Are there options to warehousing mentally ill offenders in jail?

Though the topic of the Kerrville conference was on "restorative justice," you can probably tell from my posts on the subject so far that the definition of what issues that entails remains unsettled. Two presentations I heard didn't focus on restorative justice per se, as I understand the concept, but rather on problems managing mentally ill populations in local Texas county jails. However, since that's a keen interest of mine, I was happy to get the opportunity to learn more about what's going on in two major Texas cities: Houston and San Antonio.

Scott Hickey from the Harris County MHMR Authority - one of 31 regional MHMR "community centers" in the state - gave an overview of mental illness by the numbers in the Harris County jail system based on extensive database matching with state and local sources.

Hickey found that 24% of the Harris County jail population (9,000 people at any one time) have been diagnosed with a mental illness and 11% have serious mental illness, defined as schizophrenia, bipolar disorder, and major depression.

The most frequent diagnoses for adults in the Harris Jail are bipolar disorder, conduct disorder, schizophrenia, major depression. "Conduct disorder" in this context is an interesting case (19% of those with an MH diagnosis in jail) because that's largely a designation for kids, not adults. Hickey said this means those people likely were involved with the juvenile justice system as youth before getting into trouble as adults.

People with mental illness, said Hickey, end up spending more time in jail than others with similar charges. A large number are there for minor things, he said, but it's incorrect to assume that's always the case. Those with MH diagnoses in jail are slightly more likely to be charged with felonies than non-MH offenders, he said, though in many cases these are low-level drug felonies instead of more serious crimes.

Hickey's number crunching revealed some shocking data regarding the rate of charges against Harris County residents per 100,000 people. Regular citizens, he said, accumulated 2,565 charges per 100,000 county residents. For people with mental illness, though, that figure skyrocketed to 16,354 per 100,000: A 6-1 ratio.

“We take as evidence that mental illness is being criminalized,” said Hickey. Jails are full of people with mental disorders largely because of lack of indigent mental health care and arrests for drug crimes, said Hickey.

Fewer than 55,000 Americans are treated in psych hospitals, said Hickey, while almost 10 times that many, nearly 500,000 mentally ill people, are serving time in US jails and prisons. He estimated that 6-7% of Americans have a mental disorder severe enough to impair day to day functioning, and said rates for mental illness have been flat over the years.

Less than half mentally ill get treatment, Hickey said, and when they do most have already suffered and delayed treatment for ten years. (That's particularly problematic for patients with schizophrenia, he said, because psychosis releases toxic chemicals that cause more brain damage the longer it goes untreated.)

But it doesn't end there, because those with mental disorders are more likely to stay in the system longer for low-level offenses than their "regular" counterparts - while people with mental illness are six times as likely to be charged with a crime, said Hickey, in Harris County they're 12 times as likely to end up in jail as people without them.

Hickey has performed prelimnary estimates to discover the cost of treating mental illness through the Harris County crimnal justice system.

People with mental illness committed 2,597 felony cases in Harris County in 2004, he said, and 3,505 misdemeanors. Overall, they accounted for 7,933 separate law enforcement events (the number of times police are called to scene). In all, these offenders accounted for 183,016 jail days in Harris County for all diagnoses. The total costs in 2004: $23,746,127 for 4,675 unduplicated persons, at $5,079 per person.

By contrast, people in community cost $2,311 per person for treatment through the community center.

I should mention that these figures are lowballed, for sure - I asked Hickey, for example, if they included expenses related to competency restoration for mentally ill defendants charged with crimes, but he said that was separate. Harris County is the only area in the state where the local MHMR community center provides competency restoration services in the jail instead of sending defendants to a state hospital.

Using local competency restoration services reduced waiting time for those defendants from 60 to 21 days, he said.

Hickey also discussed juvenile mental health issues, declaring that one in five kids in the juvenile justice system in Harris have a serious mental disorder. Rates of mental disorder are higher for girls than boys, he said, especially for affective and anxiety disorders. No parent of a teenager will be surprised to learn that juvenile offenses peaked at age 14 then decline thereafter.

Federal studies say 70% or more of juvies incarcerated are mentally ill, but when Harris County matched mental health records with the juvenile probation roles, they found 24.8% of kids matched. Hickey wondered why the others did not have access to mental healthcare and whether, if they had, it could have changed their criminal ways, and provided data to support the suggestion

Of kids listed in both the mental health and juvenile probation rolls, about 6,500 came in first through mental health system, and more than twice as many, 15,600, came in first through the juvenile justice system.

Hickey found that kids who get earlier MH treatment have fewer criminal referrals and court dispositions. He concluded that kids who get treatment earlier are associated with fewer charges, less serious charges, and less severe offenses over their lifetime. His results suggest there are benefits to entering through the "mental health door" instead of the courts. His findings confirm the value of early treatment and support diversion from the juvie system to the mental health system wherever possible, he said.

* * *

If Dr. Hickey defined the scope of the problem, I was pleased to hear Dr. Gilbert Gonzales from Bexar County describing systems they use to manage such folks, coordinating efforts with 43 different police departments in Bexar to divert mentally ill misdemeanor offenders from the county jail.

Bexar launched their jail diversion center planning when the 78^th Texas Legislature cut $8 million from the budget for treating mentally ill in jail in 2003. This was a big financial hit, he said, so in response the county formulated a series of jail diversion initiatives that became the Crisis Care Center.

Gonzales desribed a "jail diversion continuum" beginning when the officer comes out to the scene to jail intake, pretrial services, probation, parole, and other points in the system. Bexar's goal with the crisis care center was to create a 24-7 facility with a policy of no refusal for psych assessment and minor medical issues. They needed a method that was quick so officers wouldn't prefer to simply dump clients in jail, he said.

Researching the idea, police told them they had disaster on their hands because they had to take every person with the smallest scratch on them, even if they were mentally ill, to emergency rooms for treatment before they could get a psych referral or be taken to jail.

Working with law enforcement, they developed training in new, joint procedures that gave police one place to come for medical clearance and psych screenings. An officer can give the Crisis Care center authority for “emergency detention,” then leave within 15 minutes. Gonzales called the concept "stop and drop." Police loved it, he said, because it solved so many operational issues.

Prior officer wait times for medical clearance in San Antonio exceeded 9 hours, down to 45 minutes. For combination med and psychiatric screenings, the wait went from 12-14 hours to about an hour.

Legislators listen to dollars more than justice arguments, said Gonzales. Estimated savings to the jail in first year was $8 million, and police saved another $620,000.

Many independent entities bear different expenses for mentally ill defendants, but nobody talks so he couldn't estimate a total. Savings accrued to the local hospital, the city, the county, the Department of State Health Services, etc., but each within their own system, so the full amount is not quantifiable. He did show a chart from Bexar's data that clearly indicated when utilization of mental health services goes up, incarceration rates go down.

Gonzales cautioned that in order to work, police officers need to see diversion schemes as active partners. Officers need authority to take a longer period of time at conflict resolution, and giving them that leeway has helped keep quite a few low-level offenders out of the system..

There's also a need on the civil side, he said, for dealing with people who, left unattended, would likely need help later.

* * *

Once I learned more about the definition of restorative justice, I realized that these presentations, however interesting, really didn't fit under that rubric. Neither man spoke of victims of the mentally ill's crimes, and the only "restoration" contemplated by either was of the offenders' mental state. Hickey and Gonzales aren't practicing restorative approaches, they're government bureaucrats trying to manage the system we have, which often doesn't work very well. That's not a beef, just an observation.

However, restorative approaches that focus on "healing" inevitably must focus on healing those who are actually sick, especially when that sickness is a root cause of the crimes they commit. Healing damage to victims may repair past wrongs, but healing these populations contributes to reducing future crime. And as Dr. Hickey's research shows, using healing approaches BEFORE incarceration leads to better outcomes for offenders and victims all around.