1. Reducing the Involvement of Persons With Mental Illness & Co-Occurring Disorders in the Criminal Justice System Through Jail Diversion Programs Henry J. Steadman, Ph.D. Saks Institute Spring Symposium April 11, 2013

2. On June 30, 2005, approximately 7 million people were under correctional supervision in the U.S.  Jail: 747,529  Prison: 1,446,269  Probation: 4,162,536  Parole: 784,408

3. In 2005, there were 13 million bookings into U.S. jails.

4. PRA/CSG Jail Prevalence Study Sites:5 jails (2 – MD; 3 – NY) Time:2002 and 2006 Serious Mental Illness: Depression/Bi-Polar/Schophrenia/ Schizo-Affective/Schizophreniform/ Brief Psychotics/Delusional/Psychosis NOS Prevalence:Last month Prevalence Rates: Men – 14.5% Women – 31% Steadman, H.J., Osher, F., Robbins, P., Case, B., Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services 60, 761-765.

5. Admission to U.S. Jails (2005) 13 million Proportion of Jail Inmates With Severe Mental Disorder Men = 14.5% Women = 31.0% Number of Annual Admissions to U.S. Jails with Severe Mental Disorder 2.1 million

6. Prevalence of Current Substance Abuse Among Jail Detainees with Severe Mental Disorders MalesFemales DisorderAlcohol Abuse/ Dependence Drug Abuse/ Dependence Alcohol Abuse/ Dependence Drug Abuse/ Dependence Schizophrenia59%42%56%60% Major Depression56%26%37%57% Mania33%24%39%64% Any Severe Disorder 58%33%40%60% Detainees with severe mental disorder plus either alcohol or drug abuse/dependence = 72% Adapted from: Abram, K.M. and Teplin, L.A. “Co-Occurring Disorders Among Mentally Ill Jail Detainees: Implications for Public Policy.” American Psychologist, 46(10):1036-1045, 1991 and Teplin, L.A. “Personal Communication.” Policy Research Associates, Inc. 6/17/98

7. CMHS TCE JD: 14 Sites Traumatic Experiences (n=546)

9. “Treatment-Resistant” Clients OR “Client-Resistant” Services

10. COMMUNITY Intercept 1 Law enforcement 911 Law Enforcement Intercept 2 Initial detention / Initial court hearings Initial Detention First Appearance Court Arrest Intercept 3 Jails / Courts Jail Specialty Court Dispositional Court Intercept 4 Reentry Prison / Reentry Jail Re-entry Parole COMMUNITY Intercept 5 Community corrections Probation Violation

11. Diversion = avoiding or radically reducing jail time by using community- based treatment as an alternative.

12. “Diversion” Criminal Justice → Not filing or dropping charges (ATI) Mental Health → Not filing Condition of bail Deferred prosecution (stipulate to police report) Deferred sentencing Condition of probation

13. Diversion Reduce recidivism Reduce violence Reduce jail days Reduce costs Public’s Expectations

14. Diversion Logic Model Identify and Enroll People in Target Group LinkageComprehensive/ Appropriate Community- Based Services Improved Mental Health /Individual Outcomes Improved Public Safety Outcomes Stage 1Stage 2 Diversion Stage 3

15. Mental Health Diversion Options  Pre-Booking – Police-Based  Post-Booking – Court-Based – Jail-Based – Community Corrections-Based

16. Dispositions of Cases Handled by Three Types of Police Response at Three Sites Disposition Birmingham (N=100) Knoxville (N=100) Memphis (N=100) Taken to treatment location204275 Situation resolved on the scene 641723 Referred to treatment3360 Arrested1352

17. Las Vegas CIT Call Resolution*  485 (74%) Hospitalization 344 (71%) Involuntary  25 (18%)Onsite resolution  6 (4%)Arrest * Skeem, J., Bibeau, L. (2008). How does violence potential relate to crisis intervention team responses to emergencies? Psychiatric Services 59, 201-204.

18. COMMUNITY Intercept 1 Law enforcement 911 Law Enforcement Intercept 2 Initial detention / Initial court hearings Initial Detention First Appearance Court Arrest Intercept 3 Jails / Courts Jail Specialty Court Dispositional Court Intercept 4 Reentry Prison / Reentry Jail Re-entry Parole COMMUNITY Intercept 5 Community corrections Probation Violation

19. Rikers Island 2008 Bail Statistics (N=48,000) Council of State Governments March, 2013

20. Rikers Island Average 2008 Length of Stay* (N=48,000) Council of State Governments March, 2013 No Identified Mental Illness – 61 Days Identified Mental Illness – 112 Days * of detainees staying > 3 days

21. COMMUNITY Intercept 1 Law enforcement 911 Law Enforcement Intercept 2 Initial detention / Initial court hearings Initial Detention First Appearance Court Arrest Intercept 3 Jails / Courts Jail Specialty Court Dispositional Court Intercept 4 Reentry Prison / Reentry Jail Re-entry Parole COMMUNITY Intercept 5 Community corrections Probation Violation

22. Nathaniel Project (NYC) N=53 Prior YearCurrent Year Number of Arrests 1017 Misd.355 Felonies662

23. SAMHSA KDA (N=1,185) DivertedNon-Diverted Community days303245 # Arrests1.031.20 Arrests/mo..11.15

24. CMHS TCE JD: 14 Sites Changes in Arrests and Jail Days

25. Annualized Number of Arrests – 3 MHCs Pre 18 Months Post 18 Months % Reduction MHCMean (N) 2.2 (436) 1.4 (436) 37% TAU Mean (N) 2.6 (597) 2.0 (586) 23%

26. Total Incarceration Days Pre and Post 18 Months – 3 MHCs MHCNEWPre 18 Months Post 18 Months % Increase MHCMean (N) 75 (436) 84 (436) 12% TAU Mean (N) 75 (597) 152 (597) 101%

27. Diversion Logic Model Identify and Enroll People in Target Group LinkageComprehensive/ Appropriate Community- Based Services Improved Mental Health /Individual Outcomes Improved Public Safety Outcomes Stage 1Stage 2 Diversion Stage 3

28. Drug & Alcohol Use Number Cases Reporting Use Percent of Cases Reporting Use Mean Number of Days of Use Median Number of Days of Use Any alcohol - Last 30 Days Baseline57659.1%13.18 6 Months16928.4%5.83 12 Months10530.1%6.63 Alcohol to Intoxication - Last 30 Days Baseline37238.2%12.98 6 Months7612.8%5.22 12 Months4512.9%7.34 Illegal drugs - Last 30 Days Baseline56858.3%17.820 6 Months10117.0%9.55 12 Months5515.7%10.05

29. Daily Living/Role Functioning Scale N Mean Score (Range: 0 to 4) 1 Mean Difference From Baseline 2 Baseline9772.01-- 6 Months5941.31-0.70 12 Months3491.17-0.84 1 – Where 0 = No Difficulty and 4 = Extreme Difficulty 2 – Calculations based on those individuals having both interviews completed

30. Colorado Symptom Index (CSI) N Mean Score (Range: 0 to 60) 1 Mean Difference From Baseline 2 Baseline96831.5-- 6 Months59022.3-9.2 12 Months34621.4-10.1 1 – Where 0 = Low Symptoms/High Well-Being and 60 = High Symptom/Low Well-Being 2 – Calculations based on those individuals having both interviews completed

31. Year-by-Year CJ Cost

32. Year-by-Year Tx Cost

33. Year-by-Year Total Cost

34. Is Criminalization An Important Public Policy Concept? Macro View  Transinstitutionalization  % Detainees with MI Different Micro View  Individual more likely in jail than in community- based treatment

35.  Reduce Involvement  Minimize Inappropriate Penetration More Useful Concepts