A Novel Way to Help People in Prisons and Jails with Severe Mental Illness

Q&A with Judge Steven Leifman

Judge, how do we find ourselves in the position we are in today, with an estimated half a million people with mental illnesses in our jails and prisons on an average day? How can this possibly have happened?

I think you have to put this into context. It’s important to recognize that it’s not due to intentional meanness or cruelty. A number of factors were in play, historically.

In 1963, for example, President Kennedy signed a $3 billion bill creating a wonderful national community mental health system. It was his final public bill signing. Tragically, due to the president’s assassination, and then the subsequent escalation of the Vietnam war, not one penny of those funds that were allocated were appropriated for a system designed to be responsive to the needs of people with the most debilitating psychiatric disorders.

Another factor was the introduction of the first antipsychotic medication, chlorpromazine. It had some important benefits but it was by no means a long-term cure for people with psychotic illnesses. In the 1960s, some people thought that this medication alone would enable patients with psychosis to live successfully outside the state hospitals.

In the early 1970s, a brilliant federal judge in Alabama named Frank Johnson wrote a remarkable opinion on a case in which the state was being sued to keep its psychiatric hospitals in operation. Around this same time, exposés were coming out in the press about the horrible conditions that prevailed at state hospitals all over the country.

Judge Johnson wrote an amazing opinion. It basically said that Alabama had the most despicable, grotesque psychiatric hospital in the United States at that time. Judge Johnson ordered Alabama to make 80 specific improvements to its state psychiatric hospital. If it failed to comply, he put the state on notice that he was going to shut down the hospital and release all the residents into the community. My guess is that he expected that this would provide a strong incentive for the state to pony up the money and fix the hospital.

But they failed to fix it?

Actually, that’s not what happened. Alabama started to put up the money and, at one point, probably had the best psychiatric hospital in America, because they were under this tough federal requirement. But—they didn’t complete all of the conditions set out by the Judge, who, as a result, stated his intention to follow through with his original order: the hospital was to be closed. Alabama then appealed to the U.S. Supreme Court.

The Supreme Court for the most part affirmed the Judge’s decision, which noted that if you were in jail, you had a constitutional right to adequate healthcare. They extended that logic to those who were confined in state psychiatric hospitals—they had a right to adequate care, too. The precedent that emerged was that the states had a choice: either provide adequate care to patients in state psychiatric hospitals, or release the patients into the community.

The states could not be forced to take care of the patients.

The rest of the states took one look at this decision—this was a federal opinion so it applied to everyone—and realized that they had a choice. They could spend literally billions of dollars to upgrade their facilities; or they could close down their psychiatric hospitals and try to give the patients community-based treatment.

But as you said, the community mental health law passed under President Kennedy did not end up helping patients with serious psychiatric disorders such as psychosis—people at the time who were mostly confined to state psychiatric hospitals.

Exactly. So patients in the state hospitals ended up going from the state hospital to the street, and, too often, from the street to the jail.

There’s a remarkable irony. In 1955 there were 560,000 people in state psychiatric hospitals in the United States. The equivalent number today—if we had kept those hospitals going and taking population growth into account—is about 1.5 million patients.

That figure is almost the exact number of people that were arrested last year with serious mental illnesses. About 1.5 million people with serious mental illness were arrested last year (in about 2 million separate incidents). But the era of the large state psychiatric hospitals is long past. There are only around 35,000 state psychiatric beds left in this country today.

So “de-institutionalization” has a lot to do with the current crisis.

Yes, but to be accurate, we never de-institutionalized. There was trans-institutionalization. We effectively transferred responsibility from the really horrible state psychiatric hospitals to really horrible jails. And in many ways, in so doing we made things worse for people. When people with serious mental illnesses are incarcerated, they end up with a criminal record. They end up hanging out with real criminals, they can’t get housing, they can’t get employment. So they end up recycling through the criminal justice system throughout their entire adult life—because they’re not getting treated, either.

We’re now using the criminal justice system as we did in the early 1800s, as a place to hold people with serious mental illness, and it’s much worse today than it was in the 1840s. The numbers are just staggering. Right now about 17 percent of the U.S. jail and prison population consists of people with serious mental illnesses—psychosis, schizophrenia, major depression, bipolar disorder. And it’s significantly different between men and women. About 33 percent of all women in jail and prison have serious mental illness, compared with 14 percent of men.

What accounts for the male-female difference?

I think it’s because trauma plays a significant role in mental illnesses, and women are much more often the victims of trauma in our society. One study found that 92 percent of women in jail and prisons with serious mental illnesses were sexually abused as children. Those who were never treated end up with severe PTSD and often turn to prostitution, which is one way they end up in our criminal system. It’s pretty horrible. When they were victims at a young age we didn’t do anything to help or protect them.

You have won much praise for your plan to build what is called a “psychiatric diversion facility” in your jurisdiction of Miami-Dade County, Florida. Can you explain the purpose of this facility and why it is needed?

Rather than send people with serious mental illness who have committed misdemeanors or low-level felony offenses to prison, or even to a psychiatric hospital, the idea is to send them instead to a facility that emphasizes treatment, restoration, and reintegration into the mainstream of society. In recent years, the County has raised $42.1 million through bond issues to support this project, and construction is scheduled to start in January 2019.

As for why we need it: remember, when the existing community mental health system was set up in the 1960s and 1970s, people with the most severe mental illnesses were still in state hospitals. The community mental health system was underfunded, and it wasn’t even set up to handle the most seriously ill. So today the acutely ill are left with no state hospitalization and too often find themselves trapped in the criminal justice system.

What we’re creating in our county is what they actually need, which is a structured environment focused on treatment and recovery rather than kicking them to the curb once we’ve handled their charges in court. We want to gently and slowly reintegrate people with serious mental illnesses back to the community with the services that they need.

The new facility will be a one-stop shop. It will have primary health care. It will have an eye and dental clinic. It will have a court room. It will have a crisis stabilization unit and a short-term residential facility. It will have a day activity program run by people with mental illnesses to teach self-sufficiency. And it will have a supportive culinary employment program so we can teach employment—there are lots of jobs in Miami in the culinary and hotel industries. The facility will have living space for up to a year for those who choose to live there. We are also working with the city of Miami and the Corporation for Supportive Housing on seeing if we can develop some really great supportive, affordable, and low-income housing on land surrounding the facility, so that we have a pathway for people as they leave.

Despite the evidence, some people continue to believe that the people you are trying to help, with serious mental illness, are risky because they tend to be violent.

People with mental illness are no more dangerous than the general population and, sadly, they’re much more likely to be victims of violent crimes than perpetrators. When they are on their medications, they’re much less likely to commit a violent crime than the general population. So it’s really about getting their diagnoses right, getting them on the right medications, working with the individual to develop a treatment plan that they’re comfortable with. It’s about developing really good case management, it’s about having supportive housing so they’re helped along the road, it’s about having supportive employment so that they can do things that they like to do—which helps them stay in recovery.

Some communities in the United States have some of the aspects of our program in Miami, but no single community including Miami has all of the essential elements necessary for a complete system of care. For communities that have developed diversion programs for people with serious mental illnesses, it’s still difficult for people with serious mental illness to navigate the system because it is so fragmented. This is why our new facility is so critical to our success.

Can your vision work in other communities, in other counties and states?

I certainly hope so. I logged about 120,000 miles in 2018 to visit communities that are desperate to do this. The level of enthusiasm and support has been impressive, and I like to think it’s because we’ve turned a corner. I think people are finally starting to understand that these are just illnesses and that you wouldn’t allow your loved one to be treated like this. We’ve got to identify them earlier. We’ve got to treat them better.

So I’m actually cautiously optimistic. We’ve been able to help tens of thousands of people over the last 18 years just by diverting into the existing system, which isn’t all that great. By diverting the most ill, whom we have not been able to help, into a better kind of care, I’m optimistic that this is a program that can be replicated.

My county deserves enormous credit. Our county gets it, because of the results of our program. In 18 years we’ve been able to reduce arrests in Dade County from 118,000, when we started, to 56,000 today. Much of that reflects the impact of our treatment of people with mental illnesses.

You were actually able to close a jail.

That’s true. And that’s saving the taxpayers in Miami-Dade $12 million a year. We had a study conducted by the Florida Mental Health Institute of the University of South Florida. They used court records to identify the defendants with mental illness who made the largest demand on our resources. In a group numbering about 3,300 over a 5-year period, they identified a core group of 97 people who commanded a greatly disproportionate share of our resources. These 97 individuals, mostly men with schizophrenia, were arrested 2,200 times in the 5 years. They spent 27,000 days in our jail, the Dade County Jail; 13,000 days in a psychiatric ER; and they cost taxpayers almost $14 million, and that’s just the psychiatric side; that doesn’t even go into their primary health issues. The people of the county got nothing for it. The outcomes were horrible. That’s why we need a facility like the one I’ve described. It’s for the really acute population that cannot recover in the existing system.

To prevent the seriously ill from recycling through the system, year after year.

That is our intention—to have much better outcomes than we have today and to give people with serious mental illnesses hope for a life in recovery.

Judge Steven Leifman

Associate Administrative Judge, Miami-Dade County Court-Criminal Division, Florida

2018 Pardes Humanitarian Prize | 2012 Productive Lives Award

— Written By Peter Tarr

Click here to read the Brain & Behavior Magazine's March 2019 issue