Pretrial Diversion Across the Country and the Next Steps for Texas to Improve its Efforts and Increase Utilization
Editor’s Note: The following is Part 2 in a series, “Overincarceration of People with Mental Illness,” a report released in June 2015. The full report is available at http://rightoncrime.com/2015/06/overincarceration-of-people-with-mental-illness/. Part 1 ran in our March issue; we will continue the series in May.
By Kate Murphy and Christi Barr
Center for Effective Justice
Texas Public Policy Foundation
Pretrial Diversion Programs and Practices in Texas
The CMHS National GAINS Center describes the many points in which people with mental illness can be intercepted and diverted from incarceration to mental health treatment. Pretrial diversion can occur at two points of interception: at first contact with law enforcement and during initial detention or initial court hearings.42 People first come into contact with the criminal justice system in the community through 911 or local law enforcement.43 This contact is the first sequential intercept for developing a criminal justice-mental health partnership.44 At this intercept various service-level changes can be made to improve public safety long term. Police can be trained to respond to calls where mental illness is a factor.45 Police contacts with people with mental illness should be documented. 46 Communities can establish a police-friendly drop-off center, crisis unit, or triage center to stabilize emergencies or crises.47 Those who are diverted at this intercept should be linked to follow-up services.48 And services should be monitored and evaluated for quality improvement.49 The next intercept is after arrest but before trial.50 At this stage, arrestees should be screened for mental illness at the earliest opportunity to determine whether they are eligible for diversion.51 The state should maximize opportunities for pretrial release and link people who are eligible for pretrial release to comprehensive evidence-based services that are proven to help reduce recidivism.52 Lacking cross system coordination and limited resources are significant barriers to improving the present use of pretrial diversion for people with mental illness who are cycling through the criminal justice system. But Texas counties are working to make meaningful changes that will link people with mental illness to treatment, use taxpayer dollars more efficiently, and ultimately improve public safety. This section will discuss what Texas is doing right and some areas that need improvement.
Harris County has been working hard to improve pretrial diversion efforts for people with mental illness. Harris County operates the largest county jail in Texas with approximately 9,000 inmates, with people with mental illness representing 25 percent of all inmates.53 Because it holds a large population of people with mental illness, the Harris County jail is often referred to as the biggest psychiatric facility in Texas.54 The annual cost for an inmate with mental illness in Harris County from 2004-2008 was $7,017, compared to other inmates at $2,599.55 Every contact with the criminal justice system comes at a high cost, and many people with a mental illness re-offend and end up cycling through the jail system again and again.56 Incarcerating people with mental illnesses has high costs that waste taxpayer dollars and ultimately fail to effectively meet the needs of individuals with mental illness. To help this problem, the 83rd Legislature enacted Senate Bill 1185, creating a jail diversion pilot program in Harris County.57 The goals of the program include reducing the frequency of arrests, number of days spent in jail, increasing access to different services, improving quality of life and reducing criminogenic risk.58 The pilot program targets people with a serious mental illness, schizophrenia, bipolar, major depression, and PTSD, who have been booked at least three times in two years at the Harris County jail.59 People are referred to the program through community providers, MHMRA, courts, or law enforcement, creating many opportunities to divert eligible people away from jail.60 Once referred, individuals will receive behavioral health services, health care, housing, rehabilitation services, case management services and peer support.61 In December of 2014, there were 3,000 total individuals that met the criteria for enrollment into the program, with anywhere from 450 to 500 people in the jail at any given time.62 As of May 1, 2015, a total of 154 people had been enrolled in the program.63
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This program connects individuals with mental illness with community-based services to prevent cycling back into jail. Depending on preliminary results, this program has the potential to be replicated in other counties throughout Texas. Although more funding is likely necessary to replicate and expand this pilot program, the results and potential savings could outweigh the initial monetary cost. Because this program relies on many community-based services, the greater focus should on the benefits resulting from improved collaborations between the mental health and criminal justice systems. Any diversion program based on this model should be sure the community has the mental health infrastructure in place to support the program. A diversion program without adequate community-based services would not be able to effectively treat people or accomplish its goals. Therefore, it may be more difficult to replicate this program in counties with limited mental health services. However in counties with established community-based services, the program should be replicable with emphasis on collaboration between the existing services.
Bexar County is regarded as a model for collaboration between the mental health and criminal justice systems. Bexar County has several examples of best practices in jail diversion. For example, in Bexar County the Commissioners Court approved the Mental Health Advocacy Initiative to identify and assist people with mental illness who repeatedly cycle through the criminal justice system.64 This initiative focuses on nonviolent inmates with one or more previous incarcerations in the last year.65 Each individual in the program gets an individual treatment plan with the input of judges, attorneys, providers, and the participant.66 Over the next year, the participant receives intensive case management to ensure long term stabilization.67 Case management can include outpatient treatment to assist people with serious mental illness with treatment compliance and court orders, which has effectively reduced incidents of hospitalization, homelessness, arrests/incarcerations, victimizations, and violence.68 Additionally, Bexar County has partnered with the Crisis Care Center for its jail diversion program. Since 2003, over 17,000 people have been diverted from incarceration to treatment.69 This program has saved taxpayers over $50 million, trained over 2,600 law enforcement officers in crisis intervention, and reduced overcrowding in the Bexar County Jail from over-capacity to 500 empty beds.70 The crisis care center has a Mobile Crisis Outreach Team (MCOT) that provides 24-hour mental health crisis screening and assessment, links people to community resources, and facilitates hospitalization if necessary.71 The Crisis Care Center also has a drop-off destination for psychiatric emergencies where they screen and assess people with mental illness, link people to services, offer 48-hour crisis observation, and assist with mental health warrant applications.72 This program allows officers to leave people experiencing a mental health crisis with trained professionals who can assist them. One of Bexar County’s newest initiatives is an attempt to screen and assess every single arrestee at magistration. Upon arrest in Bexar County, every detainee is sent to the Central Magistrate Facility for screening. The University Health System screens for physical health issues and the Judicial Pretrial Services screens for mental illness. If an individual might have a mental illness, they are referred to the Local Mental Health Authority (LMHA), where they will undergo a full mental health assessment. After the assessment, the LMHA can recommend the detainee receive treatment from the mental health system rather than be incarcerated. Bexar County’s effort to screen every arrestee for mental illness could help break the cycle of recidivism that many justice-involved individuals with mental illness are caught in. Other jail diversion programs focus solely on individuals with previously known mental illnesses, but Bexar County’s new program is actively looking for these individuals, aiming to identify those who may otherwise be overlooked. Bexar County’s proactive approach should reduce the number of people with mental illness who are inappropriately incarcerated. This reduction should further the goals of improving public safety and helping individuals in need at a lower cost to taxpayers.
Bexar County is breaking new ground with its mental health screening procedures, which could help some of Texas’ neediest people and create safer communities. Texas should encourage other counties to follow Bexar County’s example of developing cost-effective programs that promote public safety and improve the lives of people in crisis who are stuck in a revolving door of Texas’ criminal justice system.
Williamson County has a strong mental health diversion program.73 Its program includes an outreach team, a crisis intervention team, and resource coordination among mental health and corrections providers.74 Williamson County’s diversion program has saved $3.2 million from costs associated with jail bookings to the administration of psychotropic medication and emergency room use.75 The diversion program is also associated with reduced use of state hospital beds.76
Williamson County also has a Crisis Intervention Team program (CIT) that has created cost-savings.77 Crisis Intervention Teams are part of the Sheriff’s Office. CIT programs are designed to improve interactions between law enforcement officers and individuals with mental illnesses and increase safety of all people involved in mental health crises.78 They receive specialized mental health training and learn about community alternatives to incarceration. The Williamson County CIT saved the county $2.3 million over the course of two years by diverting 1,088 people with mental illness from jail to community based treatment.79
Smaller communities like Smith County are also implementing innovative pretrial diversion programs. Smith County has many nonviolent arrestees, which led county leaders to open the Alternative Incarceration Center (AIC).80 The AIC is geared toward reducing the Smith County jail population, protecting the public through intensive supervision (i.e. day reporting), providing employment services, and rehabilitating offenders as they re-enter society.81 The AIC offers low-level offenders with mental illness assistance through screening, assessment, counseling, symptom management and skills training, and medication regimen compliance.82 In the first year since the inception of AIC, the jail population decreased more than 120 inmates per day and Smith County saved nearly $1 million.83 AIC has an average of 289 participants each year.84 Some 36 months of program data shows that 88 percent of participants remain successful on regular probation after six months, and 77 percent remain successful after one year.85 The diversion program costs about $1 million each year and saves $4.4 million—a net savings of over $3 million for Smith County.86 In addition to saving money, lowering recidivism, and freeing up jail space, participants who are working are able to pay restitution to victims and receive specialized services that can help them turn their lives around.87 In Brazos County, the sheriff’s office employs four fulltime CIT officers who respond to calls involving a person with or suspected of having a mental illness.88 Brazos County’s CIT program provides follow up care to everybody they encounter. Each of the deputies have cases assigned to them and will follow up, weekly or monthly, to ensure that the person has and is taking their medications, to see how they are doing, and to prevent them from going into another crisis.89
In Palo Pinto County, law enforcements officers can simply take somebody straight to the LMHA for services rather than taking them to jail if they determine a person needs mental health services.90 Law enforcement officers in Burnet County are trained to do mental health assessments on people they come into contact with who present with mental health problems. From there, they will determine whether or not to contact the LMHA for a more formal evaluation and recommendation of services. Their policy is to try and never put somebody who has a mental illness into the jail, but rather get them into an in- or out-patient treatment program.91 Similarly, Wharton County employs mental health deputies that can issue emergency detention orders and temporarily house a person with mental illness in the sheriff’s office. Then they contact the LMHA to come assess the individual and provide recommendations, usually ending with the deputy transporting the individual to a state hospital or other facility.92 Jefferson County has a special program, Assist, Stabilize and Prevent (ASAP), that works to identify people with mental illness in the community that have had contact with law enforcement. Officers then work with those individuals to prevent them from re-entering jail or hospitals. Their program has successfully diverted 400 individuals from being incarcerated.93 Ector County has three specially trained mental health officers that respond to calls involving somebody with a mental illness. The officers will do an assessment on the individual in the field and then transport them to a hospital to get care. Then the officers will transport the person to a treatment facility after a judge signs off on it. The program allows for personal relationships between the mental health officers and people in the community with mental illness to develop, resulting in better outcomes for situations that arise.94
Survey: Early Identification of Defendant Suspected of Having Mental Illness
Article 16.22 of the Texas Code of Criminal Procedure, described in the accompanying flowchart, sets out the requirements regarding early identification of a defendant suspected of having mental illness or mental retardation. It requires the sheriff’s office to notify the judge or magistrate within 72 hours if corrections reasonably believes a jailed suspect has a mental illness, which should happen at intake pursuant to the TCJS administrative rule that requires jails to run a check against the CCQ system to determine whether the detainee has a history of mental illness.95 The flowchart below describes how Article 16.22 functions. Some indication of how this system is working can be found in a 2008 survey of Texas judges that handle criminal cases. The survey received responses from 244 judges. The judges indicated that 36.6 percent of them learned of a defendant’s mental illness as early as the time of magistration, setting of bond, and appointing counsel.96 In about 30 percent of the cases was mental health screening done as early as this point in time.97
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In an effort to provide more up to date information, the Foundation contacted 153 Texas counties on their specific policies and practices regarding these requirements, receiving responses from 98 counties with various intervention, assessment, and diversion programs for those with mental illness. Almost all of the counties that responded reported that they contract with the Local Mental Health Authority (LMHA) to assess and provide treatment recommendations for people with mental illness who are booked into the jail. However, only 77 percent reported using standard screening forms to identify inmates with mental illness, 41 percent reported running names against the CCQ, and 34 percent reported notifying the magistrate or judge of an inmate’s mental health problems.98 Although many counties are using the LMHAs when encountered with inmates with mental health problems, many appear to be lagging behind in their screening process which could result in people falling through the cracks and not receiving proper treatment. By not properly identifying those with mental illness in a timely manner, the use of pretrial services and diversion programs decrease. Many of the counties noted that after booking, a person could be sent to a state hospital for treatment rather than staying in jail. To accomplish this, several counties specified that they will either drop the charges, issue time served, release the inmate on a personal recognizance bond, or get a court order for commitment.
Reliance on the state mental health hospital system is an inadequate response to the problems surrounding people with mental illness in the criminal justice system. As discussed earlier, the state hospitals presently are not capable of handling the large forensic population.99
Editor’s Note: Part 3 of this series will run in our May issue and begin with “Room For Improvement: Analysis and Recommendations.” The full footnotes referenced in the article are available online at http://rightoncrime.com/2015/06/overincarceration-ofpeople-with-mental-illness/.