Decriminalizing Mental Illness — The Miami Model

U.S. correctional institutions, local courts, and police officers frequently encounter people with untreated or undertreated serious mental illnesses, often coupled with substance-use disorders. These encounters usually stem from the alleged commission of a misdemeanor — trespassing, panhandling, petty theft — or a minor, nonviolent felony. Each year, about 11.4 million people are booked into local U.S. jails, where on any given day, 745,000 of them are held. An estimated 16.9% of jail detainees have a serious mental illness,which means that nearly 2 million people with such illnesses are arrested each year.

Florida’s Miami-Dade County faces a particular challenge because, among large U.S. communities, it has the highest percentage of residents with serious mentalillnesses, but Florida ranks 48th nationally in state funding for community mental health services. According to county judge Steven Leifman, approximately 9.1% of the county’s population (192,000 adults and 50,000 children) — two to three times the national average — has serious mental illness, but only about 1% receives services in the public mental health system.

Moreover, roughly one third of the county’s under-65 population lacks health care coverage. In general, indigent people receive treatment only when they’re in extreme crisis and present an imminent risk of harm to themselves or others, or when they enter the criminal justice system. Many communities have developed strategies to redirect people with mental illnesses away from the criminal justice system. Though these approaches reduce inappropriate arrests and incarcerations, their effect on communities’ public health and safety is often limited because they reside primarily within the legal system. What sets Miami-Dade County apart is its 15-year effort to develop a comprehensive, coordinated response to what’s recognized as a shared community problem requiring a shared community solution. This effort leverages diverse expertise and resources to divert people with mental illnesses from the criminal justice system to community-based mental health services, aiming to improve community outcomes.

In addition to grappling with inadequate funding, the local mental health system is hampered by fragmented service delivery and poor coordination, which make it difficult to navigate. Some additional funding has been secured from governmental and private sources, but the initiative’s success is largely attributable to an effort to structure patterns of service delivery and deploy existing resources in ways that are better aligned with the needs of people coming out of the justice system. These efforts have helped to reduce the size of the county’s jailed population and the number of police officers injured in the line of duty and to improve public safety.

Over the past decade, the CMHP has facilitated about 4000 diversions of defendants with mental illness from the county jail into community-based treatment and support services.

Now, Miami-Dade plans to open a facility that it says “will expand the capacity to divert individuals from the county jail into a seamless continuum of comprehensive, community-based treatment programs that leverage local, state and federal resources.” Miami-Dade’s initiative was launched in 2000, when Judge Leifman, frustrated by the fact that people with mental disorders were cycling through his court repeatedly, created the Eleventh Judicial Circuit Criminal Mental Health Project (CMHP).

As Leifman explained, “When I became a judge . . . I had no idea I would become the gatekeeper to the largest psychiatric facility in the State of Florida. . . . Of the roughly 100,000 bookings into the [county] jail every year, nearly 20,000 involve people with serious mental illnesses requiring intensive psychiatric treatment while incarcerated. . . . Because community-based delivery systems are often fragmented, difficult to navigate, and slow to respond to critical needs, many individuals with the most severe and disabling forms of mental illnesses . . . fall through the cracks and land in the criminal justice or state hospital systems” that emphasize crisis resolution rather than “promoting ongoing stable recovery and community integration.”

The CMHP includes pre-booking and post-booking jail-diversion programs. The pre-booking part follows the Crisis Intervention Team model, in which mentally ill people who may otherwise be arrested for minor offenses are diverted to crisis units to receive treatment. Law-enforcement officers undergo 40 hours of training in recognizing signs of mental illness in distressed persons and deescalating potentially violent situations. Some 4600 officers serving in Miami-Dade’s 36 municipalities and in county public schools have been trained. In 5 years, officers from the two largest police departments have responded to about 50,000 mental health crisis calls that resulted in 9000 diversions to crisis units and only 109 arrests.

The average daily census in the county jail system has dropped from 7200 to 4000, one jail facility has been closed, and fatal shootings and injuries of mentally ill people by police officers have been dramatically reduced. Participation in treatment for persons diverted pre-booking is based on the state’s civil commitment laws and the person’s desire to receive treatment. If someone appears to meet criteria for civil commitment, the treatment provider may petition the court for authorization for involuntary outpatient or inpatient placement. More often, however, diverted people do not meet these criteria and are simply provided referrals and linkages for follow-up care.

The post-booking program involves identifying people in acute psychiatric distress who’ve been booked into the county jail. After screening them for eligibility, judges can approve defendants’ transfer from jail to a crisis unit, where they receive treatment while the court monitors their progress and case managers employed by the courts and the South Florida Behavioral Health Network work with communitybased service providers to arrange ongoing treatment and housing. All participants are assessed for criminogenic risk factors and treatment needs using evidencebased tools. Once participants return to the community, case managers continue to monitor them and their treatment providers for 1 year. Participants who are eligible to apply for federal entitlement benefits are assisted in preparing and submitting applications.

People referred to the postbooking diversion program who appear to meet criteria for examination under Florida’s civil commitment laws may initially enter treatment on an involuntary basis. Once stabilized, they are asked for consent to continue participation; 80% of them agree because participation may mean more favorable disposition of their legal cases, and it provides access to resources and supports that may otherwise be out of reach. The cases of those who refuse treatment or participation follow the normal criminal justice process.

Initially, the CMHP served only people charged with misdemeanors. In 2008, the postbooking program was expanded to include defendants arrested for less serious, nonviolent felonies, who are screened by the state attorney’s office before enrollment to ensure that they have no significant history of violence and are unlikely to threaten public safety. Over the past decade, the CMHP has facilitated about 4000 diversions of defendants with mental illness from the county jail into community-based treatment and support services.

The annual recidivism rate has been about 20% among participants who committed a misdemeanor, as compared with roughly 75% among defendants not in the program. Participants charged with minor felonies have 75% fewer jail bookings and jail days after enrollment in the program than they had beforehand, and their recidivism rate is much lower than that of their counterparts outside the program. Like most mental health programs, the CMHP relies on multiple sources of support, and no program is more important than Medicaid.

Unfortunately, Florida is one of 19 states that have declined to expand their Medicaid programs under the Affordable Care Act, leaving some 3 million adults with incomes at or below 138% of the federal poverty level without insurance coverage. About 567,000 Floridians fall into this coverage gap and remain uninsured. “Expanding Medicaid would have had a profound impact on keeping people with a serious mental illness out of both the criminal justice system and the acute mental health system,” Leifman told me. Although Florida provides little funding for community mental health services, it “spends exorbitantly to house people with mental illnesses in criminal-justice settings.” Miami-Dade County stakeholders actively support the initiative’s replication in other communities.

In 2015, the Council of State Governments Justice Center, the National Association of Counties, and the American Psychiatric Association Foundation launched “Stepping Up: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails.” Miami-Dade, chosen as one of four launch sites, has been helping with planning and development. More than 240 counties in 41 states have passed resolutions to advance the goal of reducing the prevalence of people with mental illnesses in their jails, and representatives of 50 jurisdictions in 37 states recently attended a Stepping Up Summit meant to help them achieve that aim.