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Judge Steven Leifman

Chair, Task Force on Substance Abuse and Mental Health Issues in the Cour t, Supreme Cour t of Florida and A ssociate Administrative Judge, County Cour t, Criminal Division, 11th Judicial Circuit of Florida

Stemming the Flow of Persons with Mental Illness into the Justice System

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Judge Steven Leifman, Chair, Task Force on Substance Abuse and Mental Health Issues in the Court, Supreme Court of Florida and Associate Administrative Judge, County Court, Criminal Division, 11th Judicial Circuit of Florida; Tim Coffey, Coordinator, 11th Judicial Circuit, Criminal Mental Health Project

The Parable of the River

One day, two villagers were walking along a riverside when one noticed a baby in a basket floating down the river. The first villager immediately rushed into the water and saved the baby from drowning. No sooner had the villager returned to shore than another basket containing another baby was spotted floating down the river. The first villager rushed back into the water and retrieved the second baby just in time. All of a sudden a third, fourth, and fifth basket were seen coming down the river, and then dozens more.

As the first villager frantically rushed in and out of the water to save each of the babies, the second villager began running upstream. Seeing this, the first villager yelled out, “Where are you going? We have to save the babies!” The second villager yelled back, “I know… Im going to find out who’s putting the babies in the water and to stop them before they send more!”

 

This parable illustrates the difference between public health approaches that focus on addressing discrete crisis episodes involving individuals vs. emphasis on prevention and the well-being of the community as a whole. Both approaches are essential, and neither undermines the other. However the tyranny of the urgent, combined with limited resources, has historically dictated that policy and practice address immediate crises to the relative neglect of longer term prevention and population-based solutions.

People with serious and persistent mental illnesses, particularly those who become involved in the criminal justice system, demonstrate substantial disparities in rates of access to community-based mental health and primary care services. Service utilization patterns reveal disproportionate use of costly crisis and acute care services, with limited and inconsistent access to prevention and routine care.

Traditionally, mental health interventions are provided to individuals with serious mental illnesses only after they become involved in the justice system. While these interventions, such as problem-solving courts and jail diversion programs, have demonstrated remarkable effectiveness in reducing costs and improving public health and safety, research suggests that the prevalence of serious mental illness among criminal justice populations has remained largely unchanged.

The babies must be rescued from the river — that’s critical. However, we need to determine the source — what drives people with mental illnesses into the justice system to begin with? What changes in policy, legislation, and service delivery models will help to reduce criminal justice involvement and improve access to care and recovery?

It is estimated that more than two million arrests each year in the United States involve people with serious mental illnesses. Roughly three-quarters of these individuals also experience co-occurring substance use disorders. As a result, jails have become places where a disproportionate number of people with severe behavioral health disorders spend significant amounts of time; their ties to the community severed, their treatment needs unmet, and their illnesses made worse.

Because services in the community tend to be poorly coordinated across treatment settings and difficult to access, many individuals are unable to secure the types of supports necessary to facilitate adaptive community re-entry and reintegration; let alone ensure that their full range of behavioral health and primary care needs are addressed. The result is high rates of recidivism to the justice system, compromised public health and safety, chronic homelessness, and disproportionate use of high cost and inefficient acute care services.

An analysis completed by the Florida Mental Health Institute at the University of South Florida examined arrest, incarceration, acute care, and inpatient service utilization rates among 97 individuals in Miami-Dade County, Florida identified as “heavy users” of crisis and institutional services. Nearly every individual was diagnosed with a psychotic disorder, had experienced chronic homelessness, and had a history of arrests for predominantly low-level, non-violent offenses.

Over a five-year period, these individuals accounted for nearly 2,200 arrests, 27,000 days in jail, and 13,000 days in crisis units, state hospitals, and emergency rooms. The cost to the community was conservatively estimated at $13 million with no demonstrable return on investment in terms of reducing recidivism or promoting recovery. Comprising just five percent of all individuals served by local jail diversion programs, these individuals accounted for nearly one quarter of all program referrals and utilized the vast majority of program resources.

Solutions to the delivery of integrated behavioral health and primary care services that promote population health require a commitment to thoughtfully re-examining healthcare policy, legislation, and practice. There will always be a need for frontline services in the community to serve as the safety net for those who become entangled in the currents that permeate gaps in our systems of care.

However, if we continue to stand by the riverside of the criminal justice system without investing in policies, technology, and advances in understanding why people with mental illness get involved with the justice system, we’ll miss a critical opportunity. We won’t be able to redefine how we, as shared community stakeholders, can effectively manage what has become a steady, costly, and unnecessary stream of baskets flowing down the river.