developed in Seminole County to address some of the these issues. They are listed below.
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Seminole County Mental Health and Substance Abuse Task Force
A task force was formed in 1998 with membership from the Sheriff's Office, State Attorney, Public Defender, Probation Department, Seminole Community Mental Health Center, Judicial, County Commission, and other various stakeholders. The members meet monthly to discuss system coordination issues as well as potential legislative proposals. Membership on this task force includes Deputy Gregory's widow, Linda Gregory, and Alan Singletary's sister, Alice Petree.
Crisis Intervention Team
The CIT team consists of deputies who have received training to respond to crisis calls pertaining to the mentally ill for the purpose of early identification, compassionate field intervention, appropriate placement, and coordinated follow-up of mentally ill citizens.
Comprehensive in-jail mental health services
At the request of the Sheriff, the Board of County Commissioners authorized the allocation of inmate phone revenues to contract for mental health and substance abuse services from the Seminole Community Mental Health Center, significantly enhancing services in the jail.
Post-booking diversion pilot
A six-month pilot project for the diversion of nonviolent, misdemeanant inmates with mental health problems into community based, supervised treatment plans. The project is a collaboration of the Sheriff's Office, Seminole Community Mental Health Center, and the Seminole County Probation Department utilizing existing resources.
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Medical Security Program
The medical security program is a collaboration with the Mental Health Association, the Seminole Community Mental Health Center, and the South Seminole Regional Hospital designed to voluntarily register mental health consumers who will carry identification on their person making early identification and access to records more feasible.
While we have made great strides in addressing mental health issues in our community, we have only begun to scratch the surface of the problem. Many jurisdictions in this nation are just beginning to seek solutions to these issues; however, resources and technical assistance are needed. I believe this subcommittee should consider several aspects of the community mental health and criminal justice system issue as starting points to assist state and local governments.
Data Collection
A larger scope of data collection on the mentally ill in local jails is needed. Current data collected by the Bureau of Justice Statistics are limited to projections of the number of mentally ill in our jails on any given day based on the average daily population of inmates. This approach ignores the over 10 million admissions annually and therefore understates the magnitude of the problem.
National Study
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A national study is needed to assess the impact of the deinstitutionalization of the mentally ill and the corresponding movement of those individuals into jail/prison settings. The study could be done jointly by the Bureau of Justice Statistics and the Substance Abuse and Mental Health Services Administration (SAMSHSA) with focus on the issue of co-occurring disorders and the need for collaboration among agencies when requesting funding.
Pre-booking Diversion
Law enforcement officers in the field need a facility to take mentally disturbed individuals for assessment and evaluation to determine the best course of action for the individual and the community. Many individuals could be diverted from the criminal justice system for mental health and/or substance abuse treatment plans, thereby preserving jail space for those who must be managed in a secure setting. This facility would be similar to the Juvenile Assessment Center concept.
Mental Health Court
A formal, judicial process that balances a commitment to public safety with the unique needs of mental health offenders is needed to ensure an appropriate disposition in the best interests of the offender and the community.
System Integration
Coordination of community based and in-jail services is necessary to ensure a seamless, continuity of care for the mental health offender. Community agencies should be required to follow their clients into the jail and should continue to receive funding. This integration should include cross training, continuity of case management and medication adherence, and appropriate discharge planning.
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General Funding
Services in the community and the jail are drastically underfunded in the areas of case management, medication, and residential placement options.
The law enforcement community has become increasingly more aware of its role as a mental health resource. Mentally disturbed offenders are a community problem and we are committed to proactively addressing problems in our community which affect our citizens' (all citizens) quality of life.
The jail is a community institution and has become one agency in a continuum of community services for the mentally ill. Unfortunately, most agencies and most jails are ill equipped to handle this role. There is a lack of resources, training, and coordination of services within most communities.
The overall economic and social impact of these system deficiencies is difficult to compute. There is loss of sanctuary, family devastation, and all too often, loss of life. It is incumbent upon us to close the gaps in the system. Failure to appropriately treat the mentally ill is not only morally wrong, it is a legitimate, national public safety problem. Although violent crime is down, there are large numbers of mentally ill individuals in our communities who are a danger to themselves as well as a danger to others.
I would ask this subcommittee to give consideration to how the federal government can assess the magnitude of this problem from a national perspective and what assistance can be given to state and local jurisdictions. While these endeavors seem overwhelming, I believe that working together at all levels of government, we can make a positive impact.
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Mr. GEKAS. We thank you.
Mr. Schrunk?
STATEMENT MICHAEL D. SCHRUNK, DISTRICT ATTORNEY, MULTNOMAH COUNTY, OREGON
Mr. SCHRUNK. Mr. Chairman and members of the committee, thank you very much for this opportunity, and let me in advance commend you for taking on this difficult task that has been with us for a long time, and I thank you for accepting my written testimony.
Let me elaborate a little bit about being a local district attorney. I am Mike Schrunk. I have been elected the local district attorney since 1981. I have sat at mental health hearings. I have tried people with guilty but for insanity. I have processed people. And like you, being independently elected, I have field numerous constituent phone calls as to what is going wrong with the system.
Portland is not unlike your communities. It is not unlike large communities and small communities across the there. The criminal justice system in Portland, in Oregon, in the country, is treating the mentally ill by default. For one reason or another—and you have had panelists up here explaining it to you, but the impact on the criminal justice system is enormous.
You have heard the chief and the sheriff talk about the men and women on the street. Let me tell you, from a prosecutor's standpoint, America's prosecutors are good. We can make decisions to charge, and we can prosecute, and we can convict. And local sheriffs and corrections officials are very good at incarcerating people. But I ask you, is that the right thing to do with the right population? And that is what we need to look at.
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Let me tell you, after that officer on the street, he or she, had made that difficult decision to book someone, the prosecution kicks in. We have to make a decision to charge, which is terribly important in the community. And we sometimes default to charging. It has to be a fact-based decision.
We next face a decision to release. Once that person is charged and brought before a magistrate for arraignment, he or he is entitled, except in extreme cases, to release—recognizance, bail, some form of release pending trial or ultimate disposition.
We need information. We need access to safe releases. We have to make a decision to release. We have to make recommendations to that magistrate.
Now, you would think that is the end of it, but we know in this system that 90 percent of the cases plead guilty. They go by way of guilty plea dispositions, negotiation, whatever you want to call it. It happens. The men and women in the prosecutor's office need to have alternatives.
We can go empanel a jury and convict. But that is not always right. We need to have options on what to do at trial, what options instead of trial, what options instead of conviction, be it diversion, be it deferred prosecution, be it a probationary sentence with mandated mental health. And we representing the people need to have confidence in the mental health community that the mandates of a court or a magistrate will be carried out, keeping in mind that we are trying to ensure public safety. That is one of our sworn duties.
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Another party that has a dickens of a time is the defense counsel. The men and women of the defense bar, they have a client who is difficult to deal with, at best, and if mentally challenged, can be impossible to deal with without proper treatment.
We find that this is sometimes almost impossible for a defense counsel and a deputy prosecutor to get together with someone with a knowing understanding of the client, the defendant, the person who has now been charged, and to agree upon a resolution.
One of the advantages of being elected for nearly 20 years now is I know most people in my community. It is not uncommon that someone will come up to me on the street and say, ''Mike, I just finished jury duty. What were we doing wasting our time with that looney?'' Now, that is a horrible sentence or that is a horrible word to use. But they are saying isn't there something better you can do for that poor man or woman than take them to trial. And that is what I think the prosecutors are asking.
We need to be in a collaborative mode with the mental health community. We need to have options. We need to make impartial decisions. We need to be able to give the magistrate, the man or woman that is making the ultimate decision, some of those options.
I submitted in the written testimony stories of two individuals: one that escalated completely out of control because of lack of treatment until it resulted in a very serious crime. That individual should be locked up and not let loose; another one who ultimately died, 16 different commitments, petty quality-of-life thing.
The red light goes on, so I will stop. But let me leave you with this. This population are arrested more often, they stay longer in our local jails, and they will be back unless we do something.
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Thank you.
[The prepared statement of Mr. Schrunk follows:]
PREPARED STATEMENT OF MICHAEL D. SCHRUNK, DISTRICT ATTORNEY, MULTNOMAH COUNTY, ORGEGON
In the 1950's and 1960's with the advent of the psychotropic drugs, followed by the litigation of the 1960's and 1970's, states began to release large numbers of people with significant mental health issues. This process of deinstitutionalization also took place in Oregon. In the 1980's and 1990's the state legislature continued to downsize and close state mental hospitals. At the same time, the state failed to provide local communities with adequate resources to deal effectively with the mentally ill. In 1995, Multnomah County had mental health resources from the State of Oregon that translated into $440 for every mental health client. By May of 1999, that amount had been reduced to $244 per client.
Both in Oregon and nationally the result has been that the criminal justice system, by default, has become the system most likely to deal with the mentally ill. There are some who estimate that the largest facility in the country housing mentally ill persons is the Los Angles County Jail.
Within the criminal justice system, from the time a person is arrested until the time the person is sentenced, there are significant issues at every decision point that are impacted by the defendant's mental status. The police officer must decide whether to arrest the defendant, place a civil commitment hold on the defendant, or transport the defendant to a shelter or alternative housing. The prosecutor's dilemma begins with the decision to charge, which by necessity is a fact-based decision. The next important prosecutorial decision that must be made is whether the defendant should be released pending trial. This is extremely difficult. In Oregon, a court cannot mandate that the defendant take medication as a condition of release or probation. Also, the ability to monitor people on release status is limited, especially for low level crimes. Many of these people need close supervision, which is just not available. Appropriate housing oftentimes is impossible. Without medication and proper supervision, few housing programs are willing to accept individuals with criminal charges and mental health problems. The result is that the defendant stays in jail. The dilemmas do not end there.
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It is well known that the majority of criminal cases do not go to trial. They are resolved through plea negotiation. What options do we have in working out plea agreements with defense attorneys where the defendant has significant mental health issues? The degree to which there is open information sharing may conflict with the defense attorney working to present his client in the most favorable light. Similar dilemmas are present at trial and post trial. The very information needed by the criminal justice system at every decision point along the justice continuum is hampered by long standing policies and procedures related to privacy and confidentiality. The criminal justice system and the local and state mental health systems, are not set up to share information. They are set up to protect an individual's constitutional and statutory rights. The adversarial system currently in place is effective in reaching resolution on criminal cases. It is not a very effective system in resolving issues related to mentally ill defendants.
The difficulties are not just confined to the prosecutor. The decisions facing the judge and the defense attorney are often more complex and difficult. The judge must weigh community protection and be satisfied there are services available to ensure compliance with release decisions. The defense attorney often starts with a difficult client who does not want to cooperate in the process. Housing, medication, adequate supervision, and confidentiality are just some of the things the defense attorney must address in the process.
To illustrate the point that the criminal justice system is a revolving door for the mentally ill let me tell you about two individuals in Portland, Oregon. The first is a man by the name of George Conner. Mr. Conner was a mild mannered 63 year old man who suffered from severe depression and anxiety. He had been hospitalized for his mental illness. But, like a lot of people, he coped with his mental illness by self medicating with alcohol. He was a chronic alcoholic and homeless. In the last 12 years Mr. Conner had 16 run-ins with the justice system for a variety of offenses; Trespass, Alcohol in the Park, Open Container, Negotiating a Bad Check and other assorted minor transgressions. He was in and out of jail a dozen times in the past 15 years. The chronic alcoholism, the homelessness, and his general lifestyle caused severe health problems. In December 1999 he had coronary by-pass surgery. He was arrested, once again on a Trespass, and booked into jail for the last time on August 27, 2000. On August 28 Mr. Conner died of a heart attack in his jail cell. He was an elderly man who was sick and mentally ill and he died in a jail cell.
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The second case involves Zane Wright. Everyone in the local jail is well acquainted with Mr. Wright who is mentally ill. When he is not medicated he becomes psychotic. Mr. Wright acts out in ways that the local mental heath clinics cannot handle. In the past ten years he has had 65 contacts with the police which have resulted in 41 arrests. He is a difficult, aggressive, dangerous man. He has been charged with a variety of crimes, including Attempt Sodomy, Attempt Sex Abuse I, Attempt Rape, Offensive Physical Contact, Harassment, Trespass, Interfering with Public Transportation, Public Indecency, and Burglary II. When he is taken into custody, the nursing staff is able to give him a shot of a drug called prolixin. This anti-psychotic drug enables Mr. Wright to function at much more socially acceptable levels. He is then released back into the community until he stops taking his medication, which is often immediately, he has a psychotic episode, and is rearrested. This pattern; of aberrant behavior, criminality, arrest, incarceration, stabilization on medication, release, failure to continue to take the appropriate medication, a reoccurrence of the aberrant and criminal behavior, followed by rearrest and incarceration, is repeated over and over again.
These two cases reflect the revolving door of the justice system that mentally ill people pass through in almost every city in this country. In Mr. Conner's case, if he had adequate supervision, adequate housing, and adequate medication, he never would have come back to the system as often as he did, if at all. Both Mr. Conner and society would have benefited from adequate and timely services delivered outside of the jail setting. Unfortunately, we see too many cases like Mr. Conner's.
Mr. Wright is a dangerous person. The fact that he has significant mental health issues only compounds the problem. He needs much closer supervision and structure than Mr. Conner. Public safety generally requires he be incarcerated so that he does not injure other people, but his story illustrates the problem of how often he comes into the system and its ineffectiveness.
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I have described only two cases to you. Let me take a minute to cover how often cases involving the mentally ill are repeated at the local level. In 1995 the Multnomah County Sheriff's Office carefully reviewed local jail bookings and identified the mental health population. There were 39,400 bookings that year. The Corrections Mental Health Team screened 9,600 of those bookings and 1,500 of the defendants had psychiatric alerts. A psychiatric alert is assigned to an individual on the basis of prior treatment history, suicidal ideation or attempts, and disruptive or bizarre behavior. In the first ten months of 1999, even though bookings had actually declined to 36,696, the number of inmates with psychiatric alerts had risen to 3,484. These 3,484 individuals were responsible for 5,110 bookings and had a combined total of 11,221 criminal charges.
In a recent study in one county in Oregon, Marion County, the local sheriff's department found that almost one out of every five defendants booked into their jail suffered from a mental illness. The Oregon Department of Corrections has approximately 9,000 inmates in its state prisons. Of this number, it is estimated that 18% or 1,620 prisoners are mentally ill. Oregon is no exception. In a 1998 survey by the Bureau of Justice Statistics, they found that there were 238,800 mentally ill individuals incarcerated in U.S. jails and prisons. Some mental health experts say the number is probably much higher due to under reporting by people who do not disclose information or who are unaware of their illness.
At the same time we are seeing increases in the mentally ill in local jails our local ability to provide services to this population in any significant way has been dramatically cut back. This is one of the major reasons why defendants are recycled through the criminal justice system. Community members turn to the police for assistance and the police often have no other option than to take the defendant to the local jail. I expect that a similar pattern can be seen in communities and local jails across the state and across the country. It is clear that when services are not available in the community, the mentally ill population defaults to the criminal justice system.
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But there are some bright spots in the national picture. The pioneering efforts of the mental health courts, such as Judge Caycee's court in King County in Washington State, and the mental health courts in Broward County, Anchorage, and San Bernadino are examples of communities working together to address the problems of the mentally ill in the justice system. Also, the courts, the prosecutor and public defender have worked together to create a comprehensive system that provides real services and incentives to defendants with mental health issues who are not dangerous to the public. We would like to be able to replicate a similar court in Multnomah County and are working on how to do just that. All of us would like to see more community-based options available for this population.
The problems I have described here today are not limited to Portland, Oregon. They are taking place in small towns and big cities across the country. This is not a local problem. This is a national problem. The criminal justice system was never designed to care for the mentally ill. It is a tragedy not only for the individuals and families experiencing these problems on a daily basis but also for all of us nationally. We know there is a better way to treat people caught up in the criminal justice system.
The criminal justice system is in need of training, technology, and resources to allow local communities to create options for every decision point on the criminal justice continuum from arrest to post sentencing. We need your best thoughts on these problems and we need your help. We need to have the benefit of pilot programs that set a premium on collaborative projects involving, not just the criminal justice system, but the community and the mental health system as well. There is a better, a more humane way to work with these individuals who come through the doors of the justice system simply because there is nowhere else for them to go. Our challenge is to create a path that is fair to everyone, treats people with dignity, and balances public safety concerns with individual needs.
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Mr. GEKAS. We thank the gentleman, and we turn to Dr. Slate.
STATEMENT RISDON N. SLATE, MEMBER, BOARD OF DIRECTORS, NATIONAL ALLIANCE FOR THE MENTALLY ILL, LAKELAND, FL
Mr. SLATE. Yes, thank you, Mr. Chair, Ranking Member Scott, and Ms. Jackson Lee. It is certainly an honor to be here today and for you all to consider this very critical issue.
I am going to tell you why I am testifying today. I come at this issue from both sides of the fence, if you will. I am a criminologist with a Ph.D. from Claremont Graduate School. I worked for 2 years as assistant to the warden at a maximum security death row facility in South Carolina. We had a psychiatric unit there as well. And I became a United States probation officer in 1986.
Shortly thereafter, I was diagnosed as manic-depressive. I had a manic episode. In the span of 2 weeks, my wife left me while I was in the hospital, ultimately divorced me, and I was asked to resign my position for medical reasons as a Federal probation officer, which I did.
As you might imagine, it took me a little while to brush myself off and pick myself up, but I did. I went back to something that was very familiar to me—that was education. I had a master's degree at the time, so I started teaching at a community college, started applying to Ph.D. programs. I was accepted and offered a full fellowship to the Claremont Graduate School in Claremont, California, ultimately obtained a Ph.D., and all the while remained on lithium, the medication that holds my manic depression in check.
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I went from California to Maine, taught in Maine for 4 years, full-time job, criminal justice professor, and then went from Maine to Florida, took a job at Florida Southern College, where I currently am now. And in taking that job, I had to look for a new doctor. I had been with doctors in five different States over an 8-year period of time, from 1986 to 1994. My new doctor decided I was not manic-depressive. He took me off my medication. I ended up going to a football game in Columbia, South Carolina, and at that football game, I had a psychotic episode. I was manic again.
This time, ultimately—and it is in the written testimony, and I will make a long story short. In essence, the police encountered me. My wife was there holding the vial of medication saying, ''My husband is a criminologist. He should be on this medication. His doctor took him off this medication. He needs treatment. He needs help.'' They took me directly to jail. I was placed in jail in Columbia, South Carolina. I was assaulted by correctional officers when they moved me to a strip cell, and I was also assaulted by an inmate in Columbia.
The reason that I tell you this story—I mean, the arrest has since been expunged, the whole 9 yards. The reason that I tell you this story is this: If this can happen to me, with a Ph.D. in criminal justice, with my knowledge and my background of the criminal justice system, it can happen to anybody. And people are getting hammered right and left by this system, and they have nowhere to turn. The whole time I was in that jail in Columbia, I received no medical treatment, no medical attention whatsoever. And you know how I got out of jail? A United States probation officer that I used to work with back in 1986, he got wind of the fact that I was in that jail. He came down to that jail under no authority whatsoever. He flashed his badge and he said, ''This guy is going with me.'' And guess what? The jailers were more than happy to relinquish me because they didn't know what to do with me.
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He got me into treatment and back on medication. Fortunately, I was working with a very understanding administration at Florida Southern College, and I am a criminology professor at Florida Southern College right now. I am fine on medication. I take my medication religiously.
But something has to happen in terms of this process. There has to be better linkages between the criminal justice system and the mental health system. And I will tell you now that I would not be before you today if it were not for the love, support, and encouragement of my wife, Claudia Slate, and my mother, Virginia Slate, and for the grace of God, because I could have died in that jail cell.
And I just think—I have got a number of recommendations in here as to suggestions that I think we can use to help straighten out this problem. I have got an article in the attachments on mental health courts that I did. But something must be done.
And I will close with this: Horace Mann once said that, in essence, an individual should be ashamed to die until they had done something for humanity, until they had won a victory for humanity. I know that you all here in Congress win victories for humanity often. But I am asking you to win this one for humanity because, indeed, people are getting hammered out there, and you all have the legitimate authority to do something in this instance. And I know that you can, and it is the right thing to do.
Thank you.
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[The prepared statement of Mr. Slate follows:]
PREPARED STATEMENT OF RISDON N. SLATE, MEMBER, BOARD OF DIRECTORS, NATIONAL ALLIANCE FOR THE MENTALLY ILL, LAKELAND, FL
Chairman McCollum, Ranking Member Scott, and distinguished Members of the Subcommittee, good afternoon. It is certainly an honor to appear before you, and I commend each of you for taking the time to consider the critical issues here today. My name is Risdon Slate, and I am a professor of criminology at Florida Southern College in Lakeland, Florida, as well as a member of the board of directors of the Florida National Alliance for the Mentally III (NAMI) and president of our local NAMI chapter. I am also a person who suffers from manic-depressive illness (bipolar disorder), a biochemical brain imbalance that causes severe, uncontrollable mood swings, from wildly euphoric manic, sometimes delusional, episodes to dark, suicidal depressions. Today, thanks to correct diagnosis and medication, I, like 80 percent of those afflicted with this illness, can live a productive, successful life. I am testifying before you today because I have seen the plight of people with mental illnesses in the criminal justice system from both sides of the fence as a criminologist and former corrections official and federal probation officer, and, during one terrifying weekend in 1994, as an inmate.
In June of 1986 I had reached what I thought was the pinnacle of success in my life. I was 26 years old with a master's degree in criminal justice, married to my high school sweetheart, with two years of work experience under my belt as administrative assistant to the warden at a mediuni/maximum security, death row prison in Columbia, South Carolina. I had been appointed to what I thought was my dream job, where I had interned as a graduate student, as a United States Probation Officer. Then within a two week span of time, I was diagnosed with manic-depressive illness (bipolar disorder), forced to resign my job as a federal probation officer for medical reasons, and I was left while hospitalized and ultimately divorced by my wife. It truly felt that my life had fallen apart.
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As you might imagine, it took me a little while to brush myself off and pick myself up. During my process of recovery, I encountered Dr. Roger Deal, who told me that he had some good news and some bad news for me. He indicated the bad news was that I was manic-depressive. For the good news, he told me that to be manic depressive one had to be of above average intelligence and that he got his kicks, his jollies, by putting people like me back together again and sending them back into the world to be successful. Fortunately, I was prescribed lithium (an element on the periodic chart)—a medication that worked for me. In the ensuing years, I was accepted into the Claremont Graduate School, earned my Ph.D., and obtained a full-time faculty position as a professor of criminology at the University of Maine at Augusta. In 1993, I accepted my current position as a professor of criminology in Florida. Throughout all of these years, I kept my mental illness in the shadows. Only my immediate family knew that I suffered from manic-depressive illness, and I paid for my medication and psychiatric consultations out of pocket, as I did not want to establish a paper trail. I was worried about the stigma associated with mental illnesses.
I felt like my life was once again back on track. Then, I had the misfortune of encountering a psychiatrist upon relocating to Lakeland, Florida, who ignored my successful treatment history for the past eight years and decided that I was not suffering from manic-depressive illness after all. He discontinued my medication entirely, and I soon spiraled into a serious manic episode that led to my encounter with the criminal justice system from the other side—as a jail inmate. The episode coincided with a trip that I and my new wife took to South Carolina for a football game in Columbia. By the time we made it to the game, I was completely psychotic. And a problem with illnesses of my type is that the events I experienced were extremely vivid and real to me, as the area of the brain that controls my cognitive awareness had become impaired. I did not realize I was ill. I believed that I could literally control the players on the football field like chess pieces and somehow will the South Carolina Gamecocks to win. Of course, if you know much about Gamecock football prior to this year, the task proved too daunting, and they lost to the Georgia Bulldogs.
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For many people with mental illnesses, the only way to get ''treatment'' is to be arrested. The police often refer to such arrests as ''mercy bookings.'' So, the next day I managed to get myself arrested. Convinced that there was a federal conspiracy against me that cost me my job in 1986, 1 became paranoid that these conspirators had learned of my return to the area and were now out to get me. In my. delusional state, I ended up skinny dipping in the pool at the condominium complex where my wife and I were staying. When the police arrived, I was compliant and pleased because I could now seek protective custody in their jail from the conspirators who were out to get me, and I told them so. All the while, to no avail, my wife stood by helplessly crying, showing the officers the vial containing the medication that I should be taking and informing them that I was mentally ill in need of treatment. Of course, my stay in jail proved to be a nightmare.
I was taken directly to the local jail where I was placed in a holding cell with approximately fifteen other detainees. During my two days in jail, which seemed like an eternity, I was assaulted by another inmate and by correctional officers who eventually put me in isolation in a strip cell. (The seriously mentally ill are reportedly three times more likely to be assaulted in correctional facilities than situation-normal inmates). Since I had thrown away my wallet to prevent the conspirators from being able to identify me, I was unable to pay the bail of $500.00 set by the magistrate. My wife tried desperately to convince the staff that I was seriously mentally ill and desperately in need of treatment. Despite her efforts, and my bizarre behaviors, I never saw a doctor or received any medication or treatment during my stay in jail. In fact, I was repeatedly punished for behaviors that I could not control due to my untreated mental illness.
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Ironically, I was finally extricated from my ordeal after a U.S. Probation Officer with whom I had previously worked in 1986 was alerted to my plight. That officer, Ronald L. Hudson, appeared at the jail and, with no authority whatsoever, flashed his badge and told my captors, ''He's coming with me.'' According to Ron, my jailers were actually relieved to release me to him, as they were clueless as to how to handle me. (Most jails across the country do not have specialized units for housing persons with mental illness, and the vast majority of detention officers have had little to no training in dealing with such persons). Upon my release, Ron then took me to a local hospital where I finally received treatment. By intervening as he did, he may well have saved my life. I was put back on lithium, my condition stabilized, my arrest was ultimately expunged via retained counsel, and an enlightened college administration allowed me to resume my career as a professor after a period of recuperation.
My tribulation culminated in Columbia, South Carolina, but unless interventions are made, this could happen in almost any jurisdiction in America. My point in telling this story is that if this can happen to me, with a Ph.D. in criminology and my background and knowledge of the criminal justice system, it can happen to anybody. Most people with severe mental illnesses don't have the wherewithal, the financial resources, or the friends to receive the help that I do. Most people with severe mental illnesses who come into contact with the police and correctional systems have not committed serious crimes. Most of these people have been arrested and charged with non-violent misdemeanors or minor felonies resulting from their untreated mental illnesses rather than their inherent criminal tendencies. For these people, jail is the worst environment possible. It is an environment that is almost guaranteed to make their psychiatric symptoms worse.
Since my ordeal in South Carolina, I have come out of the shadows with my mental illness, and I am no longer ashamed of being mentally ill. What I am ashamed of is how people with mental illnesses are treated in our society. I believe that my nightmarish experience in that jail cell led me to an epiphany: I must come out and be an outspoken advocate for those people with mental illnesses who cannot speak out. Horace Mann once said, ''An individual should be ashamed to die until he had won a victory for humanity.'' It is time that we as a society take measures to end what Fox Butterfield has called the ''last great discrimination—mental illness.'' Thanks to the love, support, and encouragement of my wife, Claudia Slate, my mother, Virginia Slate, and the grace of God, I am here before you today. And I call upon you, with your legitimate authority, to intervene on behalf of those who are unable to do so, because you are in a position to do something positive and because it is the right thing to do!
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RECOMMENDATIONS
In terms of my recommendations, we would do well to embrace the concept of ''therapeutic jurisprudence'' in our handling of the mentally ill that encounter the criminal justice system. Therapeutic jurisprudence seeks to follow the consequences, both therapeutic and antitherapeutic, for both the mental and physical health of those individuals who are processed through the criminal justice system and the resultant aftermath. (For further discussion of this concept, please see page 440 of Attachment A). Instead of the traditional criminal justice system that looks to the past to rind fault, assess blame, and mete out punishment, we should look to the future and try to construct a workable solution that will seek to prevent the revolving door injustices all too common for the mentally ill, the criminal justice system, and society.
(1) Resources should be put into creating partnerships between criminal justice and mental health systems to prevent the unnecessary incarceration of people like me who are behaving the way they are because they are sick, not criminals. A number of promising approaches for diverting individuals with mental illnesses from the criminal justice system into treatment have emerged, including pre-booking diversion such as the Memphis Police Crisis Intervention Team (CIT) program and post-booking diversion, such as Mental Health Courts (see attachment A article on mental health courts). Such diversions can be readily utilized as conditional releases. Ultimately, the determination about what works best in a particular community should be made at local levels. In Polk County, Florida, where I reside, I am chairing a task force that is doing exactly that by bringing together the key players in the area mental health and criminal justice systems to provide training for law enforcement officers on how to appropriately deal with the mentally ill in crisis in accordance with available community resources (see attachment B on community interventions for people in crisis). Another local jail diversion task force that I am a member of is comprised of judges, prosecutors, public defenders, law enforcement personnel, correctional officials, mental health professionals, mental health advocates, and consumers. Perhaps more flexible federal rules around funding streams that will allow localities to develop programs for example for persons with co-occurring disorders could be considered. Federal funding of research centers that can collect cutting edge material on programs, practices, and research, distill it, and get it to localities in forms that will enable local leaders to leverage it for advocacy efforts is needed. On going treatment alternatives following an individual as they move along through different stages of development should be considered, instead of one-time interventions. I am hopeful that we can develop a plan and obtain resources to implement an effective system for creating alternatives to incarceration for non-violent, low level offenders with mental illnesses.
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(2) Some people with severe mental illnesses commit crimes that are so serious that it is necessary to incarcerate them. Resources must be available to provide appropriate treatment to these individuals so that they can function in the correctional setting and so they can eventually successfully reintegrate back into society. Not doing so creates risks for those individuals, for correctional personnel, and for general society after they are released.
(3) Criminal justice personnel, including magistrates and judges, should be trained to recognize the signs and symptoms of mental illness and instructed how to appropriately handle the mentally ill in crisis. Currently, in Florida, minimum training standards for law enforcement officers require approximately one hour of instruction in this area and that training is aimed at the mechanics of the commitment process. There is a crucial balance between ensuring individual liberties and the appropriate treatment for persons with mental illness, while protecting societal interests. Crisis intervention training for criminal justice personnel and mobile crisis stabilization units should not be considered panaceas in and of themselves, as community based mechanisms for ensuring compliance with pre and post trial conditions for persons with mental illness should be put in place. Such follow-up is essential with this population so that they do not put themselves and others at risk and/or continue to recycle through the system.
(4) An effective strategy for reducing the numbers of people with severe mental illnesses in the criminal justice system must include community treatment. Most people with brain disorders such as schizophrenia, manic-depressive illness, and major depression in our country don't have access to even minimally adequate treatment. Is it any wonder why these people end up involved with criminal justice systems? The shame of it all is that we know how to effectively treat most people with severe mental illnesses. We just don't make these treatments available to people. Thus, ''deinstitutionalization'' has turned into ''trans-institutionalization.'' Today, we institutionalize people with severe mental illnesses in jails and prisons instead of hospitals. Persons with mental illness cannot simply be diverted from the criminal justice system without adequate community resources and supports put into existence at the state and local level. It is imperative that an array of inpatient and community treatment options be made available to people with severe mental illnesses to reverse this national tragedy. Thank you for your consideration, and I look foward to responding to any questions you may have.
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SUMMARY
In June of 1986, I had earned a master's degree in criminal justice, had two years of experience under my belt as a correctional official, and was just beginning my career as a United States Probation Officer. That promising career soon came to a screeching halt when, within a two week span of time, I was diagnosed with manic-depressive illness, forced to resign my dream job for medical reasons, and I was left while hospitalized and ultimately divorced by my wife. It truly felt like my world had ended.
However, I was encouraged by treatment professionals, and the prescribed medication—lithium (an element on the periodic chart)—worked for me. As a result, I was able to put my life back together, went on to the Claremont Graduate School, earned my Ph.D. in criminal justice, took a job in 1989 as a full-time criminal justice professor in Maine, and then moved to Florida in 1993, where I currently reside and work, taking a job as a criminology professor at Florida Southern College.
Upon my arrival in Lakeland, I located a new physician so I could continue my medical prescription for lithium. Unfortunately, this psychiatrist decided that I was not mentally ill and convinced me to stop taking the medication that I had been taking for eight years. I complied with his advice, and my condition soon deteriorated.
During a visit to South Carolina, I suffered the second manic episode of my life. When police were called, although I was exhibiting bizarre behavior and my wife desperately tried to advise them of my illness and show them the vial containing the medication that I should be taking, they took me to jail and put me in a holding cell with approximately fifteen other detainees. Due to my strange behavior, I was first assaulted by an inmate and then by detention officers who ultimately isolated me in a strip cell.
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Finally, a federal probation officer with whom I had once worked, Ronald L. Hudson, intervened. Flashing his badge, he convinced my captors to release me. He has since told me that the jailers were glad to oblige him, as they were admittedly at a loss as to how to deal with my behavior. He transported me to a hospital. Ron probably saved my life, as at no time during my stay in the jail, even after appearance before a magistrate who sat my bail at $500.00, did I see any medical personnel or receive any medical treatment.
If such experiences can happen to me, with a Ph.D. in criminology and my background and knowledge of the criminal justice system, they can happen to anyone. I call upon you to intervene on behalf of those who are unable to do so, because it is the right thing to do! By the grace of God and due to the love, support, and encouragement of my wife, Claudia, and my mother, Virginia, I appear before you today to offer the following suggestions.
In terms of recommendations, persons with mental illness and the practitioners they encounter within the criminal justice system should have more options/choices/alternatives available for successful resolution of problems for the sake of all concerned parties, including the public. Certainly, there will be some mentally ill individuals who will require incarceration, but we must ensure them adequate treatment, not only for their benefit, but also for the well-being of correctional personnel and the potential welfare of society should they be released. Partnerships between the key players in criminal justice and mental health systems should be fostered. Better training related to persons with mental illness for all parties, particularly within the criminal justice system, should be explored. Promising approaches, such as crisis intervention training for police officers and mental health courts, are already in operation in a few venues across the country. Innovative federal funding schemes for such partnerships should be explored which will lend flexibility to the particular needs of local communities. However, solely diverting someone from the criminal justice system should not be considered a panacea in and of itself. Many of those diverted will require follow-up, either pre or post trial, to ensure compliance with conditions which will serve to ensure that they do not put themselves or anyone else at risk and/or they do not recycle through the system. To assure this, sufficient inpatient and community based treatment structures need to be in place. Today we often institutionalize persons with mental illness in jails and prisons, instead of in hospitals. We can ill afford this deinstitutionalization to trans-institutionalization movement any longer.
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[NOTE: Additional material submitted by Mr. Slate is on file with the House Judiciary Committee's Subcommittee on Crime]
Mr. GEKAS. We thank the gentleman.
We turn to Judge Cayce.
STATEMENT OF JAMES D. CAYCE, JUDGE, SUPERIOR COURT OF THE STATE OF WASHINGTON, SEATTLE, WA
Mr. CAYCE. Thank you very much. I also appreciate the opportunity to be here and address you today as a representative of the third branch of government. We are always interested in doing this and always appreciate the opportunity, but we are not always, unfortunately, invited. So I thank you, and it is truly an honor especially to be here at the Federal level addressing this important topic.
When I hear Risdon—and I have heard this a couple times—explain his story, I wish I had the power to apologize to him on behalf of the judge that handled his case and the judicial system that mishandled him so poorly. Obviously, I don't have that power. What I would hope would happen, if he or someone like him appeared in my mental health court, the mental health court that I started that I am no longer at, that they would be treated differently, that he would come out of that setting with a new-found respect for the justice system.
As someone who is passionate about justice, I actually get tired of hearing how our system is broken. I don't think it is. I am proud of our justice system. I am proud to be a member of that, and I think it works very well and it is an effective system.
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I do agree that a significant failure of the justice system is when individuals with mental illness, for whatever reason, come before the criminal courts. The result often is a serious injustice. It is an injustice to those defendants who appear in our courts with the mental illness, and it is an injustice to their victims.
I would like to focus some of my time on just telling you a little bit about a day in the life of a lower-court judge. As I indicated, I am now in the superior court, which is a court of general jurisdiction, handling felony and civil cases. But misdemeanor courts handle cases up to a year in jail as a maximum. They handle such things as DUIs, harassment, assault, domestic violence. They also handle traffic infractions, speeding tickets, parking tickets, small claims, sometimes civil cases up to a certain amount of jurisdiction. We handle what are called routinely the rocket dockets. We have a high-volume, fast-paced business.
On criminal calendars, for instance, arraignments, maybe in a two-and-a-half-hour period, 100 people would have to come through the court. Likewise, pretrial hearings, you have got a half-day to handle between 25 and 40 individual cases. Sentencing calendars often exceed 30 cases in a half-day. And I am actually finding that at the felony level that is also the case. When you get to the trials, my last trial took 10 days, but those pretrial hearings are handled in a fast and in a routine manner.
That doesn't work with individuals often who appear before the courts with a mental illness. Sometimes it works, but often it does not. In the other cases, I think we do a good job, and I think it is adequate. But for a variety of reasons, when we encounter individuals with significant mental illnesses, we need to slow down. We need to take individual time, attention. We need people in the system that have specific knowledge and training that are able to handle those individuals and their complex problems. We need access to resources to be able to address the root causes of the criminal behavior, if there is criminal behavior, and we need people who care about doing business in a different and better way.
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In addition to significant mental illness, a majority of the people that have come through the mental health court are facing homelessness, chemical abuse or addiction, usually no support from family members. In the 275 cases I have handled, I don't believe one person had a spouse or a significant other. Very few had family members until sometimes we would get them involved in treatment and the family would come back. But we need to do business in a different and better way when it involves this class of individuals coming into our criminal courts.
The good news is that there are better ways. There are various programs around the country that we can turn to, and as evidenced today, there is a significant interest in change. And I think we can overcome the problems by these collaborative efforts around the country. What we need is leadership at the Federal, State, and local level. We need motivation and not from the tragic incidents which led us to our mental health court and many other programs led them to get the funding and the interest in doing business in a different way. But we need motivation from grants, from folks like you, from community members who are electing local officials. We need technical assistance, research and evaluation, and flexibility to implement programs that work at the local levels.
I see that my time is up, and I thank you very much for this opportunity.
[The prepared statement of Judge Cayce follows:]
PREPARED STATEMENT OF JAMES D. CAYCE, JUDGE, SUPERIOR COURT OF THE STATE OF WASHINGTON, SEATTLE, WA
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Dear Chairman McCollum, Ranking Member Scott and Subcommittee Members:
Thank you for the opportunity to testify concerning this issue of critical importance to those of us in both the criminal justice and mental health systems. Unfortunately, it is the lack of meaningful coordination between these systems that often hinders our ability to effectively handle criminal cases involving seriously mentally ill defendants. Poor communication and coordination result in not only an inefficient use of scarce public resources but, also, both the unjust treatment of mentally ill defendants and a decrease in public safety.
I am pleased to tell you about a pilot Mental Health Court program we started in King County District Court. Our Mental Health Court was the product of a major, coordinated planning effort led by the Mental Health Court Task Force, which I chaired. Attached (Exhibit 1) is a ''problem statement'' which explains the justice system out of which the Mental Health Court arose. This traditional method of case processing described in the problem statement is certainly not unique to King County. The Mental Health Court is a collaborative program implemented by District Court in conjunction with its agency partners, the Department of Community and Human Services, the Office of the Prosecuting Attorney, and the Department of Adult and Juvenile Justice. This ''problem-solving'' court opened its doors in February 1999 and has been in daily operation since that time.
The goals of the Mental Health Court program are to:
humanely serve the seriously mentally ill who enter the criminal justice system at the District Court level,
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facilitate improved coordination between the criminal justice and the public mental health treatment systems to effectively serve joint clients,
protect public safety (by reducing the likelihood that dangerous defendants will be released without treatment or without a referral for involuntary commitment proceedings),
reduce the numbers of mentally ill misdemeanants in jail (either by, when appropriate, expediting their cases or by releasing into community treatment programs with supervision), and
reduce criminal recidivism among mentally ill misdemeanants.
The key elements of the program design are:
referred cases are heard on a separate calendar, allowing more time and attention to be spent on these cases as needed without disrupting regular calendars, and allowing hearings to be scheduled on a fast-track basis.
a specialized team approach is used, with a dedicated judge, defense attorney, prosecutor, probation officers, and a mental health clinician. This approach promotes increased mental health expertise in general in the legal team and greater familiarity with case specifics. This approach also promotes an increased comfort level and trust among mentally ill defendants.
an emphasis on facilitating access to and use of appropriate treatment services (whether these are mental health inpatient or outpatient services, dual-diagnosis services, brain injury rehabilitation services or developmental disabilities case management services).
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increased supervision of defendants in pre-trial status or on probation. Defendants' compliance during the pre-trial stage is monitored by the clinician, and during the probationary period by specialized probation officers. The Mental Health Court Judge schedules frequent status and review hearings throughout the life of the case.
I have also attached (Exhibit 2) a copy of an article I co-authored with Kari Burrell, Program Manager for the Mental Health Court. I hope the article can assist the reader in understanding the motivation for the creation of the court, as well as how it differs from ''business as usual''. The Mental Health Court program received 199 referrals in 1999 and anticipates receiving at least 250 referrals in 2000. The cases handled in Mental Health Court represent some of District Court's most difficult and time-consuming cases. The defendants are very high-risk clients and tend to have multiple social service issues (e.g. lack of housing, chemical dependency issues, and anger management issues in addition to their serious mental health issues) that often interfere with their ability to appropriately handle their criminal charges.
In planning for the Mental Health Court program, the first two years were identified as a ''pilot'' phase, with funding to be continued if initial program results were positive. Anecdotally at least, experiences from the first year of operation (1999) were very positive and indicate that the MHC intervention is very effective in getting this population the services they need and back on track in terms of being law-abiding citizens. District Court has contracted with a team of researchers from the University of Washington to complete an external evaluation of the program. The evaluation will be conducted in two phases: the first phase will be an initial ''process'' evaluation and is scheduled for completion September 30, 2000. Attached hereto (Exhibit 3) is a draft version of the Executive Summary for the Mental Health Court Process Evaluation due to be released within the next few weeks. The second phase will be an extensive ''outcomes'' evaluation and is scheduled for completion in two to three years. The results of these evaluations will assist the County in making decisions regarding ongoing Mental Health Court program implementation and funding.
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It is not my intention to attempt to convince you that King County has found the answer to handling criminal cases involving the seriously mentally ill. We do hope the program we have developed will prove to be an effective justice innovation for our community that will motivate others to seek solutions that are equally effective for their unique jurisdictions. Finally, I would again like to express my appreciation for the opportunity to appear and provide testimony today. I applaud your willingness to expend valuable committee time on this important topic. I sincerely hope that, working together, we can make a difference.
EXHIBIT 1
''PROBLEM STATEMENT''
During the past decade, case processing in the King County District Court has emphasized efficiency and effectiveness. While these processes provide for an efficient criminal justice system, the inevitable result has been for defendants to appear before several judges on the same case. This model is not always in the best interest of defendants with mental illness.
For example, a defendant who is booked into the King County Jail will first appear before a judge for a probable cause hearing. The judge conducting the hearing may gain some insight into the defendant's mental health. However, the dockets for these hearings are often full, leaving judges limited time to explore mental health issues with defendants. Furthermore, the judge hearing the first appearance calendar, in all likelihood, will not see this defendant again on the current charge, as the case is typically assigned to another judge for a pretrial hearing. At the pretrial, the defendant will also encounter a new public defender and new prosecuting attorney. There is a significant possibility that the case would be transferred to a different court for trial where again there would be a new judge and prosecutor. Mentally ill defendants in the criminal justice system may have several charges filed against them in the course of a year. It is unlikely that the different cases would be heard by the same judge, with the same prosecutor or public defender, and it is quite possible that the cases may end up in different courts.
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While a case processing approach that divides the work load in this manner provides for an efficient and predictable level of service for most District Court defendants, the approach often creates barriers that prevent the Court from identifying and addressing the unique needs of the mentally ill offender. Under this system, judges do not have the opportunity to acquaint themselves with the circumstances surrounding the offender's entrance into the criminal justice system. Furthermore, judges have varying levels of expertise around mental illness. Even if the judge is able to identify the mental illness and is comfortable in dealing with these issues, the existing system lacks sufficient resources and mechanisms to easily link these individuals with the treatment services they need. As a result, the punishment handed down by the Court does little to address the root of the problem. Mentally ill offenders continue to cycle through the criminal justice system, often spending unnecessary time in jail and lacking access to mental health treatment services. In fact, a 1991 study of mentally ill offenders in the King County shows that inmates charged with misdemeanor offenses who are admitted into the Psychiatric Unit had an average of six prior bookings into the King County Jail in the three years prior to their current offense. The study also demonstrated that the average length of stay in the Jail for inmates with mental illnesses was three times longer than for the average inmate.(see footnote 1) As a recent New York Times article states, ''jails and prisons have become the nation's new mental hospitals.''(see footnote 2)
EXHIBIT 2
Newspaper: Washington State Bar News
Date: June 1999
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Headline: King County's Mental Health Court: An Innovative Approach for Coordinating Justice Services
By: Hon James D. Cayce and Kari Burrell
It is rare that an idea to improve on our system of justice gets virtually unanimous support and commitment. Yet, the concept of creating a Mental Health Court in the King County District Court has done just that. From its first mention over one year ago through its implementation in mid-February, the idea that we can do a better job in handling misdemeanant cases involving mentally ill defendants has received tremendous support. This support has included not only the commitment of time and energy from literally hundreds of planning participants, but also the necessary financial backing. The general consensus going into this project was that it was ''the right thing to do'' for many reasons.
In August 1997, retired Seattle Fire Captain Stanley Stevenson was fatally stabbed by a man later found to be criminally insane. That tragic incident has been the catalyst for some sweeping and innovative changes in the criminal justice and public health systems in which mentally ill offenders are handled. Shortly after the Stevenson incident, King County Executive Ron Sims formed a statewide task force of individuals representing the key treatment and legal service systems involved with the mentally ill. The task force included judges, prosecutors, public defenders, police, mental health professionals, mental health board, family advocates and government officials. Retired Justice Robert Utter was selected to chair the Mentally Ill Offenders Task Force. After an intense two months of meetings, the Task Force Report was issued with numerous recommendations for change and the implementation phase began. The civil and criminal laws under which these cases come before the Superior Court and the Courts of Limited Jurisdiction have been revised to give the courts far more options in dealing with this complex population. One of the numerous system changes recommended was a pilot Mental Health Court project to test whether an alternative approach to handling cases for mentally ill misdemeanants could be more effective than the regular court system in reducing jail time and recidivism, and in providing better linkages to the mental health treatment community. Executive Ron Sims asked King County District Court Presiding Judge James Cayce to chair a Mental Health Court Task Force for the purpose of further exploring this specific recommendation.
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The issues that the Mental Health Court Task Force convened to address in Washington state are similar to issues faced by numerous localities nationwide. There is some evidence that, with the movement to substantially reduce the use of state mental hospitals as a treatment option for the mentally ill, the numbers of mentally ill in the community who receive inadequate or even no treatment has increased. Furthermore, some have hypothesized that, in fact, an emerging trend is the ''criminalization'' of mental illness: that the mentally ill are landing in jails and prisons with increasing frequency due to issues related more to their illness and less to the crimes they may have committed. The National Alliance for the Mentally Ill estimates that 25 to 40 percent of the mentally ill today will come in contact with the criminal justice system for one reason or another.1
National research studies have documented that the numbers of mentally ill incarcerated in jails and prisons is a significant percentage of the overall jail and prison population. One source indicates that more than seven percent of the incarcerated are diagnosed as having one of the three serious mental disorders (schizophrenia, bipolar disorder and major depression) and that more than 50 percent have other mental health diagnoses.2 A study completed in 1997 indicated that the numbers were even higher—more than 10 percent of the incarcerated population had a diagnosis of a serious mental disorder. This study indicated that in jails (rather than prisons), nine percent of men and 18.5 percent of women in custody were seriously mentally ill. This rate of serious mental illness is four times higher than the rate in the general, non-incarcerated population.3
The growing number of mentally ill in the jail and prison population is problematic for a number of reasons. There is the concern that many individuals are arrested for behavior that probably could have been better addressed through the mental health treatment system. Another concern is that jail and prison environments may further aggravate, rather than improve, mental health conditions. Finally, there is evidence that the mentally ill are arrested and jailed more frequently and have longer average jail stays than the general population. A 1991 study of mentally ill offenders in the King County Jail showed that inmates with misdemeanor charges admitted to the Jail's Psychiatric Unit had an average length of stay three times longer than that of other misdemeanants. The longer jail stays for this population in King County may be partially attributed to concerns about releasing inmates without a treatment alternative.
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In February 1998, Judge Cayce and 10 others from King County, the City of Seattle and Jail Alternative Services visited Broward County, Florida, to observe the then only operating Mental Health Court in the United States. All trip participants, including judges, attorneys and treatment providers, were enthusiastic about what they saw and how well they thought the model could be implemented, with some modifications, in King County. The Mental Health Court Task Force met initially in April 1998 to explore how the Court could work cooperatively with other criminal-justice agencies and the treatment community, and to develop specific recommendations for a King County Mental Health Court model. In August 1998, a final Mental Health Court Task Force report was released which outlined a proposed blueprint for the pilot court. After the report was released, King County Budget Office staff worked with the various partner agencies to secure funding.
Resources for King County's pilot Mental Health Court project came from three sources: leveraged existing funds and staff, additional new county funds, and an externally funded grant. The Prosecuting Attorney's Office, the Office of Public Defense, and the District Court have all absorbed portions of the staffing costs of this program. Additional new funds from the County General Fund, the County Criminal Justice Fund, and the County Mental Health Fund have been temporarily allocated to this project. The treatment funds allocated for the pilot project are coming from the County Mental Health Division's ''fund balance,'' a non-renewable source of funding. If the pilot proves successful, a more permanent source of treatment dollars will have to be secured. A final funding source for the pilot came from the federal Bureau of Justice Assistance, which provided an 18-month grant of $150,000.
The pilot King County District Court Mental Health Court was launched on February 17, 1999. On April 29, 1999 the pilot court program was dedicated to the memory of Captain Stanley Steven-son. Many of the program policies and procedures are being established as the project unfolds. But the important elements of the model, as outlined by the Mental Health Court Task Force Report, are all in place. The Mental Health Court differs from a regular court in three fundamental respects. First, the cases are heard on a separate calendar and are all handled by the same core team of professionals. Second, there is an increased emphasis on linking the criminal justice system and the mental health treatment system. Third, the participants in this program receive increased court supervision.
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As proposed by the task force, cases referred to the Mental Health Court program are transferred from the regular calendars and set on their own calendar. Mental Health Court cases receive extra courtroom time, ensuring that the intricacies of the case are addressed and that the defendant is fully engaged in the proceedings. In regular courtrooms, judges may rotate and different prosecutors and defense attorneys may appear for hearings. All cases handled in the King County Mental Health Court are seen by the same judge, prosecutor, public defense team (with the exception of those represented by private counsel), treatment community liaison, and probation officer. The core team approach ensures that defendants work with a limited number of individuals who become familiar with the specifics of their case and treatment needs. This approach also ensures that the court team gains growing expertise in mental health issues and the relatively complex legal issues that can arise.
The second manner in which the Mental Health Court differs from other court venues is the emphasis on creating and maintaining a strong linkage with the mental health treatment community. A Court Monitor functions as a liaison between the court and the treatment community. The Court Monitor links the defendants with appropriate community treatment resources and monitors both the defendants' and the service providers' compliance in fulfilling the elements contained in each individualized treatment plan. In addition, each defendant's mental health case manager is encouraged to join his or her client in court for hearings to report on progress, both successful and unsuccessful. Case managers are encouraged to strengthen their clients' personal support networks, and family members are also welcomed and encouraged to participate.
The third important component of the Mental Health Court model is that defendants who opt into the program receive greater supervision and support. As mentioned above, case managers and family members are encouraged to be actively involved in a defendant's case. Mental Health Court cases are scheduled for more frequent review hearings than are regular cases. Also, Mental Health Court defendants on probation are assigned to a mental health specialist probation officer who carries a reduced caseload. Regular probation officers may have caseloads of up to 300 cases; the Mental Health Court probation officer has a caseload capped at 20-40 cases, so that these cases may be given intensive supervision as is warranted.
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Mentally ill misdemeanant offenders are not required to appear before the Mental Health Court; rather, the program is an alternative for those who are interested in and committed to seeking treatment to ameliorate the mental health conditions that contribute to their unlawful behavior. Defendants are given a choice of ''opting in'' to Mental Health Court if they are willing to waive a trial on the merits of their case and are willing to comply with a supervised treatment plan. Based on experience to date, defendants who do choose to opt into the program are likely to be offered either a deferred or a reduced sentence. An important exception to the voluntary nature of this program is for cases in which competency is at issue: defendants in these cases may be referred to Mental Health Court, regardless of their preference, until the competency issues can be resolved. The Mental Health Court will not accept a defendant into this alternative court program if the defendant's mental health condition does not appear to be of a serious nature and to be a contributing factor in the alleged crime. The Mental Health Court program is not simply a jail-diversion program—out-of-custody defendants are equally eligible to participate, and in-custody defendants are not automatically released, as many present a significant public-safety risk.
During the first two months of operation, the court received referrals for 49 misdemeanant defendants, approximately six referrals per week, who were identified as having either a serious mental disorder, dementia, a brain injury or a developmental disability. The early experience of the Court indicates that many of the Court's cases are very complex. Thirty of the defendants, roughly 60 percent of the total group, were not enrolled in mental health treatment services at the time of referral. Eighteen of the defendants, roughly 35 percent of the total group, presented with housing issues; nine defendants had unstable housing arrangements; and nine defendants were homeless. Fourteen of the defendants, roughly 30 percent of the total group, presented with a dual diagnosis of a serious mental illness and a drug or alcohol addiction, and needed referrals to MICA (mentally ill/chemically abusing) treatment services. Defendants with a housing and/or a dual diagnosis treatment need are very difficult to place if they are also either acutely psychotic or have a history of committing violent acts. Additionally, many of the defendants (at least 25 percent) have active cases in other court jurisdictions including municipal courts, superior court, and other counties, making case planning more complicated due to other outstanding warrants or probation requirements.
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One early outcome of the Mental Health Court pilot project has been that service gaps in the currently available community services continuum have been highlighted. Appropriate in-patient MICA services are not available and crisis or transitional housing for this population is also not readily available. Additionally, in this era of managed care, contingency funds for wraparound service needs (such as temporary medication coverage or transportation costs) are also difficult or impossible to obtain. The Mental Health Court team will likely be undertaking a grant-writing campaign in hopes of securing additional, non-county funds for the unmet needs of this pilot program.
Cases heard in Mental Health Court so far vary widely in terms of the defendants' current charges and past criminal histories, the degree to which their mental illness impacts their life functioning, and their ancillary service needs. Some defendants referred to Mental Health Court are facing their first criminal charge. An example is 19-year-old Mr. Smith,5 facing a domestic violence assault charge for allegedly hitting his mother, with whom he lives. Mr. Smith's mother appeared with him at his first Mental Health Court appearance and explained that he had been an honor student, soccer player and a band member in high school, but that he had experienced his first mental break about a year ago and has not been the same since. Mr. Smith's mother believes that his assaultive behavior is attributable to his mental disorder and is not indicative of a battering problem. Mr. Smith had not been enrolled in formal mental health services at the time of his first appearance with the court, and his mother requested assistance in facilitating this process. His mother also requested assistance in locating appropriate alternative housing for him because she fears for the safety of her young, disabled granddaughter, who also lives in her home. As the treatment team works to find appropriate resources for Mr. Smith, the legal team will determine whether he appears competent to assist in his own defense and proceed to trial, and will work with him to explain the benefits and tradeoffs if he opts into the program.
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Another case involves a defendant with a more chronic mental health disorder and criminal history. Although there are indications that Ms. Jones6 began experiencing symptoms of a mental disorder at least 10 to 15 years ago, she had been a high-functioning member of the community—a multilingual mother of two small children, a teacher, and a doctoral student close to completing work for her Ph.D. More recently, however, Ms. Jones' mental condition has seriously deteriorated. She is divorced, is no longer employed, has become well-known to the staff in the Prosecutor's office, and is considered to be quite dangerous. Over the last five years she has acquired a lengthy history of various stalking, assault and trespassing charges all related to her compulsion to contact a few men she dated or was married to previously. All of Ms. Jones' prior charges had to be dismissed because of her incompetency to assist in her own defense or proceed to trial. Ms. Jones appeared before the Mental Health Court in early March with a new set of charges. She was found to be incompetent, but the charges were not dismissed, as she was eligible for hospitalization for the short period of time allowed under the new law for competency restoration. Ms. Jones' competency was successfully restored after a few weeks' stay at Western State Hospital and she returned to Mental Health Court. Ms. Jones communicated to the Court for the first time that she accepts that she has a mental illness and that she will most likely need to commit to lifelong treatment. Ms. Jones accepted a plea agreement offered by the prosecutor, which suspended jail time in return for strict compliance with a supervised mental health treatment program and other probation conditions, including weekly visits with her probation officer.
As demonstrated by the case examples outlined above, our early experience with this project indicates that a number of misdemeanants who appear before King County District Court present challenging public safety concerns and have complex treatment needs. As we noted above, it is rare that an idea to improve on our system of justice gets virtually unanimous support. However, it has been with the cooperation, top to bottom, of all three branches of government in King County and the community mental health treatment system, that the initially vague concept of a Mental Health Court has resulted in a project that we are proud to say is receiving both local and national recognition. It is our opinion, after our first few months of operation, that the Mental Health Court is a vast improvement over the old way of handling the mentally ill misdemeanant population. We see a positive difference in the defendants' personal level of satisfaction with their role in the system, the use of our limited jail resources, and in protecting public safety.
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EXHIBIT 3
67345c.eps
67345d.eps
67345e.eps
67345f.eps
84
67345g.eps
Mr. GEKAS. We thank you.
We turn to Dr. Wilkinson.
STATEMENT REGINALD A. WILKINSON, DIRECTOR, OHIO DEPARTMENT OF REHABILITATION AND CORRECTION, AND VICE PRESIDENT, ASSOCIATION OF STATE CORRECTIONAL ADMINISTRATORS, COLUMBUS, OH
Mr. WILKINSON. Thank you, Mr. Chairman, Ranking Member Scott, Member Jackson Lee, for having the opportunity to provide testimony on behalf of the Association of State Correctional Administrators, which represents directors of corrections for all 50 States, the Federal Bureau of Prisons, and the United States Territories. I enter my more voluminous testimony for the record.
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To cut to the chase, in the not too distant past many of the inmates with mental illness currently housed in correctional facilities would not be there at all. Many would likely have been committed to the custody of State or local mental health facilities.
As it is, an estimated 283,000 adults, as was mentioned in Congressman McCollum's statement, in jails and prisons have a diagnosable mental illness. That number is expected to grow. This makes those in my position, directors of corrections, de facto mental health directors as well as directors of correctional agencies.
There is not a typical method for handling an individual with mental illness who commits a crime. In some counties in Indiana and Ohio, they are diverted to mental health facilities before sentencing. In areas of Florida and Washington, they are guided to special mental health courts. In other jurisdictions, they are taken to jail where they may not receive the kind of care that they require. Finally, some individuals with mental illness are sent to jails and prisons where their illnesses are neither identified or treated.
Well, why do we want to do good mental health at all? Offenders, first of all, have a constitutional access to mental health care while they are in the custody of correctional agencies. Effective treatment makes our prisons safer and easier to manage. Ultimately, good mental health care in prison means better protection for the community and the thousands of persons who work in our facilities. Ninety-five percent of all prisoners will eventually leave the custody of correctional facilities. There is no such thing as locking people up and throwing away the key. And we want them to re-enter our communities in better shape than when they left them.
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Above all, we must provide quality mental health care to offenders because it is simply the right thing to do. Many of these individuals have complex disorders, which include substance abuse and mental retardation. Others have committed sex offenses and other violent crimes, so we must deal with the phenomenon of co-occurring disorders. Treating one disorder without addressing the other is sometimes futile. Correctional systems must be equipped to provide a holistic menu of programs including alcohol and other drug abuse treatment, literacy, and much more.
Inmates with mental illness may also exhibit unpredictable and even violent behavior at times. They also may suffer from fears that others are trying to harm them. Often their illness makes it difficult for them to follow prison rules and procedures. Sometimes their peculiar and inappropriate behavior creates animosity and tension among other inmates, which can lead to altercations or worse.
Some inmates with mental illness are perceived as weak and may be preyed upon or manipulated by stronger inmates. As such, they require a higher degree of staff supervision. However, many inmates with mental illness receive treatment and co-exist as normally as possible in the prisoner population. Others require placement within a residential prison mental health facility or unit. Individual treatment plans are crucial for each prisoner.
Funding for mental health services to inmates is handled in various ways. Some are budgeted through departments of mental health while others are disbursed through the prison system's medical budgets. Regardless of the method, paying for good mental health treatment is an ongoing struggle for correctional agencies.
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Currently, State departments of correction receive technical assistance from some Federal agencies, but none from agencies that disburse money for health care, for mental health care.
Even the very best treatment will fall apart if it is not continued in the community upon release. This often results in the individual once again getting into trouble and finding his or her way back to the justice system. Mood-altering and stabilizing drugs often make the difference between an offender co-existing normally or committing serious harm. However, the newest and safest psychotropic drugs are extremely expensive, and most correctional systems struggle with the high cost of prescribing these medications. There is a high probability that offenders who need psychopharmacology and do not take them will eventually re-offend.
If current public policy dictates that correctional systems are now catch-all agencies for many persons with mental disabilities, then correctional administrators must be given the resources to address the complexities of providing health care to offenders who suffer from such disabilities. It is clear that comprehensive medical care for offenders yield positive results. Offenders are better able to cope within the prison environment. Releasees stand a better chance of not recidivating. Employees are safer and fewer citizens are victimized.
Mr. Chairman, I applaud you and this committee for taking the time through this hearing to consider the kind of testimony that I have offered, as well as my colleagues, and I stand available, as well as the members of our association, to assist in any way possible. I want to say that I appreciate the leadership of Senator Mike DeWine and Congressman Ted Strickland from Ohio for noting this most important mission for correctional and mental health agencies. And, finally, I would like to say there needs to be a better merging of the public health and the public safety agencies in this Nation on all levels of government.
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Thank you very much.
[The prepared statement of Mr. Wilkinson follows:]
PREPARED STATEMENT OF REGINALD A. WILKINSON, DIRECTOR, OHIO DEPARTMENT OF REHABILITATION AND CORRECTION, AND VICE PRESIDENT, ASSOCIATION OF STATE CORRECTIONAL ADMINISTRATORS, COLUMBUS, OH
I. INTRODUCTION
Chairman McCollum and members of the House Judiciary Subcommittee on Crime, my name is Reggie Wilkinson. I am Vice President of the Association of State Correctional Administrators, Past President of the American Correctional Association, and Director of the Ohio Department of Rehabilitation and Correction. I would like to thank you for providing me the opportunity today to offer testimony on behalf of the Association of State Correctional Administrators. ASCA is the organization which represents directors of corrections for all 50 states, the U.S. Federal Bureau of Prisons, all U.S. territories, four large city corrections agencies, the Correctional Service of Canada, and the province of Ontario, Canada. This testimony will address issues related to the management and treatment of offenders with mental illness committed to our nation's prisons, jails, and community corrections programs.
When a person with a mental illness commits a crime, it is typical for him or her to become involved with the justice system. The outcomes of this involvement have evolved throughout the years. In the not-too-distant past, many of the inmates with mental illness currently housed in correctional facilities would not be there at all. A likely scenario was that they would have been civilly committed to the custody of mental health facilities. Most would agree that the process of deinstitutionalization has reduced the number of persons committed to state mental institutions, but that the requisite community mental health resources do not always exist at the needed level to insure that all of these persons receive the treatment necessary to prevent future criminality. In fact, most corrections administrators agree that there is a relationship between deinstitutionalization and an increase in the number of inmates with mental illness.
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II. NATIONAL SCOPE
Prison populations have soared in most jurisdictions as state mental health hospital patients have dwindled in number. Last month, newspaper headlines announced that the number of people behind bars in the United States broke the two million mark (Bureau of Justice Statistics, August 10, 2000). By contrast, there are about 70,000 people housed in various mental institutions. Among the general population of the United States, 2.8 percent of adults are estimated to have a serious mental illness. This number jumps to between six and 15 percent, or 283,000 adults in jails and prisons, reported as having a diagnosable mental illness. That number is expected to grow as more and more affected people enter the justice system. Consequently, this makes those in my position de facto ''mental health directors'' as well as corrections directors.
Mental health experts recommend two major actions to address this emerging problem: First, special attention must be given to mental health issues in courts, corrections, and law enforcement. Improvement must be seen in the areas of police encounters or crisis intervention, unnecessary arrests and incarcerations, delayed release, increased recidivism, and increased costs. Second, the mental health and the justice system must be better aligned and more cooperative (Ohio Forensic Newsletter, August 2000).
III. WHAT HAPPENS AFTER ARREST?
There is no ''typical'' method of handling an individual with mental illness who commits a crime. In some counties in Indiana and Ohio these individuals are diverted to mental health facilities before sentencing. In various counties in the states of Florida and Washington they are guided to special mental health courts where their unique needs and circumstances are taken into consideration. In cities and counties with appropriate resources, they are taken to jail but receive mental health services while incarcerated. In some jurisdictions, mental health care and treatment for offenders is privatized. Finally, and most unfortunately, some individuals with mental illness are sent to jail and prison systems where their illness is neither identified nor treated.
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IV. WHY PROVIDE GOOD MENTAL HEALTH CARE SERVICES?
We begin with the assertion that appropriate mental health care is a constitutional right. But mental health care is also good for security, and spending early is much better than spending a lot more later.
Effective treatment makes our prisons safer and easier to manage. Prison wardens are keenly aware that inmates exhibiting symptoms of mental illness can cause unrest and tension in the general population. It is obvious that a large proportion of those inmates have better control over their actions when they receive the appropriate treatment for their illness.
Ultimately, good mental health care in prison means better protection for the community. Ninety-five percent of all prisoners eventually leave the custody of correctional facilities, and we envision them leaving better prepared to adjust in the community than when they were arrested. Beyond all the legal and practical reasons one might express, above all, we must provide quality mental health care because it's the right thing to do!
V. CO-OCCURRING DISORDERS AND OTHER ISSUES
It is not sufficient to address the mental health needs and concerns of certain offenders in a vacuum. Many of these individuals have complex disorders which include retardation and substance abuse (approximately 85 percent of prison inmates have a documented history of alcohol and other drug abuse). Convicted felons also have complex criminal behaviors such as committing sex offenses and other violent crimes, which complicates treatment efforts. Treating one disorder without addressing the others is often futile. In order to make a real difference, correctional systems must be equipped to provide a holistic menu of programs, including alcohol and drug abuse, illiteracy, domestic violence, effective parenting, anger management, and much more.
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Jurisdictions vary in the number and types of services available to assist inmates with mental illness. While some individuals need specialized housing, many of these inmates receive treatment and co-exist as normally as possible in the prisoner population. Good management and effective clinical care are required to manage this ''outpatient'' system of mental health care.
For years, corrections personnel have attempted to discern the difference between prisoners who are ''mad'' versus those who are ''bad.'' For both security and health care reasons, we need to know whether offenders are demonstrating purposeful, negative behavior as opposed to those who are ''acting out'' because of a mental illness. Mental health professionals working closely with security professionals assist in this task, but we can do a better job. For many years, the clashing of treatment and clinical professionals with security staff has created difficult management issues. The signs now point to a significant reduction in this type of friction.
Let me provide you with some examples of the day-to-day challenges that correctional staff face in the management of this special needs population. Inmates with mental illness may exhibit unpredictable and sometimes violent behavior towards staff and other inmates. This behavior can be exacerbated when prisoners don't take their prescribed medications. Staff must closely monitor inmates to insure compliance with treatment protocols. Some offenders with mental illness may also suffer from the distorted belief that staff intend to harm, rather than help them. This makes it difficult for these inmates to follow prison rules and procedures. Additionally, the peculiar and sometimes inappropriate behavior of prisoners with mental illness can also create tension with other inmates leading to verbal and/or physical altercations. These factors make it difficult for many prisoners with a serious mental illness to function in the general population of our correctional institutions.
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Whether the prisoner has an acute psychiatric illness or a personality disorder, correctional staff should be concerned with preventing further deterioration. Suicide, and suicide attempts, are stark examples of the consequences of unknown or unattended deterioration. Accordingly, prevention and amelioration of mental health related problems, from an administrative and clinical perspective, must be a conscious, ongoing mission.
Unfortunately, prisoners with a ''weakness,'' either physical or mental, are at a disadvantage and are sometimes preyed upon by ''stronger'' inmates. There is, of course, a constitutional duty to protect vulnerable inmates, and those with mental illness and developmental disabilities often fall into that category. Knowing inmates' physical and mental limitations allows staff to most appropriately house, classify, program, and treat prisoners. Quality mental health care includes screening and evaluations that provide this crucial information.
Partnering with appropriate organizations augments any agency's ability to provide state of the art services to offenders with mental disabilities. For example, an ongoing relationship with state and local mental health departments whose staff have a great deal of knowledge and experience, can be mutually beneficial. Working closely with community mental health agencies and boards can provide assurance of quality mental health care for offenders, especially those being supervised in the community.
VI. ORGANIZATIONAL STRUCTURE
The structure of mental health services in correctional systems varies widely. As mentioned, many inmates can be treated within the general prison population. Others require placement within a residential prison mental health facility or unit. Many systems provide ''step-down'' or ''step-up'' units for those requiring stabilization and for those who demonstrate improvement. Individual treatment plans are crucial for each inmate with a mental illness.
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Although inmates with mental illness do demonstrate criminal and/or disruptive behavior, the line often is blurred as to whether the behavior stems from the illness or is willfully deviant in nature. Regardless of the cause, criminal and unruly behavior cannot be tolerated in a prison setting. An inmate's mental condition should be taken into account at a disciplinary hearing, not as an excuse but as a way to fashion a disposition consistent with security and treatment needs. Clinical staff should routinely monitor the physical and mental conditions of prisoners with mental illness assigned to disciplinary segregation units.
A more recent concern for prison administrators is the placement of dangerous inmates in so-called high-security or ''super-max'' facilities. Correctional administrators are struggling with policy decisions regarding the assignment of prisoners with mental illness to these facilities because of their behavior, while taking the impact of their illness into consideration. Research is also underway as to whether placement in a maximum security prison causes or exacerbates mental illness.
Funding for mental health services to inmates is handled in various ways. Some are budgeted through departments of mental health, while others are dispersed through prison system medical budgets. Regardless of the method of funding, paying for good mental health treatment is an ongoing pursuit for correctional agencies.
A source of funding currently available to state departments of correction are technical assistance and block grants provided through the U. S. Department of Justice Office of Justice Programs and the National Institute of Corrections. Correctional administrators would like to see funding for additional block and demonstration grants specific to mental health issues, that would include appropriations for research, technical assistance, training, and clinical care.
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The successful administration of treatment for offenders with mental illness is also a constant challenge. Solutions vary significantly across the country. Some jurisdictions have adopted the use of employee treatment teams and quality assurance protocols for the administration of clinical services for offenders with mental illness. Multi-disciplinary teams can be successfully deployed to tackle specific and more general tasks.
Many states and jurisdictions have a dichotomous working arrangement in treating offenders with mental illness. Some provide services within the correctional system. Others provide services through a separate agency. And some are privatized.
VII. MENTAL HEALTH STAFFING
The recruitment and deployment of trained personnel is crucial to high quality mental health care. Enhanced care means an enhanced staff, making recruitment a perpetual process. Staff training is also vital. Specialized mental health training should be provided for non-mental health staff such as corrections officers and clerical workers to increase knowledge about mental illness, support appropriate attitudes and behaviors, and better integrate security and mental health concerns.
For many mental health clinical and administrative staff, working in corrections is a new career choice. Agencies must ensure that clinical staff adapt to the correctional environment, regardless of one's credentials.
VIII. COMMUNITY REENTRY
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One of the biggest challenges for the treatment of offenders with mental illness is providing a seamless reentry to the community. As is the case with the aforementioned 95 percent of all prisoners, transition to the community is inevitable. For public health and public safety reasons, operating a holistic mental health service delivery program for offenders is paramount. Even the very best treatment in prison will fall apart if it is not continued in the community upon release. This often results in the individual once again getting into trouble and finding his or her way back into the justice system. If any correctional agency is to have a positive impact on minimizing the problems associated with the reintegration of offenders with mental illness to the community, the process must be well coordinated.
In some cases, parole and probation officers are responsible for the supervision of released offenders including those with mental illness. They should be responsible for linking offenders with community health care and treatment providers, and even escorting released offenders to their first appointment. In some cases, especially now with the inception of ''truth in sentencing,'' many offenders are not supervised at all in the community following release. In these cases, no one but the offender is responsible for ensuring that medications are ordered and taken, appointments made and kept, and behavior monitored.
It is vital to public safety and to a seamless transition for the offender that correctional entities work closely with the community to optimize the exchange of critical information involving released offenders. In some cases, clinical social workers assigned to state prisons, along with mental health staff, coordinate and link mental health services for prisoners released to communities.
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IX. PSYCHOTROPIC MEDICATIONS
Many offenders in prisons, jails, and in the community require regular participation in a psychopharmacology regimen. Mood altering and stabilizing drugs often make the difference between offenders co-existing normally in confinement or in the community, and committing serious harm to themselves or others. However, the newest and safest psychotropic drugs are extremely expensive. Most correctional systems struggle with the high cost of prescribing these medications.
Further, once released from prison or jail, offenders are only given a short supply of medications: on average, two weeks worth or less. Community mental health agencies cannot afford to supply medications to all who need them, whether they are convicted offenders or not. Parole and probation officers can play an important role in helping to ensure that offenders with mental illness are supplied with and take their medications, but even this process is plagued with problems. There is a high probability that offenders who need psychotropic medications and do not take them will eventually reoffend.
X. CONCLUSION
The daily responsibilities that confront a correctional agency often are wide-ranging and formidable. Operating a comprehensive mental health service delivery system for offenders is one of the biggest challenges faced by correctional administrators. There is a long history in our nation's quest to address mental illness in prisons and jails. Duties include assessment, treatment, staffing, training, resources, and continuity of care. The goal of providing a holistic mental health system is becoming increasingly compromised by evolving budget limitations.
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Articulating that it's the ''right thing to do'' by providing the delivery of quality mental health care services is easier said than done. As noted, the numbers alone make this a daunting task. Even without the benefit of empirical research data, one certainly can extrapolate that there are persons now being sentenced to prison who in past years would have been committed to mental health hospitals.
If current public policy dictates that correctional systems are now catch-all agencies for many persons with mental disabilities, then correctional administrators and other stakeholders must be prepared to address the complexities of providing mental health care to offenders who suffer from such disabilities.
To reiterate an earlier point, this does not suggest that persons who commit crimes should not be punished for their voluntary misdeeds. Those with a mental illness, like the rest of us, must recognize that there are consequences for their behavior. However, the process of prescribing the proper treatment in conjunction with the appropriate sanction for offenders with mental illness is in need of careful study and immediate attention.
It is clear that comprehensive mental health care for offenders yields positive results. Offenders are better able to cope within the prison environment, releasees stand a better chance of not recidivating, employees are safer as they perform their duties in calmer environments, and fewer citizens are victimized, therefore improving public safety.
Chairman McCollum, I applaud you and this committee for taking the time through this hearing to thoughtfully consider ways that the federal government can partner with states and localities to address these difficult issues. I would also like to thank Senator Mike DeWine, Congressman Ted Strickland, and other members of Congress for their recent efforts to introduce legislation (HR 2594/S 1865) that would establish pilot mental health diversion courts. This process may help improve the crisis intervention process at an early stage, while helping to improve community health and public safety. I am aware that there are other bills pending in Congress that also would provide states with resources to assist in these efforts. On behalf of correctional administrators across the country and beyond our borders, I would like to pledge our help to this committee and to Congress to develop model legislation that can truly improve the lives of thousands of offenders with mental illness, and minimize their interaction with the justice system.
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Thank you.
SUMMARY
Between six and 15 percent, or 283,000 adults in jails and prisons are reported as having a diagnosable mental illness. That number is expected to grow as more and more affected people move from the streets into the justice system. Mental health care is a constitutional right. Effective treatment makes our prisons safer and easier to manage. Good mental health care in prison also means better protection for the community. Beyond all the legal and practical reasons one might express, we must provide quality mental health care because it's the right thing to do!
Jurisdictions vary in the number and types of services available to assist inmates with mental illness. There is a constitutional duty to protect vulnerable inmates including those with mental illness and developmental disabilities. While some individuals need specialized housing, many receive treatment and co-exist as normally as possible in the prisoner population. Others require a residential prison mental health facility or unit. Many systems provide ''step-down'' or ''step-up'' units for those requiring stabilization and for those who demonstrate improvement. Individual treatment plans are crucial for each inmate with a mental illness. Many of these individuals also have complex disorders which include substance abuse and retardation which must be treated. Staff must also be concerned with preventing further deterioration. Partnering with appropriate organizations augments any agency's ability to provide state of the art services.
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Some mental health services are budgeted through departments of mental health, while others are dispersed through prison system medical budgets. Regardless of the method of funding, paying for good mental health treatment is an ongoing pursuit for correctional agencies.
The recruitment and deployment of trained personnel is crucial to high quality mental health care. Specialized mental health training is also vital, and should be provided for non-mental health staff such as corrections officers and clerical workers to increase knowledge about mental illness. Agencies must ensure that clinical staff understand and adapt to the correctional environment.
We must also provide offenders with mental illness with a seamless reentry to the community. Even the very best treatment in prison will fall apart if it is not continued upon release. Disruption in treatment often results in the individual once again getting into trouble. Parole and probation officers are often responsible for the supervision and treatment of released offenders. However, many offenders are not supervised at all following release. It is vital that correctional entities work closely with the community to optimize the exchange of critical information and treatment involving released offenders.
Like anyone with a mental illness, offenders benefit from regular participation in a psychopharmacology regimen. Mood altering and stabilizing drugs often make the difference between an offender co-existing normally in confinement or in the community and committing serious harm to others or to him or herself. There is also a high probability that offenders who need psychotropic medications and do not take them after release will eventually reoffend. These drugs are extremely expensive and most correctional systems struggle with the high cost of prescribing them.
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It is clear that comprehensive mental health care for offenders yields positive results. Offenders are better able to cope within the prison environment, releasees stand a better chance of not recidivating, employees are safer as they perform their duties in calmer environments, and fewer citizens are victimized therefore improving public safety.
Mr. GEKAS. We thank the gentleman.
We turn to our final witness, Senator Thompson.
STATEMENT OF ROBERT J. THOMPSON, CHAIRMAN, LAW AND JUSTICE COMMITTEE, PENNSYLVANIA STATE SENATE, HARRISBURG, PA
Mr. THOMPSON. Thank you, Mr. Chairman. I appreciate that kind introduction. I also want to thank you on behalf of the members of general assemblies throughout the United States, Republican and Democrat, who are trying to address this problem.
In a former life, I was a county commissioner in Chester County, Pennsylvania, and had the responsibility of overseeing the mental health/mental retardation people who were implementing the Federal court order deinstitutionalizing mental facilities in Pennsylvania. It was issued by Judge Raymond Broderick, as you will recall.
I also want to thank Mr. Scott and Ms. Jackson Lee for being here to listen to us, and also Chairman McCollum for calling this hearing.
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I am here to bat clean-up for the panelist that have been here so far. You have heard some extremely touching testimony from some real experts in the mental health field in the field of criminal justice, and in the field of corrections.
We as legislators have to listen to these concerns and listen to these experts as we develop legislation to address the problem. At the Council of State Governments, I have chaired an effort to bring representatives of all the key stakeholders together from across the country, and similar to the objective of this hearing, our goal has been to exchange views and to try to come up with some recommendations. The level of frustration that these individuals shared regarding the problem really impressed those of us who are lawmakers.
Crime victims wanted to know why the State and local governments haven't taken action sooner. Local law enforcement officials and prosecutors and judges believed that they were wasting a disproportionately large percentage of their time and resources on individuals who should be treated in other fashions. Corrections administrators resented that criminal justice and mental health officials had abdicated their responsibility for that population, leaving the resource-starved prison and jail officials to manage this difficult and very-expensive-to-serve population. Lawmakers across the States have learned that warehousing some categories of mentally ill offenders in jail or prison is, practically speaking, a budget buster. Corrections in Pennsylvania ranks third behind only education and public health and welfare in the current general fund budget, and that area has grown dramatically in the last few years.
While they may have different views on the problem and different perspectives at looking at that problem, they all seem to agree on two issues, and I think everyone who has been here today agrees on two issues: that many individuals are swept into prison or jail because of their mental illness and are there because there are no resources available within the community to hold these individuals accountable or to develop a proper treatment plan; and, in addition, there are violent offenders with mental illness who should be incarcerated, but we fail to equip corrections administrators with the resources to identify these inmates. As a result, many times these inmates are returned to the community in far worse shape than they were when they entered the door.
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Translating the consensus that has been developed by these experts into programs and policy and legislation will be tricky. One size won't fit all. Each of our States and counties have different needs. In short, we need team work and cooperation among Federal, State, and local governments to solve the problem. There is excellent precedent for this.
Under the leadership of Chairman McCollum and Congressman Scott, a juvenile crime bill has been developed which recognizes the differences between the juvenile justice systems and effectively encourages holding juvenile offenders accountable for the delinquent behavior. The bipartisan leadership of this subcommittee, of Congressman Strickland, Senators DeWine, Kennedy, Wellstone, and Domenici make up optimistic that Congress will assume a similarly constructive and vital role in the question of mentally ill offenders.
The role Federal agencies have assumed is equally encouraging. We have had extensive assistance by the Department of Health and Human Services, particularly the Center for Mental Health Services. That reflects their understanding of the problem. And we have had technical support by the Office of Justice Programs in the Department of Justice, which has helped us to begin to learn about successful programs developed by jurisdictions across the country.
You have learned today and heard today of the frustrations about the impact of the mentally ill on the criminal justice system. We have a foundation at the Federal Government to work with States to begin addressing this problem, and we have to all work together before another tragedy occurs.
I thank you very much for your time.
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[The prepared statement of Mr. Thompson follows:]
PREPARED STATEMENT OF ROBERT J. THOMPSON, CHAIRMAN, LAW AND JUSTICE COMMITTEE, PENNSYLVANIA STATE SENATE, HARRISBURG, PA
My name is Bob Thompson and I am the Chair of the Law and Justice Committee in the Pennsylvania State Senate. I also serve as the Vice-Chair of the Criminal Justice Board of Directors for the Eastern Region of the Council of State Governments (CSG). On behalf of Republican and Democratic state legislators from across the U.S., thank you members of the Subcommittee, and particularly Chairman McCollum, for convening this hearing.
My colleagues in the Pennsylvania State Senate and in state legislatures across the U.S. have been discussing with growing concern the impact of the mentally ill on the criminal justice system. Crime victims, law enforcement officials, corrections administrators, and leaders in the mental health community individually approach us, explaining with increasing urgency why the current system must change. We in Harrisburg and in other state capitols across the U.S. have wondered what measures we could take, given the number of constituencies involved, to address this complex problem.
At CSG, I have chaired an effort to bring together representatives of all the key stakeholders from across the U.S. Similar to the objective of this hearing, our goal has been to convene these constituencies to exchange with policymakers their views regarding the impact of the mentally ill on the criminal justice system. The level of frustration they shared regarding the problem greatly impressed my fellow state lawmakers and me.
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THE FRUSTRATION
Crime victims wanted to know why state and local government officials had not taken appropriate action before a tragedy had occurred.
Although there is no empirical support for the strong connection the public assumes between mental disorder and violence, family members of victims, like Kendra Webdale, across the country are justifiably furious with state and local officials for letting mentally ill offenders slip through the cracks. Why were these misdemeanants or non-violent felons bounced between the courts, local jails, psychiatric hospitals, and state prisons and never properly diagnosed with a mental illness (and frequently a co-occurring substance abuse problem)? Why weren't these offenders held accountable to a treatment plan? Why hadn't someone held the mental health community accountable for the delivery of these services?
Local law enforcement officials, prosecutors, and judges believed that they were wasting a disproportionately large percentage of their resources on individuals with mental illness.
Police chiefs, district attorneys, and judges all had strikingly similar accounts of individuals with mental illness, whom they had arrested, prosecuted, arraigned, or sentenced. In some cases, they embarked upon a lengthy—but usually futile—attempt to ensure a proper diagnosis of the individual and the development of a treatment plan for him or her. Almost always, they reached a point of hopeless frustration, concerned about the other responsibilities they had temporarily abandoned. The offender then served a stint in jail or prison. After the offender's release into the community, police invariably responded to a call for service involving the same individual and a new crime, setting in motion the same sequence of events.
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Corrections administrators resented that criminal justice and mental health officials had essentially abdicated responsibility for this population, leaving resource-starved prison and jail officials to manage this difficult and expensive-to-serve population.
Corrections administrators described the detrimental impact this population had on the general morale in jails and prisons. An increasing percentage of assaults between inmates and staff involved individuals with mental illness. Staff frequently reassigned these inmates to high security cells—originally designed for gang leaders and inmate disciplinary problems.
State lawmakers have learned that warehousing some categories of mentally ill offenders in jail or prison is, practically speaking, a potential ''budget buster.''
As a member of the Senate Appropriations Committee in Pennsylvania, I am acutely aware of the unsustainable rate at which the budgets for our county jail system and Department of Corrections are growing. We want to continue ensuring that we throw away the key when we lock up violent offenders. We cannot afford to maintain that practice if we continue incarcerating nonviolent offenders or misdemeanants who are in prison or jail only because they have a mental illness.
THE CONSENSUS
Without question, there are programs, policies, and legislation discussed in conjunction with mentally ill offenders, which spark controversy and polarize criminal justice and mental health communities. Outpatient commitment and the use of the insanity defense are two such issues. These are thorny subjects, which need to be evaluated and sorted out on the state and local level.
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As testimony today reflects, however, there's much on which everyone agrees. Many individuals are swept into prison or jail because of their mental illness and because there are no resources available in the community to hold these individuals accountable to a treatment plan. There are also some violent offenders with mental illness who should be incarcerated, but we have failed to equip corrections administrators with resources to identify and to treat these inmates. While in prison these offenders decompensate, jeopardize the safety of staff and inmates, and return to the community in far worse shape than when they had entered the facility.
Translating this general consensus about what is needed into programs, policy, and legislation in our respective jurisdictions will be tricky. In each of our states and counties, we will need to listen carefully to the relevant constituencies about the kind of training, resources, and research they need. We also will need to apply to our state and local agencies bits and pieces of what's working across the country. In short, federal and state governments will need to work in tandem.
A FEDERAL/STATE PARTNERSHIP
There is excellent precedent for such cooperation under Chairman McCollum's leadership. On legislation addressing matters such as juvenile justice, the Chairman and Congressman Scott have worked together closely, and we have seen the results: a juvenile crime bill that includes programs that simultaneously recognize the differences between states' juvenile justice systems and effectively encourage holding juvenile offenders accountable for delinquent behavior. The bipartisan leadership of this Subcommittee, Congressman Strickland, and Senators DeWine, Kennedy, and Domenici makes us optimistic that Congress will assume a similarly constructive and vital role on the question of mentally ill offenders.
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The role federal agencies have assumed is equally encouraging. Extensive assistance provided by the Department of Health and Human Services—specifically the Center for Mental Health Services—reflects their understanding that health and crime issues must be evaluated in conjunction. Reports from the Department of Justice effectively called attention to the impact of the mentally ill on the criminal justice system. Technical support coordinated by the Office of Justice Programs has helped us to begin to learn how some jurisdictions have made inroads with this problem.
You have heard today the shared frustrations—which we have been listening to for some time now in state capitols across the country—about the impact of the mentally ill on the criminal justice system. The foundation exists for the federal government to work with the states to begin addressing this problem. We must not wait for yet another tragedy to prompt us to act.
Mr. GEKAS. We thank you, Senator.
The Chair yields to itself 5 minutes for the first round of questioning.
I remember very well when I was in the senate of Pennsylvania we developed—and later when I came to the Congress the same thing occurred—a special set of options on the conviction of someone of first-degree murder in which, where previously mental illness was an element in the case, the choices were limited to not guilty by reason of insanity and guilty, period. But the alternative that we developed, which seems to have worked, is that if the law enforcement arena finds him guilty of the crime and the mental health community finds him mentally ill, we can render a verdict of guilty but mentally ill, and thus incarcerate him in such a way that he would receive treatment for the mental illness. That seems to me, although it is a death case, a first-degree murder case, the way that both sectors can hone in on a particular subject.
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My question is I am curious to know whether anyone believes that that kind of sentencing could occur for a lesser crime and start to use both segments of the community forces—law enforcement, who imprisons, and the mental health, who treats. Can it be done in other segments of the law? Yes?
Mr. SLATE. What I would see as a possibility would be the idea of perhaps withholding adjudication, particularly if we are talking about minor types of offenders who may be mentally ill and their mental illness caused the event to occur. Perhaps you could withhold the adjudication and have a conditional release saying that if you will comply with your medication, if you will go to therapy, if you will do this, that, and the other, then we will consider ultimately dropping the charges that we have against you. But, in essence, you could hold the charges over the individual's head to get them to comply to a certain extent. And if they didn't——
Mr. GEKAS. Conditional release is what the lady was complaining of in the death of her sister, if you recall the various releases of that individual who killed her sister. Wouldn't it be better to have a conditional imprisonment until we can determine that he could be better treated at a community-related system or in a mental hospital rather than to go the other way?
Mr. SLATE. If I am not mistaken, I believe her situation was mostly in the treatment venue, and the situation that you were posing, as I understood it, would be that there would have been some sort of criminal violation that has occurred. So, in essence, you could hold over the individual's head the criminal charges. And if they did not comply with whatever the conditions were, then you could, in essence, say, okay, we will just put you in jail if you are not going to comply.
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Mr. GEKAS. But we do that now. We do that now——
Mr. SLATE. Well, not everywhere, and maybe——
Mr. GEKAS. Does someone else want to venture an opinion?
Mr. SCHRUNK. Mr. Chair, Mike Schrunk. Exactly what Pennsylvania does, many States on a guilty but insanity plea or finding by a jury will sentence to—in Oregon, we call it the Psychiatric Security Review Board for a like period of time if they were being incarcerated. So often in many of the cases that I think we at this panel are dealing with—and you heard reference to not the high-end felonies but to the low-end felonies, perhaps, but the misdemeanors and the quality of life, their mental illness doesn't rise to the level where they would be qualified for not guilty but for insanity or guilty but for insanity.
And so what happens, they are in a never-never land. No one would disagree that they have a mental disability or a mental illness. Their quality-of-life crime, were they convicted for it, it is the ones you hear the horror stories in some of the written testimony, where over a 5- or 10-year period someone has been arrested 62 times and it is just you know, a slap on the wrist, 30 days, 30 days, 30 days, and they are continually back in chewing up resources.
And so what you are talking about is absolutely right on the violent felonies, and that has proved successful in a number of States. But the other area where Dr. Slate is talking about, many people have experienced with a deferred prosecution, a diversion, or a straight probation. And perhaps Judge Cayce would be a good person to respond.
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Mr. GEKAS. Judge Cayce?
Mr. CAYCE. I was going to comment, first at the felony level, what had happened in Washington was basically at some point the legislature says these judges don't know what they are doing and we are going to tell them what they have to do at sentencing, and it is basically X number of years in prison. And they took away our discretion to impose affirmative conditions, and now they are backtracking and giving us some of that discretion so that we can do some of these innovative things.
At the misdemeanor level, we have always had complete discretion to impose any kind of affirmative conditions we wanted, which enables us to do things like the mental health court. And some of the people—many of the people that we see have pages and pages of rap sheets, violent and non-violent offenses, but all of them are going to be out of jail no matter what, at the misdemeanor level, within a matter of weeks or months. So is it better to get them into treatment, case management services, probation services, and get them stabilized? Or is it better to just lock them up, no treatment, basically, unless they voluntarily take medications and then have them released with no services? And we have found—and I think that the research shows—that it is effective to get them out of jail up front and get them into community treatment with the court supervision in appropriate cases.
Mr. GEKAS. The time of the Chair has expired.
The gentleman from Virginia is recognized for 5 minutes.
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Mr. SCOTT. Thank you, Mr. Chairman.
Mr. Eslinger, you indicated on the question of who pays for the services that the inmate pays for the mental health services. Does anyone have authority to make the inmate pay for those services?
Mr. ESLINGER. We pay for it out of our phone revenues. When inmates use telephone services in our facility, we collect X amount of dollars.
Mr. SCOTT. We were talking about those phone calls rates in another——[Laughter.]
That is another forum.
Mr. ESLINGER. Actually, I think it is only 28 percent, by the way. But we collect those monies and put it back in the general fund and ask the commission to specifically fund our mental health services.
Mr. SCOTT. So when the inmate gets services, you don't have to order them to pay anything additional?
Mr. ESLINGER. No. However, we do charge a booking fee, a $10 booking fee, a $2 subsistence fee, as well as copayments for some over-the-counter medication as well as some other services that we provide. We do charge that.
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Mr. SCOTT. If an inmate is released at the end of his sentence, do you have any authority to require follow-up?
Mr. ESLINGER. No, we do not. However, we have developed this partnership with community mental health that we do have a plan, a discharge plan for that particular inmate, and this isn't just for end of sentences, but this is also a pretrial inmate. Many of our clients, many of the inmates, are pretrial inmates. So we do have a plan in place, and the individual then—information is given to the deputy sheriff who works that, what we call community service area. So not only does mental health but the neighborhood deputy checks on the well-being and ensures compliance, as well as any other supervised sanctions, like county probation or Department of Correction probation officer.
Mr. SCOTT. Now, do these inmates at the end of their sentence—do you provide—I mean, is that a voluntary situation where they can do it if they want, most do because they know they need the services?
Mr. ESLINGER. Most do, yes. We currently have no sanctions in place other than supervised court-ordered sanctions to ensure compliance to this. Now, if a judge—obviously, if the courts gets involved, then obviously we have the ability to enforce that.
Mr. SCOTT. Mr. Schrunk, we haven't gone into as much—I guess we need to—the right of people not to be forced into things they don't want to do. I mean, you can't make somebody get services if they don't want services.
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Mr. SCHRUNK. Yes, sir, that is correct, and——
Mr. SCOTT. And if you don't have a conviction, you don't have any authority to order them to do anything.
Mr. SCHRUNK. That is absolutely correct.
Mr. SCOTT. And as you have indicated, you get guilty plea negotiations—somebody mentioned it, maybe it was you—you get guilty plea negotiations where the case is coming through, and they get the routine sentence that everybody else gets for similar types of crimes which involve a fine or time of jail, and when they get it, they get it and that is what they get, you don't have authority to add on to that some more, unless they want to accept it as part of the plea or you go to court and let the court try the case and impose that kind of sentence?
Mr. SCHRUNK. We do have that authority on a negotiated plea where we have the information. That is one of the breakdowns of the system. The mental health and the justice systems don't always communicate properly and exchange information. And there are valid reasons for it, but——
Mr. SCOTT. That means all you have got is the charge and you don't know anything else, they accept the 30 days and you run it through, then you find out that there is a mental health problem?
Mr. SCHRUNK. That is correct. If we——
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Mr. GEKAS. Would the gentleman yield?
Mr. SCOTT. I will yield.
Mr. GEKAS. But in those kinds of cases, after someone is found guilty in a jury trial, shall we say, the judge before imposing sentence puts the case in the hands of a probation officer who is supposed to report back as to whether there exists any mental illness or other family problems or chronic mediation problems, those kinds of things, so that the sentence will take that into consideration?
Mr. SCHRUNK. Yes, sir.
Mr. GEKAS. Doesn't that come up on a routine basis?
Mr. SCHRUNK. Yes, sir, that is, if the charge is serious enough. Whenever we are dealing with literally thousands and hundreds of thousands of cases a year that cycle through, cycle through, there simply isn't time and perhaps another person at this table would be the probation department for further hearings of some of the difficulties they have, but yes. And, Mr. Scott, you are absolutely correct. Once a conviction is obtained, within certain parameters a magistrate, the sentencing judge, can impose conditions and can require mental health treatment.
Mr. SCOTT. As a condition of probation, if you give 30 days plus a year probation conditioned on—then you can lob on conditions.
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Mr. SCHRUNK. You can condition, and we try and leverage the clout of the plea. And, again, I defer to my colleague, my judicial colleague here, Judge Cayce, at the table, to talk about that. But it is not always as easy as it sounds to mandate medication, and frequently you will find people that are acting out, finally committing criminal acts with a pocket full of pills. And that has been the extent of the counseling, here is a 30-day supply. It is a sad situation. We need a collaborative effort.
Mr. SCOTT. Could I ask Judge Cayce just to follow up?
Mr. GEKAS. The gentleman is granted another minute because of the Chair's interference.
Mr. SCOTT. Thank you. [Laughter.]
And could you add to that your authority to order mental health treatment if the defendant doesn't have any money? Can you order the department of whatever to provide the services?
Mr. CAYCE. We can in King County District Court through the mental health court because the county has said we are going to fund treatment for every defendant who comes through that court if they are clinically eligible. We don't care about financial eligibility. If the State and Federal Government aren't going to pay for it, then we are. So, yes, we can because there is a pot of money available.
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If they don't have the ability to pay for treatment, we can't order that they get it and then punish them for not getting it when, in fact, the lack of ability to pay was the reason that they didn't get the treatment.
The cases that you identified, the quality-of-life cases, are the ones that are difficult because it is not a crime to be mentally ill and it shouldn't be a crime. And if the incident for which they are before the court warrants a day in jail and the case should be closed, then we shouldn't impose a day in jail and then all these other conditions on top of it. We should be providing them opportunities for treatment, but we shouldn't punish them because of the mental illness that is presented. And that is why it is the criminal justice response to this problem, but it alone is not enough. Other people have to step forward and provide assistance as well.
Mr. SCOTT. Just a clarification. You run a drug court in your county?
Mr. CAYCE. We have a drug court at the felony level.
Mr. SCOTT. And do you have a mental health court?
Mr. CAYCE. Yes, at the misdemeanor level.
Mr. SCOTT. At the misdemeanor level.
Mr. CAYCE. Separate courts.
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Mr. SCOTT. Now, do you have any evaluation that can show that the mental health court actually reduces crime and recidivism? Has your program been evaluated?
Mr. CAYCE. It is in the process of an evaluation. The initial evaluation is going to be out within a matter of days. In fact, the executive summary is attached to the materials that I have provided. And, yes, it does show that the people who have come through the court are receiving more treatment, are receiving fewer arrests and fewer criminal convictions. There is going to a longer-term outcomes evaluation that is a 2- to 3-year process, and we hope as well that the results are positive.
Mr. SCOTT. Thank you, Mr. Chairman.
Mr. GEKAS. I thank the gentleman.
The lady from Texas is recognized for a period of 5 minutes.
Ms. JACKSON LEE. Thank you very much. I hear a resounding and singular theme, which is collaboration, integrated systems, larger picture, and I thank you for your honesty and straightforwardness. We happen to be in the Crime Subcommittee of the House Judiciary Committee, but we use the terminology here—and, Senator you may be aware of it—omnibus. It may be that we need an omnibus approach. I know there are several legislative initiatives that seem to approach that, but let me pose my dilemma.
Mr. Schrunk, if I could just briefly get from you—I was waiting for you to finish the 16 different committal person's end story who died. Could you just briefly tell me what happened with that individual?
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Mr. SCHRUNK. He was arrested—originally he was arrested and convicted of—excuse me, arrested 41 different times, convicted of quality-of-life crimes: trespassing, public indecency, urinating in a park.
Ms. JACKSON LEE. Misdemeanor.
Mr. SCHRUNK. Misdemeanor. Nothing that, as Judge Cayce said, you would get a day in jail or 2 days in jail. At no time did we have a resource or availability to put him in with any leverage in a mental health system. He ultimately was arrested the last time and died in jail, an old, mentally ill individual. You know, a sad commentary on this human being's life.
There are others like that. Officers on the street will tell you of the continual arrest, recycle, recycle.
Ms. JACKSON LEE. So we are missing the continuum of care. Let me then pose this question and my dilemma, and I do want to thank the National Alliance for the Mentally Ill of which you are board member, locally or nationally, but I do want to thank you and the National Mental Health Association, along with many other advocates that have sometimes been in the desert advocating on these issues. But here is my dilemma. I practiced law in the area of mental illness, committals, and would have to visit my clients in the settings that they would be in. Some of them would be in community health centers, and they were in various states of consciousness and reality.
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To Dr. Slate, I would fight the ultimate fight to have you released. There is a question that weaves throughout this of the due process question and the inability to—or the lack of the approach to involuntarily commit. You were in a situation where you were almost a hostage.
On the other hand, I think that Kendra's case warrants my fight for that person to be committed against his will. As I understand it, something about insurance, how outrageous, walked away, nobody did anything about it, and a tragedy occurred.
How do we answer that dilemma? I like the New York law that says that if you don't follow treatment—I think, Mr. District Attorney, you were talking about that—then you are involuntarily committed. We have had these circumstances where the client stands up and says, ''I am not going to stay,'' and we are in a dilemma. And it is frustrating and it is difficult. And the families are threatened.
So go at it, gentlemen who are on this panel, to answer that, and then I would like Dr. Wilkinson just to tell me, do you really want these people—my concern was we deinstitutionalize, we cede it to the snake pit, we didn't do anything about fixing the snake pit, and we put them in jail. I don't know, Dr. Wilkinson. I appreciate your leadership. Do you want them?
So my first question, maybe Dr. Slate will take me on on the due process question, and still find room in his heart that there should be involuntary commitment for people who refuse their treatment, because I am trying to save lives and I am also trying to build up lives of the individuals who needed treatment, and I guess then it falls on us. We need to provide the dollars for that kind of treatment.
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Dr. Slate, thank you.
Mr. SLATE. Ms. Lee, I will definitely not take you on, that is for sure. [Laughter.]
I will say that, as I am sure all of the members of the subcommittee are aware, there is crucial balance here between individual liberties and treatment and also the protection of society. And I guess that is why you all are sitting over there and you have to make these hard decisions, and we are sitting over here.
But I can say this: that while there are various mechanisms in place—and I am familiar with Kendra's law, if you will, in New York. There are some other means as well to address it, such as the concept of myself right here. I know I am mentally ill. There is no question about it. I could essentially establish a guardianship where I put in a legal document my mother, my wife, my doctor, whoever I want to name, and essentially say these people are close to me; if they start seeing that I am having a problem, then they can get me into treatment even if I say I don't want to be in treatment.
The reason being is when you do have the manic depression, as I do, when you are mentally ill, again, that area of the brain is affected so that you don't realize that you are acting abnormal oftentimes. I certainly didn't, until later on in retrospect.
Another thing that could be done, which is perhaps less forceful than what some people call forced treatment, is something called advance directives. It is almost like a ''do not resuscitate'' clause, and you can essentially say if I start to act in an abnormal fashion, then I give somebody else the right to get me into treatment. And I don't know how you do that. I don't know how it works. I don't know what States have it. But you might wear a band or, you know, a bracelet or something that would signify that, if we trained people to look for that sort of thing.
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But what that does is it at least would give me, the mentally ill individual, some choice, some choice in the matter. However, you know, I certainly am aware of going the extra mile here in saying there may come a time when individuals should not have a choice because they don't know, you know, what is proper under the circumstances.
I just want to leave it at that, and I would just offer those two suggestions.
Ms. JACKSON LEE. I appreciate it if Mr. Schrunk and Dr. Wilkinson could be allowed to briefly respond, Mr. Chairman. I thank you for your indulgence.
Mr. SCHRUNK. Let me briefly tell you from a prosecutor's standpoint, I believe that if we work together in a collaborative fashion we can provide mental health services without depreciating individual rights. And I think this is one of the areas that we have got to work on. And so often you—not you, but we have been driven to opposite sides of the room, and we have not been able to get together.
Judge Cayce uses the words ''voluntary treatment'' in his mental health court. You get an alternative. You can go mainstream in the criminal justice system, or you can take the mental health court route. That is one way. You have seen that successful in the drug court realm. So I think that is a dilemma, and I think it is doable, preserving patient rights.
Patient information confidentiality is another area that we need to really pull up our socks and do hard work on.
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Ms. JACKSON LEE. Dr. Wilkinson?
Mr. WILKINSON. Congresswoman Jackson Lee, not only do I not want the inmates who are mentally ill, I don't want the 46,000 other inmates in our system, either. [Laughter.]
Ms. JACKSON LEE. We will call you for another hearing.
Mr. WILKINSON. But I am not naive enough to know that we have to have the more predatory prisoners locked up, and many of them need to be there for longer periods of time than what they are today, if not for the rest of their lives, considering some of the crimes that they have committed.
On the other hand, as Chairman Gekas has mentioned earlier, what about those ones who commit lesser crimes? Well, there are a number of options available, including at the court level, treatment in lieu of conviction. And if that treatment plan has not been followed, then that person can be convicted of that crime and punished. I believe that persons who are mentally ill who have committed crimes should be punished, but in some cases, those crimes should be held in abeyance, the punishment for those crimes, until the proper treatment has been sought, because it is a public safety issue for me running a prison to have persons who are untreated running around with the rest of the general population.
We release in Ohio 53 percent of our entire admissions in less than a year's period. These are the people we have to focus on. These are the people who really need help, and these are the people who are not getting help because of truth in sentencing, because in many cases they are not obligated to be on parole, they are not obligated to be on probation, they are not obligated to go to a halfway house; but instead they need the help of community mental health agencies. And there is much more to this story, but I will end with that.
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Ms. JACKSON LEE. Thank you.
Mr. SCOTT. Mr. Chairman, could I indulge you for about 30 more seconds?
Mr. GEKAS. Without objection, the gentleman is recognized.
Mr. SCOTT. Are you suggesting that the abolition of parole has resulted in an inability to deal with a lot of these problems, that if there was eligibility for parole and you had that period of transition and you had the fact that the person had to qualify and convince the parole board that they were ready to go, that would be a better system than this half-truth in sentencing?
Mr. WILKINSON. Well, I think the system of indeterminate sentencing has not worked. You can have truth in sentencing and still have a period of post-release supervision that will allow at least a transitional period of follow-up for persons who have mental illness or mental retardation or other kinds of disabilities. So, no, I am not advocating that we return in many cases to the traditional parole system, even though it still exists, but I have a problem with having no responsibility for follow-up with persons at all once they leave the custody of our correctional facility.
Mr. GEKAS. The time of the gentleman has expired. Everybody's time has expired. My heart has expired. [Laughter.]
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I thank the members of this panel, and I thank everyone who was involved in whatever way in this most informative hearing. We hope that it will breed results and more of the cooperation which everyone seems to desire.
Thank you very much. This committee stands adjourned.
[Whereupon, at 3:53 p.m., the subcommittee was adjourned.]
A P P E N D I X
Material Submitted for the Hearing Record
PREPARED STATEMENT OF THE NATIONAL COUNCIL FOR COMMUNITY BEHAVIORAL HEALTHCARE
The National Council for Community Behavioral Healthcare is pleased that the Subcommittee is examining the important issue of the criminalization of people with mental illness. The National Council represents over 800 safety-net providers of mental health and addictions treatment services. Providing services to public sector consumers regardless of their ability to pay, our member organizations unfortunately encounter the issue of criminalization in communities across the United States everyday.
THE PROBLEM
A 1999 U.S. Bureau of Justice Statistics report points to a shocking picture of the criminalization of people with mental illness. The report estimates that in mid-year 1998 there were 283,800 people with mental illness in the nation's prisons and jails, and a further 547,800 were on probation in the community.
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Social Service Needs
In examining inmates' life circumstances before incarceration, the Bureau's report finds that, relative to other inmates, those with mental illness are more likely to have encountered a range of serious problems. Specifically, ''Mentally ill offenders reported high rates of homelessness, unemployment, alcohol and drug use, and physical and sexual abuse prior to their current incarceration.'' Thirty percent of the inmates with mental illness in jails reported that they had been homeless in the year prior to their incarceration, while 20 percent of those in state or federal prison reported that they had been homeless. It is reasonable to think that problems like homelessness, unemployment, and abuse are factors that make it more likely that an individual will become involved with the criminal justice system, as is the presence of a mental illness.
Public Safety and the Public Welfare
In dealing with the issue of criminalization, it is important to consider the degree to which mental illness presents a threat to public safety. A widely-publicized 1999 study, the MacArthur Violence Risk Assessment Study, found that individuals with mental illness that did not have substance abuse problems presented about the same risk of violence as did other people in their communities who also had no substance abuse problems. There is no epidemic of violence due to mental illness: factors such as the presence of an addictive disorder play a more important role. (In fact, studies have shown that the most powerful demographic predictors of individual violent criminality are gender and age. For example, boys in late adolescence and young men are populations that stand out as having a high risk for violent offending.) This evidence runs counter to the horrific popular image of mental illness as an insidious threat to society, an image reinforced by the high profile news media reporting of incidents of violence that involve people with psychiatric disabilities and by the stereotypes that Hollywood often relies upon in depicting people with these problems.
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The relative lack of salience of mental illness as a public safety concern does not diminish the fact that criminal behavior among people with mental illness presents a significant problem that must be addressed. Incarceration is neither good for these individuals, nor good for prisons and jails. The Bureau of Justice Statistics report cited above found that 39 percent of the inmates with mental illness in state and federal prisons had not received mental health services from the time that they had been admitted. Additionally, corrections administrators and staff routinely complain that they do not have the expertise or resources needed to handle the special needs of individuals with mental illness and their facilities are burdened by people who would be better handled in other settings.
The Treatment Gap
We believe that high rates of criminalization of people with mental illness are a symptom of limited access to a full range of mental health and addictions treatment services. Individuals seeking care face many barriers to access. More than 42 million Americans lack health insurance according to the Census Bureau. Those who do have insurance often face gaps in their coverage when it comes to paying for mental health services. While most insurance plans cover outpatient mental health services, very few plans provide coverage equivalent to that provided for other illnesses. Overall spending for mental health care has not kept pace with general health care spending in recent years. The Substance Abuse and Mental Health Services Administration recently released a report which found that inflation-adjusted mental health and addictions treatment expenditures grew by only 3.7 percent annually between 1987 and 1997, while all health care spending grew by 5.0 percent each year on average.
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Services such as community mental health centers, partial hospital programs, case management programs, and psychosocial rehabilitation programs help many individuals recover from the disabling aspects of mental illness. The Surgeon General's 1999 report on mental health finds that there is adequate science to prove the effectiveness of a wide range of interventions.
However, the report also describes the serious policy challenges involved in making care available, pointing out that, ''The U.S. mental health service system is complex and connects many sectors (public-private, specialty-general health, health-social welfare, housing, criminal justice, and education). As a result, care may become organizationally fragmented, creating barriers to access. The system is also financed from many funding streams, adding to the complexity, given sometimes competing incentives between funding sources.'' These multiple sources of financing include consumer out-of-pocket spending, private insurance, county sources, state sources, federal block grants, Medicaid, and Medicare—and parties managing these monies all seem to have an interest in having others pick up the bill through ''cost-shifting.'' Too often, this organizational complexity has resulted in long waiting lists forconsumers or a failure of systems to provide the full-range of services proven effective in improving health outcomes.
Traditionally, the public sector has played an important role in providing services to people with mental illness, particularly for those who experience disability as a result of their illness. In 1963, President John F. Kennedy signed into law a bill that would lead to the establishment of more than 750 comprehensive community mental health centers throughout the country. Today, these centers provide services to the uninsured and underinsured who are unable to afford care. Even though they keep many from falling through the cracks of a fragmented system, they are unable extend their services to reach all in need. As a result, people with mental illness can be placed in institutions of last resort such as state hospitals and, more and more frequently, prisons and jails.
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Deinstitutionalization
Many find the policy of deinstitutionalization an easy target when we consider the unmet needs of people with psychiatric disabilities. However, the failure of deinstitutionalization must be examined closely before we consider a return to heavy reliance on long-term inpatient treatment. State hospitals have simply proven themselves inadequate to the task of handling the needs of most people with serious mental illness. While a necessary part of the treatment continuum for a few people with psychiatric disabilities, state hospitals have failed to prove they can reliably provide effective clinical services in a cost-efficient manner to large numbers of clients.
Many researchers find the real failure of deinstitutionalization in the states' dumping of people with psychiatric disabilities into communities without an effort to ensure that community-based services had the resources necessary to provide for their needs. The dollars needed to support these services simply did not follow the clients through the hospital door. The National Association of State Mental Health Program Directors' 1996 State Profile Database reports the percentages of state mental health authority budgets that are available to support community-based services, and these data show that the average state devotes less than half of its mental health program funds to support services in communities. The dollars remain institutionalized, while the vast majority of people receiving mental health services receive them in the community—and there is broad consensus among clinicians that this is the most appropriate setting for most of these clients. These funds need to be redirected to support under-resourced community-based programs.
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THE SOLUTION
As a matter of national policy, much can be done to reduce the chances that individuals with mental illness will come into contact with the criminal justice system. Resources can be moved to expand access to a full range of community-based mental health services. Congress can continue to work to expand insurance coverage for the uninsured and can extend efforts to address the lack of parity in insurance coverage which exists for mental health care. The federal Center for Mental Health Services can continue to encourage states to provide adequate resources for community-based programs. Finally, the criminal justice diversion programs which have shown much promise—especially those which intervene at the pre-booking stage—are an important last line of defense should a person with a psychiatric disability fail to get the support needed to avoid involvement with the criminal justice system.
PREPARED STATEMENT OF HON. SHEILA JACKSON LEE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS
Chairman McCollum, and Ranking Member Scott thank you for bringing this opportunity to discuss the shameful secret about our nation's criminal justice system, that we are incarcerating our nation's mentally ill, instead of seeing that they receive adequate medical treatment.
As members of the House Judiciary Subcommittee on Crime we each know that early 1.8 million individuals are incarcerated in our nation's jails and prisons; an increase of 127% since 1985.
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It is long overdue that this committee should address the issue of those who are mentally ill and in our nation's state and federal prison systems. At the end of 1999, 283,800 persons with mental illness were held in federal, state prisons and local jails—making these the largest facilities for people with mental illness in the United States; Jails and prisons have become by default psychiatric facilities. These make shift mental health wards go without the benefit of adequate medical staff, medication, or proper training of guards, who should be medical personal.
This is not the ''Dark Ages'', but you could not tell that by looking at how our society treats mentally ill people. The United States is supposed to be the most advanced nation on the Earth, but in many ways we are one of most underdeveloped nations when considering our approach to mental health and the mentally ill.
Today's hearing is a step forward to highlight and address many of the things that are wrong with a system that the most vulnerable among us are locked up in jails and prisons without adequate health services—while our country enjoys the greatest economic boom in thirty years. Our nation's unemployment rate is at its lowest point in 30 years; core inflation has fallen to its lowest point in 34 years; and the poverty rate is at its lowest since 1979. The last seven years we have seen the Federal budget deficit of $290 BILLION give way to a $124 BILLION surplus.
The statistics on our nations incarcerated mentally ill is as depressing as the good news of our nation's economy is joyful. The facts are that men and women with mental illness spend on average, 15 months longer in state prisons and five times longer in jails. Research has supported many of the effective strategies that work for people with mental illness in the criminal justice system, yet the corresponding leadership and funding to replicate these strategies have not been provided. According to Ron Honberg, executive director for legal affairs for the National Alliance for the Mentally III (NAMI), health care programs, such as Medicaid, will not provide treatment services to those who are incarcerated. This means that any treatment an inmate receives must be subsidized by the penal facility. Dr. Honberg added that the criminal justice system is slow and complicated meaning that few prisoners who really need help will ever get it.
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In June 1995, approximately 9.8 million people are booked into jails across the country annually. Seven percent of jail detainees have acute and serious mental illnesses upon booking. In addition, more than 50% have other mental health diagnoses, including dysthmia (8%), anxiety disorders (11%), and anti-social personality disorders (45%). The report ''Criminalizing the Seriously Mentally III: The Abuse of Jails as Mental Hospitals, Washington, DC,'' that was prepared by Public Citizen's Health Research Group in 1992 found that the four most common offenses committed by the mentally ill were: assault and/or battery, theft, disorderly'conduct, and drug and alcohol-related crimes. In total, 63% of jail detainees have a mental illness or a substance disorder, and 5% have both. These figures indicate that 320,000 jail inmates are affected by mental health or substance abuse problems on any given day, of whom 25,350 people have a serious mental illnesses and co-occurring substance disorders.
This situation is costing states when families of the mentally ill sue when their loved ones do not receive proper medical attention. In May 1999, a federal judge in the State of Texas approved a $1.18 million settlement award to eight mentally ill individuals who were previously confined at the Hidalgo County Jail in Edinburg. The inmates had filed a lawsuit in 1994 that claimed the jail violated their civil rights and failed to provide humane conditions and legal services. One of the plaintiffs, suffering from schizophrenia, had been arrested for hitting his father and confined in the facility where he remained for four years without a trial. Upon release, mental health officials determined his condition had deteriorated significantly due to his incarceration. As part of the settlement approved by U.S. Distridt Judge Ricardo H. Hinojosa, Hidalgo County agreed to several provisions for improving jail mental health services, including immediate classification of mentally ill inmates; psychiatric evaluation and regular treatment of individuals'suffering from mentally illness; and separation of the mentally.ill from general population ininates.
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Approximately 13% of the prison population have both a serious mental illness and a co-occurring substance abuse disorder. Thus an estimated 642,500 inmates are affected by mental health or substance abuse problems on any given day—of which 132,000 have a serious mental illness and a co-occurring substance abuse disorder. The one-year prevalence rate of serious mental illnesses among prisoners was 5% with schizophrenia, 6% with bipolar disorder, and 9% with depression; which are treatable if discovered and addressed by mental health professionals.
Effective Strategies
People with serious mental illness require a comprehensive community-based treatment approach that ensures public safety and reduces recidivism in criminal justice institutions. We must work to help communities and families recognize the importance of identification of mental illness and remove the stigma of medical treatment. We must work to educate people especially in the African American and Hispanic Communities who are highly sensitized regarding the attitudes of the group and maintaining a sense of community in the face of mental illness. In many minority communities there is a sense that to admit mental illness is to acknowledge a spiritual flaw or character deficit.
Effective strategies that work for people with mental illness in the criminal justice system should consist of Diversion programs that assist people with serious mental illness and substance abuse disorders avoid the criminal justice system, such as mental health courts; it has been recognized by mental health professionals for some time that many people who engage in taking illegal drugs are attempting to self medicate for a mental health disorder. It is sad to admit that in our society there is greater acceptance of addictions to alcohol and drugs than mental illness. Screening and assessing individuals with mental illness upon entry into the criminal justice system is vital to addressing the problems that many penal facilities face. It is human and just that this country have the compassion and common sense to openly offer medical assistance to those in need.
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A commitment to treatment for individuals with mental health and substance abuse disorders would go a long way in address our pressing need to cut the level of demand for illegal drugs coming into our country.
Successful transition program that will impltment appropriate support services (such as, housing arrangements, vocational and educational needs, mental health and addiction treatment), to ensure fewer problems for people reentering the community.
Further, we should provide training to law enforcement and criminal justice system personnel to identify persons with mental health and substance abuse disorders. Therefore, it is important that this Congress increased funding for jail diversion initiatives funded through the Substance Abuse and Mental Health Services Administration (SAMHSA) Jail Diversion Knowledge Dissemination Application (KDA) Initiative which is a partnership between the Center for Mental Health Services (CMHS) and the Center for Substance Abuse Treatment (CSAT);
In the State of Texas the Crisis Intervention Teams, or ''CIT'' is a professional diversion program started in Memphis, Tennessee 10 years ago, teaches a voluntary team of patrol officers a safe way to interact with the mentally ill in crisis. Police officers receive 40 hours of experiential training in mental health issues and communication/de-escalation techniques. For example, officers learn how -to deal with individuals who might be suicidal, delusional, or are experiencing side effects from medication. Officers are also trained to ask pertinent questions to better recognize persons with a mental illness.
CIT is expanding across the state and across the nation. The Mental Health Association of Houston Texas established the CIT initiative in 1997, with the Houston Police Department.
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As a result of the Houston CIT initiative, 50 Houston police officers a month are trained in CIT. These officers comprise 25% of the patrol force, which comes to about 725 officers. The $300,000 Houston CIT initiative is funded through the Federal Center for Mental Health, Knowledge Development and Application (KDA) Jail Diversion Initiative.
As a result of the programs dramatic success, all outlying Houston police departments, including all of the 48 incorporated towns, will begin implementing CIT. Starting in January 2000, the Houston MH—A will be training 100 officers a month.
How ever, I believe that we must do more—earlier in the lives of potential offenders. That is why I introduced H.R. 3455, the Give a Kid a Chance Omnibus Mental Health Services Act of 1999. To amend the Public Health Service Act with respect to mental health services for children, adolescents and their families.
I would only ask that my colleagues join me in finding a way to assist our nation's mentally ill, by addressing the problems that have been documented regarding the treatment of the mentally ill in the judicial system. Thank you.
PREPARED STATEMENT OF THE AMERICAN FEDERATION OF STATE, COUNTY AND MUNICIPAL EMPLOYEES (AFSCME)
The American Federation of State, County and Municipal Employees (AFSCME) submits the following statement for the record in support of H.R. 2594, ''America's Law Enforcement and Mental Health Project.'' AFSCME has 1.3 million members who work in federal, state, county and local government offices and correctional facilities. We represent over 100,000 members employed in the correctional system, including 60,000 members who are corrections officers.
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In the 1960s, with the closing of many of our nation's mental health hospitals, our nation's prisons realized an alarming influx of the mentally ill into the criminal justice system. Without adequate treatment and follow up, many found themselves on the street without any resources. Unsupervised, non-medicated and ravaged by their illnesses, they found their way into local jails or prisons. In fact, our nation's jails and prisons are now the largest providers of mental health services in this country. The Los Angeles County Jail and Rikers Island Jail in New York are the largest and second largest providers of mental health services in the country.
The exploding incarceration rate of the mentally ill has had a dramatic impact on corrections officers. As a result of the deinstitutionalization of our mental health hospitals, corrections officers not only provide security in the nation's correctional facilities but they are responsible for the incarceration of the mentally ill who need and deserve special care.
Corrections officers are neither trained nor qualified to provide essential care for mentally ill inmates. These inmates present severe behavior management problems for corrections officers because their behavior is unpredictable and volatile. One frequent manifestation of the their mental illness is self-mutilation. As a result, they must be monitored continually. An AFSCME corrections officer in Ohio describes an incident where one of his inmates swallowed a razor blade after using the blade to mutilate himself. The same officer recalls another inmate who ruptured his own intestine and was taken to the hospital. While in the hospital, he broke his finger. He then took off the splinting device and used it to open his incision. He subsequently died of toxic poisoning.
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While corrections officers are spending an inordinate amount of their time monitoring the mentally ill, the general prison population takes advantage of the situation by breaching security. This creates a serious safety problem in the facility. To remedy this situation, mentally ill inmates are often placed in segregation cells with no treatment options as a means of controlling or limiting their actions, to protect them from more violent criminals and to protect corrections personnel.
Not only are mentally ill inmates isolated from the general population, they are not provided adequate treatment for their illnesses. The Albany Times Union reported on May 18, 2000 that New York's former chief judge Sol Wachtler, who was convicted on charges of harassing his former lover and who was diagnosed with a bipolar disorder, said that while he was in a federal prison he saw a psychiatrist only once and was segregated from the rest of prison population because he had been stabbed. Violent criminals prey on the weak in prison, and the mentally ill are prime targets.
Corrections personnel who have to confront mentally ill inmates are being subjected to additional stress beyond the norm. Not only do these officers have to cope With the most violent members of our society but they also have to endure the extremely unpredictable and often violent behavior of mentally ill inmates who cannot be controlled.
Our nation has close to two million people locked up on any given day in our jails and prisons. The Bureau of Justice Statistics has estimated that the incidence of those diagnosed with the most serious mental disorders is 16 percent of this population. Those in the mental health field say that the figure is closer to 20 percent.
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H.R. 2594, America!s Law Enforcement and Mental Health Project, would authorize 25 demonstration projects in which certain nonviolent inmates who suffer from a mental illness could voluntarily enter into a separate judicially supervised program. Passage of this bill would lead the way for diversion of the mentally ill from prison to treatment centers where they can receive much needed care and proper treatment. Additionally, the bill would authorize funds to adequately train corrections offices to identify and address some of the needs of mentally ill inmates.
AFSCME strongly supports this legislation. Those who suffer with mental illness or those who are developmentally disabled are best able to lead productive lives if they are provided continuing supervision and mental health treatment plans, including life skills training, housing placement, vocational training education, job placement, health care and relapse prevention. Incarceration of the mentally ill is not a humane answer to our nation's mental health problem because jails and prisons are not therapeutic environments by either intent or design. Our society can and must do better for our less fortunate citizens.
(Footnote 1 return)
Policy Research Associates, Inc. ''Diversion and Treatment Services for Mentally Ill Detainees in the KCCF.'' December 1991.
(Footnote 2 return)
''By Default, Jails Become Mental Institutions,'' New York Times. March 5, 1998.