Jail Diversion: Reduced costs by spending more on mental health

PART 1

WESTBOROUGH, MA July 6, 2017 Jail diversion is a hot topic across the country. The numbers of persons incarcerated for minor offenses and drug crimes has grown. Many of these individuals have mental illness or drug abuse in addition to their criminality. The interaction between poly-substance abuse or dependence and exacerbation of underlying mental health symptoms is complex. It is the focus of mental health advocates and criminal justice experts nationwide as it pertains to jail diversion and reduced use of force among law enforcement.  In Massachusetts, there is a move away from mandatory minimum sentences for all drug crimes except for those involving the distribution of narcotics. Arguably, the impact on behavioral functioning when persons are gripped with co-occurring illness is a recurrent problem for law enforcement and first responders. I have written about the impact of co-occurring illness such as alcoholism on mental and behavioral health is previously published posts here on Word press Human Behavior (Sefton, 2017). It is difficult to uncover which comes first – the addiction or the diagnosed mental illness and yet they are inextricably linked in terms of the strain on public resources and health risk to those so afflicted. Why is this important?

The importance of treatment for substance dependence and mental illness cannot be understated as violent encounters between law enforcement and the mentally ill have been regularly sensationalized. The general public is looking for greater public safety while at the same time MH advocates insist that with the proper treatment violent police encounters may be reduced and jail diversion may be achieved. The referral infrastructure to provide a continuum of care in this growing population is available in very few places across America.

Models of Care

Yet in places like Bexar County, Texas the county jail population has dropped by over 20 percent as a result of crisis intervention training for police officers and mobile mental health teams to intervene with those in crisis. I have seen this for myself during a visit with the San Antonio Police Department where I rode with two members of the Mental Health Unit – Officers Ernest Stevens and Joseph Smarro. It takes training, medical and psychiatric infrastructure, community compassion, and active engagement with members of the community often left to fly under the radar to effectively reduce the jail population. When necessary those most in need must have 24-hour availability for detoxification, emergency mental health, and access to basic needs such as food, clothing, and medicine. In San Antonio they offer so much more including pre-employment training, extended housing, interview preparation including clothes, and opportunity for jobs.

Behavioral Analysis and Law Enforcement

The unpredictability of behavior in those who carry a “dual” diagnosis has emerged in the criminal justice system when jail diversion programs and treatment options are brought forth raising the specter of frustration over the limitations within the system. Cities everywhere are grappling with how best to intervene with the mentally ill in terms of alternative restitution for drug-related misdemeanor crimes in lieu of mandatory jail sentences that many crimes currently require. Some believe, as much as 20-40 percent of all incarcerated persons suffer with mental health diagnoses and are not getting the treatment they require. To provide a bare bones system would add billions to state and federal dollars spent on the needs of inmates at a time when measurable outcomes for in house care are limited.

In my practice I see many cases of co-occurring pain syndromes with other physical debility such as stroke or traumatic brain injury. Generally the emotional impact of two or more diagnosed illnesses yields a greatly reduced capacity for adaptive coping and puts a great stress on the individual system. The importance of addressing co-occurring substance abuse or dependence is now well recognized and with treatment can result in healthy decision-making, growth in maturity, and greater self-awareness. If legislators have a serious desire to reduce statewide numbers of incarcerated persons a comprehensive plan must be considered for both pre-arrest and post-arrest. Infrastructure for enhanced understanding of addiction and greater treatment options must be explored through a joint public and private initiative.

PROPOSED JAIL DIVERSION INITIATIVE

PRE-ARREST JAIL DIVERSION – No crime committed

If police encounter subjects with a known history of mental illness through their community policing efforts they should return the subject to his family or primary psychiatric caregiver – this might be a physician, physician’s assistant (PA), a nurse practitioner (NP), even a psychologist for immediate crisis intervention. Depending upon the nature of the police encounter such as during the nighttime hours the subject may be transported to a local emergency department for psychiatric evaluation. This model has grown less popular because of the growing wait times in local hospital emergency departments – especially for those suspected of mental illness and tends to make them increasingly agitated. Persons with mental illness are often homeless and come into police contact simply on the basis of panhandling or looking suspicious and out of place in the neighborhood. Often they are reported to police because they are talking to themselves, suspicious, and menacing toward pedestrians making them afraid.

The hospital alternative might be to establish regional psychiatric emergency intake centers available 24-hours daily. At one point states had regional hospitals that have been closed down releasing thousands of institutionalized patients into the community. The plan for de-institutionalization was to provide a neighborhood center at which the patient could continue his or her treatment and receive their needed medication to keep them symptom free.

Minor crime committed

When a crime is committed by someone with known or suspected mental illness such as simple assault, disorderly conduct, or shoplifting the responding police officer’s will have discretion whether to bring forth charges or not in exchange for an alternative disposition that would defer jail time. These are not new concepts. Law enforcement has always had the discretion to arrest or not arrest for many minor offenses. The choice often comes down to the subject demeanor and his response to police officer directives at the time of the encounter. In some cases an officer must arrest such as in the setting of domestic violence, child abuse, or as a result of a felony being committed.

In these cases charges may be brought and held as long as the subject entered treatment or remained abstinent from use of drugs or alcohol – the jail diversion plan. If they failed to follow the terms of their diversion plan the charges would be re-instated and sent to district attorney for prosecution.  The alternative is a revolving door of addiction and petty crime that, at times, will escalate into violent crime. As a society more can be done to reduce criminality and jail diversion through empathic, sensitive treatment options.

Police as therapist: the inherent risk of unconditional positive regard 

WESTBOROUGH, MA January 12, 2017 Changes in the responsibility for those afflicted with major mental illness must remain in the hands of medical and psychiatric providers who are trained in contemporary diagnosis and treatment models. Yet a growing mental health strategy has emerged to train and educate first responders – including the police to deescalate and divert those with mental illness from jails into treatment.  The problem with diversion here in Massachusetts and New England is that a continuum of care is lacking. Since the closure of the state hospital system here in Massachusetts the community-based treatment centers have been overwhelmed by the volume of cases they must see.  To say they have failed is shortsighted and disingenuous and behalf of the Globe Spotlight team.

Make no mistake about it, putting police officers in the place of psychotherapists and psychiatrists is not going to happen here or anywhere. But cops are being asked to act as mediators to diffuse encounters with persons with suspected mental illness. The intention is to reduce violent encounters between the police and those with mental health issues. “Most people with mental illness are not dangerous, and most dangerous people are not mentally ill” according to Liza Gold, 2013. Yet in the past several years there have been many high profile officer-involved shootings involving people afflicted with a variety of psychiatric conditions including major depression raising the specter of suicide by cop.

POLICE ACT AS CRISIS MEDIATORS WITH MENTALLY ILL

It is very risky putting the police in the role of crisis intervention specialists to manage those who may be emotionally distraught. For one thing the high incidence of drug and alcohol intoxication in these cases makes any negotiation or mediation almost impossible. I was always taught that until the patient is sober there is no meaningful assessment or interaction is possible.  Police are the front line responders to crises of all kinds. Asking them to serve in this new role presents a level of officer specialization like never before.  Some officers are being asked to offer unconditional positive regard to those encounters in an effort to slow the scene giving time for intervention to take hold.  In some places like San Antonio, TX and Vancouver, BC it works.  But it has taken a long time to gain traction. If the goal is to avoid incarcerating those with mental illness this is especially difficulty in the absence of a treatment continuum as I have said.  In the cities just mentioned there is a well established mental health infrastructure that affords the police various options for the unstable citizens they are asked to assist.

In most larger communities a dearth of mental health services exist resulting in a large number of mentally ill persons being held in custody – sometimes a county house of correction or any one of

Dr. Michael Sefton brought out myths of mental illness while serving as a police officer retiring in 2015

16 prisons in the Commonwealth of  Massachusetts. The Spotlight team at the Boston Globe has featured the plight of those who are sent to prison with comorbid mental illness and substance abuse. The fact is that criminality and mental health are often difficult to disentangle.

The National Alliance for the Mentally Ill believe as many as 20 to 40 percent of prison inmates may have severe mental illness and may not be receiving the needed treatment to allow them to rehabilitate.  Yet in the absence of the mental health infrastructure needed to provide treatment – including hospital care for those most unstable, few viable options were put forth.

The Boston Globe fails to inform readers that criminality and mental illness are not mutually exclusive.  Drug addicts break into homes to feed the hunger of their addiction.  In prototypic fashion, the Globe offers no alternative and no solution aside from casting blame on the Commonwealth of Massachusetts. Without a doubt the stories they report are heart wrenching and emotionally palpable for the readers. But not all those in custody who are suspected of preexisting mental illness are helplessly suffering without therapy.  Most are not.  In many cases being incarcerated allows an addict to become clean and sober and begin the first steps of recovery. Those who are most resistant to therapy and fail to attend psychotherapy, anger management, and medication monitoring have a higher risk of violence and substance abuse. This fact must be considered when responsibility for treatment failure is studied.  

Those relationships that suppress the normal, effusive, life force are detrimental to health much like a toxin said Sefton in 2013.

ALTERNATIVE SENTENCING

With so many incarcerated persons with suspected mental illness change must be initiated  by having services available to those on the front lines.  The criminal justice system and the department of mental health have an opportunity to work together now that the pendulum once again swings toward a treatment model. The police can be trained to control the scene through intervention and mediation strategies by slowing things down. When charges are brought alternative sentencing models may offer leverage that include mandated treatment in lieu of jail time.  Studies show that those who remain in treatment are less violent than those who fail or drop out of treatment, Torrey, et.al., 2008.

Mental health patient often rely on community services and social welfare including housing, disability payments, medical care and more.  Access to these services may be tied to participation in treatment including psychotherapy, medication, if prescribed, and substance abuse treatment.  Here is Massachusetts M.H. Advocates reject this notion as unfair a response that remains unique across the country.

The interaction of substance abuse and mental illness is complex.  Persons with drug and alcohol addiction must be expected to become sober with the help of substance abuse treatment and family support. The risk of violence and suicide declines when sobriety can be maintained.  The 12-step programs have great success and are free to anyone willing to attend. Family members may attend Al-Anon or some drug-specific family support group.

Mental health infrastructure is necessary for the system to work.  In San Antonio it has taken 15 years to establish a system that works and saves lives.


Torrey, CF et. al. The MacArthur violence risk assessment study revisited: Two views ten years after its initial publication. Psychiatric Services, vol. 59, issue 2, February 2008, pp. 147-152.

Probationary lapse: Massachusetts officer killed by career criminal

Some arm chair psychologists are critical of probation officers in central Massachusetts following the shooting death of a police officer.  Critics believe that Jorge Zambrano should have been in jail rather that be free to take his murderous intentions to the street.  He had at least three arrests that were said to have resulted in resistance and ultimately violence toward police officers.  This information must have been provided to Officer Tarentino at the time of the traffic stop.  Whenever an operator is checked either on the mobile data computer in the police cruiser or by a police dispatcher flags come up indicating that the operator has a history of violence.  This is a necessary officer safety protocol. 

Unfortunately, that same level of safety awareness is not provided to judges when they are making decisions about bail or no bail holds for the like of Jorge Zambrano and thousands of other career criminals who are in and out of court like a revolving door. It is up to the office of probation and parole to provide this essential information on “dangerousness” to judges as they review charges and consider bail in the cases being brought before them each day.  Otherwise, decisions about bail cannot be made with any accuracy leaving law enforcement and the general public at great risk from those who are dangerous. We have seen this disconnect over bail among domestic violence assailants and the family members they terrorize.  Sometimes serious aggression toward a spouse including strangulation and forced sexual contact are ignored or minimized when this violence occurs within the scope of a “relationship” and yet information about violent tendencies must be provided to potential victims whenever a threat exists.  

“There are points when pre-incident indicators scream for containment of violators.  Relationship behavior should be considered – especially when relationship violence is apparent in case after case”.  Michael Sefton, 2015

Bail decisions rarely include the incidence of violent behavior – especially that which occurs toward law enforcement otherwise Officer Tarentino may be alive today.  In an article in the Boston Globe detailing the criminal history of the killer of Auburn, Massachusetts Police Officer Tarentino. Zambrano was a career criminal from what was described in several background articles. I was especially sickened by the remarks of Mr. Scola the attorney for Zambrano.  Scola verbalized his surprise that Mr. Zambrano could do something so violent toward a police officer. I am puzzled by that remark and wonder if Scola has actually passed the bar examination because anyone could see that Zambrano was on the fast track toward a violent explosion of hate.

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“He was a high risk for violence and recidivism,” said DOC spokesman Christopher M. Fallon. 

Former Boston police commissioner Edward Davis, now a private security consultant, said Monday night that judges have to consider a defendant’s “propensity for violence” at sentencing according to a Boston Globe article written in the aftermath of the killing of Ronald Tarentino, Jr..  “There are some people who are not amenable to counseling,” said Davis, whose security clients include The Boston Globe. “When you see a repeat record of violent activity, then you have to get really tough with a person like that and get them off the street.”

“There’s nothing more dangerous than that space, that moment, when a guy who is facing charges that can send him back to jail sits there behind death’s door, sizing up both his chances and the cop drawing nearer in the sideview mirror.”  Kevin Cullen Boston Globe   (5-24-16)