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Improved Mental Health Through Mindfulness-Based Programs

Judson Brewer,
M.D., Ph.D.
The Honorable
Steven Leifman
Patricia (Tish)
Jennings, M.Ed., Ph.D

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Eleventh Judicial Circuit Criminal Mental Health Project

BY JUDGE STEVEN LEIFMAN

PROBLEM STATEMENT: According to the most recent prevalence estimates, 16.9% of all jail detainees (14.5% of men and 31.0% of women) experience serious mental illnesses. Nationwide, it is estimated that 1.8 million people with serious mental illnesses are booked into jails annually; and on any given day, 500,000 people with mental illnesses are incarcerated in jails and prisons. Considering that as of 2016 there were only about 20,000 beds in civil state psychiatric hospitals, this means there are 25 times as many people with mental illnesses in correctional facilities as there are in all civil state treatment facilities combined.

Although these national statistics are alarming, the problem is even more acute in Miami-Dade County which is home to the largest percentage of people with SMI of any urban community in the Unites States. Roughly 9.1% of the population in Miami-Dade County (175,000 adults) experiences SMI, yet only 1% of the population (24,000 adults) receives treatment in the public mental health system. As a result, police officers have increasingly become the first, and often only, responders to people in crisis due to untreated mental illnesses. Too often, these encounters result in the arrest and incarceration of individuals for criminal offenses that are directly related to individuals’ psychiatric symptoms or life-health contexts (e.g., homelessness, addiction, poverty).

The Miami-Dade County jail currently serves as the largest psychiatric institution in Florida and contains nearly half as many beds serving inmates with mental illnesses as all state civil and forensic mental health hospitals combined. Of the roughly 55,000 bookings into the jail last year, approximately 11,000 involved people with mental illnesses requiring intensive psychiatric treatment while incarcerated. On any given day, the jail houses approximately 2,400 individuals receiving psychotherapeutic medications, and costs taxpayers roughly $180 million annually or $500,000 per day. Additional costs to the county, the state, and taxpayers result from crime and associated threats to public safety; civil actions brought against the county and state resulting from injuries or deaths involving people with mental illnesses; injuries to law enforcement and correctional officers; ballooning court caseloads involving defendants with mental illnesses; and uncompensated emergency room and medical care.

On average, people with mental illnesses remain incarcerated 4-8 times longer than people without mental illnesses arrested for the exact same charge, at a cost 7 times higher. With little treatment available, many individuals cycle through the system for the majority of their adult lives.

Eleventh Judicial Circuit Criminal Mental Health Project

The Eleventh Judicial Circuit Criminal Mental Health Project (CMHP) was established to divert nonviolent misdemeanant defendants with SMI, or co-occurring SMI and substance use disorders, from the criminal justice system into community-based treatment and support services. Since the inception, the program has expanded to serve defendants that have been arrested for less serious felonies and other charges as determined appropriate. The program operates two components: pre-booking diversion consisting of Crisis Intervention Team (CIT) training for law enforcement officers and post-booking diversion serving individuals booked into the jail and awaiting adjudication. All participants are provided with individualized transition planning including linkages to community-based treatment and support services.

The CMHP’s success and effectiveness depends on the commitment of stakeholders throughout the community. Such cross-system collaboration is essential for the transition from the criminal justice system to the community mental health system. Program operations rely on collaboration among community stakeholders including: the State Attorney’s Office, the Public Defender’s Office, the Miami-Dade County Department of Corrections and Rehabilitation, the Florida Department of Children and Families, the Social Security Administration, public and private community mental health providers, Jackson Memorial Hospital-Public Health Trust, law enforcement agencies, family members, and mental health consumers.

Pre-Booking Jail Diversion Program

CIT PROGRAM: The 11th Judicial Circuit Criminal Mental Health Project (CMHP) has embraced and promoted the Crisis Intervention Team (CIT) training model developed in Memphis, Tennessee in the late 1980’s.  Known as the Memphis Model, the purpose of CIT training is to set a standard of excellence for law enforcement officers with respect to treatment of individuals with mental illnesses.  CIT officers perform regular duty assignment as patrol officers, but are also trained to respond to calls involving mental health crises. Officers receive 40 hours of specialized training in psychiatric diagnoses, suicide intervention, substance abuse issues, behavioral de-escalation techniques, trauma, the role of the family in the care of a person with mental illness, mental health and substance abuse laws, and local resources for those in crisis.

The training is designed to educate and prepare officers to recognize the signs and symptoms of mental illnesses, and to respond more effectively and appropriately to individuals in crisis. Because police officers are often first responders to mental health emergencies, it is essential that they know how mental illnesses can impact the behaviors and perceptions of individuals. CIT officers are skilled at de-escalating crises involving people with mental illnesses, while bringing an element of understanding and compassion to these difficult situations. When appropriate, individuals in crisis are assisted in accessing treatment facilities in lieu of being arrested and taken to jail.

OUTCOMES: To date, the CMHP has provided CIT training to more than 6,500 law enforcement officers from all 36 local municipalities in Miami-Dade County, as well as Miami-Dade Public Schools and the Department of Corrections and Rehabilitation. Countywide, CIT officers are estimated to respond to 16,000-19,000 mental health crisis calls per year. Last year alone, CIT officers from the Miami-Dade Police Department and City of Miami Police Department responded to more than 11,000 calls, resulting in nearly 1,700 diversions to crisis units and just 19 arrests. Since 2010, these two agencies have responded to nearly 72,000 mental health crisis calls resulting in 38,000 diversions to crisis units and 138 arrests.

City of Miami and Miami-Dade Police Departments Annual CIT Calls

Miami-Dade PD +
Miami PD
2010 2011 2012 2013 2014 2015 2016 2017 Total Rate per
1,000 calls
CIT Calls  7,779  9,399  10,404  10,626  11,042  10,579  11,799  11,799  83,427
Arrests Made 4 45 27   9 24 10 19            11        149 1.8
Diverted from Jail  1,940  3,563 2,118 1,215 1,871 1,633 1,694  1,860  15,894  190.5
Transported to Crisis  3,307  4,642 5,527 3,946 5,155 7,417 8,303 8,818  47,115 564.7
Use of Force 29 75 72 59 79 69 58 67 513 6.1
Officer Injuries 11 21 26 12      16           86 1.0
Consumer Injuries 127 262 211 203 276     1,079 12.9

FISCAL IMPACT: As a result of CIT, the average daily census in the county jail system has dropped from 7,200 to 4,400 inmates (39% reduction), and the county has closed one entire jail facility at a cost-savings to taxpayers of $12 million per year. Across all law enforcement agencies in the county, it is estimated that CIT results in approximately 3,757 fewer jail bookings of people with serious mental illnesses annually. With an average length of stay of 29.2 days per booking at a cost of $156 per bed/day, this reduction in jail admissions results in 109,704 fewer inmate jail days (300 years) annually and a cost avoidance of over $17 million per year.

Post-Booking Jail Diversion Program

The CMHP was originally established in 2000 to divert nonviolent misdemeanant defendants with SMI and possible co-occurring substance use disorders, from the criminal justice system into community-based treatment and support services. In 2008, the program was expanded to serve defendants that have been arrested for less serious felonies and other charges as determined appropriate. Post-booking jail diversion programs operated by the CMHP serve approximately 600 individuals with serious mental illnesses annually. Over the past decade, these programs have facilitated roughly 4,000 diversions of defendants with mental illnesses from the county jail into community-based treatment and support services. In order to determine the appropriate level of treatment, support services and community supervision, the CMHP screens each program participant in regards to Mental Health, Substance Use and Criminogenic Risks and Needs. A two page summary is developed that is used to develop an individualized transition plan aimed at reducing criminal justice recidivism and improved psychiatric outcomes, recovery and community integration. The evidence-based screening tools include:

    • The Texas Christian University Drug Screen V (TCUDS V)
    • Ohio Risk Assessment: Community Supervision Tool (ORAS-CST)

MISDEMEANOR JAIL DIVERSION PROGRAM: All defendants booked into the jail are screened for signs and symptoms of mental illnesses by correctional officers.  Individuals charged with misdemeanors who meet involuntary examination criteria are transferred from the jail to a community-based crisis stabilization unit as soon as possible. Upon stabilization, legal charges may be dismissed or modified in accordance with treatment engagement.  Individuals who agree to services are assisted with linkages to a comprehensive array of community-based treatment, support, and housing services that are essential for successful community re-entry and recovery outcomes.  Program participants are monitored by CMHP for up to one year following community re-entry to ensure ongoing linkage to necessary supports and services.  The vast majority of participants (75-80%) in the misdemeanor diversion program is homeless at the time of arrest and tends to be among the most severely psychiatrically impaired individuals served by the CMHP.

OUTCOMES: The misdemeanor diversion program receives approximately 300 referrals annually. Recidivism rates among program participants has decreased from roughly 75 percent to 20 percent annually.

FELONY JAIL DIVERSION PROGRAM: Participants in the felony jail diversion program are referred to the CMHP through a number of sources including the Public Defender’s Office, the State Attorney’s Office, private attorneys, judges, corrections health services, and family members.  All participants must meet diagnostic and legal criteria[1]. At the time a person is accepted into the felony jail diversion program, the state attorney’s office informs the court of the plea the defendant will be offered contingent upon successful program completion.  Similar to the misdemeanor program, legal charges may be dismissed or modified based on treatment engagement.  All program participants are assisted in accessing community based services and supports, and their progress is monitored and reported back to the court by CMHP staff.

OUTCOMES: Individuals participating in the felony jail diversion program demonstrate reductions in jail bookings and jail days of more than 75 percent, with those who successfully complete the program demonstrating a recidivism rate of just 6 percent. Since 2008, the felony jail program alone is estimated to have saved the county over 15,000 jail days, more than 35 years.

Forensic Hospital Diversion Program

MIAMI-DADE FORENSIC ALTERNATIVE CENTER (MD-FAC) PROGRAM: Since August 2009, the CMHP has overseen the implementation of a state funded pilot project to demonstrate the feasibility of establishing a program to divert individuals with mental illnesses committed to the Florida Department of Children and Families from placement in state forensic hospitals to placement in community-based treatment and forensic services.  Participants include individuals charged with 2nd and 3rd degree felonies that do not have significant histories of violent felony offenses and are not likely to face incarceration if convicted of their alleged offenses. Participants are adjudicated incompetent to proceed to trial or not guilty by reason of insanity. The community-based treatment provider operating services for the pilot project is responsible for providing a full array of residential treatment and community re-entry services including crisis stabilization, competency restoration, development of community living skills, assistance with community re-entry, and community monitoring to ensure ongoing treatment following discharge. The treatment provider also assists individuals in accessing entitlement benefits and other means of economic self-sufficiency to ensure ongoing and timely access to services and supports after re-entering the community. Unlike individuals admitted to state hospitals, individuals served by MD-FAC are not returned to jail upon restoration of competency, thereby decreasing burdens on the jail and eliminating the possibility that a person may decompensate while in jail and require readmission to a state hospital. To date, the pilot project has demonstrated more cost effective delivery of forensic mental health services, reduced burdens on the county jail in terms of housing and transporting defendants with forensic mental health needs, and more effective community re-entry and monitoring of individuals who, historically, have been at high risk for recidivism to the justice system and other acute care settings.

OUTCOMES: Individuals admitted to the MD-FAC program are identified as ready for discharge from forensic commitment an average of 52 days (35%) sooner than individuals who complete competency restoration services in forensic treatment facilities, and spend an average of 31 fewer days (18%) under forensic commitment. The average cost to provide services in the MD-FAC program is roughly 32% less expensive than services provided in state forensic treatment facilities.

Access to Entitlement Benefits

SOAR ENTITLEMENT UNIT PROGRAM: Stakeholders in the criminal justice and behavioral health communities consistently identify lack of access to public entitlement benefits such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and Medicaid as among the most significant and persistent barriers to successful community re-integration and recovery for individuals who experience serious mental illnesses and co-occurring substance use disorders. The majority of individuals served by the CMHP are not receiving any entitlement benefits at the time of program entry. As a result, many do not have the necessary resources to access adequate housing, treatment, or support services in the community.

In order to address this barrier and maximize limited resources, the CMHP developed an innovative plan to improve the ability to transition individuals from the criminal justice system to the community. Toward this goal, all participants in the program who are eligible to apply for Social Security benefits are provided with assistance utilizing a best practice model referred to as SOAR (SSI/SSDI, Outreach, Access and Recovery). This is an approach that was developed as a federal technical assistance initiative to expedite access to social security entitlement benefits for individuals with mental illnesses who are homeless. Access to entitlement benefits is an essential element in successful recovery and community reintegration for many justice system involved individuals with serious mental illnesses. The immediate gains of obtaining SSI and/or SSDI for these people are clear: it provides a steady income and health care coverage which enables individuals to access basic needs including housing, food, medical care, and psychiatric treatment. This significantly reduces recidivism to the criminal justice system, prevents homelessness, and is an essential element in the process of recovery.

OUTCOMES: The CMHP has developed a strong collaborative relationship with the Social Security Administration in order to expedite and ensure approvals for entitlement benefits in the shortest time frame possible. All CMHP participants are screened for eligibility for federal entitlement benefits, with staff initiating applications as early as possible utilizing the SOAR model. Current program data demonstrates that 78% of the individuals are approved on the initial application. By contrast, the national average across all disability groups for approval on initial application is 27%. In addition, the average time to approval for CMHP participants is approximately 40 days. This is a remarkable achievement compared to the ordinary approval process which typically takes between 9-12 months.

Florida Criminal Justice, Mental Health, and Substance Abuse Reinvestment Grant 2017

JAIL IN-REACH TEAM: Miami-Dade County on behalf of the Eleventh Judicial Circuit Criminal Mental Health Project (CMHP) was awarded the 2016 Florida Criminal Justice, Mental Health, and Substance Abuse Reinvestment Grant for $1.2 million dollars for three years. The project represents a collaborative effort among community partners that seek to improve the assessment, referral, diversion, and care coordination among individuals with serious mental illness (SMI) and possible co-occurring substance use disorders that are reentering the community from the criminal justice system. The project aims to reduce the cycle of arrests and incarceration for people who need behavioral health treatment and community support that will promote recovery and community integration.

The target population includes adults with SMI who are frequent recidivists to the justice and acute care treatment systems. All project participants will be assessed using validated, evidence-based risk and need assessment tools (TCUDS V, and ORAS-CST). Those identified to be at moderate to high risk of future recidivism to the justice and/or acute care treatment systems, and who are eligible for CMHP services, will receive enhanced transition and reentry supports, as well as linkages to and monitoring of evidence-based treatment and support services in the community.

OUTCOMES: Anticipated outcomes include increased public safety, decreased demand for services in the criminal justice and acute care treatment systems, and improved access to community-based treatment and recovery support services. It is hypothesized that more efficient identification, transition planning, diversion, and service linkages will result in improved access to treatment and support services in the community, which in turn will result in improved mental health, criminal justice, and public safety outcomes.

Recovery Peer Specialists

Recovery Peer Specialists are individuals diagnosed with mental illnesses who work as members of the jail diversion team. Due to their life experience they are uniquely qualified to perform the functions of the position. The primary function of the Recovery Peer Specialists is to assist jail diversion program participants with community re-entry and engagement in continuing treatment and services. This is accomplished by working with participants, caregivers, family members, and other sources of support to minimize barriers to treatment engagement, and to model and facilitate the development of adaptive coping skills and behaviors.  Recovery Peer Specialists also serve as consultants and faculty to the CMHP’s Crisis Intervention Team (CIT) training program.

Mental Health Diversion Facility

Since 2006 the courts have been working with stakeholders from Miami-Dade County on a capital improvement project to develop a first of its kind mental health diversion and treatment facility which 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. This project, which is funded under the Building Better Communities General Obligation Bond Program, was established to build on the successful work of the CMHP with the goal of creating an effective and cost efficient alternative treatment setting to which individuals awaiting trial may be diverted.

The diversion facility will be housed in a former state forensic hospital which has been leased to Miami-Dade County and is in the process of being renovated to include programs operated by community based treatment and social services providers. Services offered will include crisis stabilization, short-term residential treatment, day treatment and day activities programs, intensive case management, outpatient behavioral health and primary care treatment services, and vocational rehabilitation/supportive employment services. The proposed plan for the facility includes space for the courts and for social service agencies such housing providers, legal services, and immigration services that will address the comprehensive needs of individuals served.

The vision for the mental health diversion facility and expansion of the CMHP’s diversion programs is to create a centralized, coordinated, and seamless continuum of care for individuals who are diverted from the criminal justice system either pre-booking or post-booking.  By housing a comprehensive array of services and supports in one location, it is anticipated that many of the barriers and obstacles to navigating traditional community mental health and social services will be removed, and individuals who are currently recycling through the criminal justice system will be more likely to engage treatment and recovery services. Creation of this facility will also allow for the movement of individuals currently spending extended amounts of time in the county jail into residential treatment programs and supervised outpatient services supported by more sustainable funding sources. It is anticipated that the facility will begin operations in 2020.

Conclusion

The CMHP has demonstrated substantial gains in the effort to reverse the criminalization of people with mental illnesses. The idea was not to create new services but to merge and blend existing services in a way that was more efficient and continuous across the system. The Project works by eliminating gaps in services and by forging productive and innovative relationships among all stakeholders who have an interest in the welfare and safety of one of our community’s most vulnerable populations.

The CMHP provides an effective and cost-efficient solution to a community problem. Program results demonstrate that individualized transition planning to access necessary community based treatment and services upon release from jail will ensure successful community re-entry and recovery for individuals with mental illnesses, and possible co-occurring substance use disorders that are involved in the criminal justice system.


[1] Legal criteria specify a current most serious charge of a third degree felony, with not more than three prior felony convictions.