Treatment in Lieu of Jail: Diversion Succeeds

By Arnold Mann

Letty Trinidad, a mother of three, is one of the success stories from San Antonio's jail diversion program in Bexar County, TX.

When San Antonio police took 36-year-old Letty Trinidad to jail last year, it was the culmination of a series of incarcerations and suicide attempts fueled by drug and alcohol dependency and major depression that had plagued the mother of three since her teens.

This time, however, staff from the jail diversion program at the San Antonio Center for Health Care Services (CHCS) intervened on her behalf and arranged for her admission to a drug and alcohol rehabilitation center.

Today, Ms. Trinidad attends support group meetings at CHCS. She also takes classes and volunteers at the San Antonio chapter of the National Alliance for the Mentally Ill, learning how to help others with mental illnesses and substance abuse. She is living on her own, with her three children. And she found a job. "I know I can do this," said Ms. Trinidad. "I just feel good about myself."

Ms. Trinidad's success story is one of many in Bexar (pronounced "bear") County, TX. San Antonio is 1 of 20 community sites nationwide currently funded by SAMHSA's Targeted Capacity Expansion (TCE) grants for Jail Diversion Programs. "Bexar County initiated its program to help people with severe mental illness get out of county jails, off the streets, into treatment programs, and back to meaningful, productive lives," said Leon Evans, Executive Director of the CHCS jail diversion program.

Leon Evans (l), Executive Director of Bexar County's jail diversion program, and Neal Brown (r), Chief of the Community Support Programs Branch at SAMHSA's Center for Mental Health Services.

Similar success stories are unfolding in other communities assisted by SAMHSA's TCE grants.

SAMHSA's Center for Mental Health Services (CMHS) has awarded these TCE grants since 2002. Participating communities receive up to $300,000 annually for up to 3 years and contribute at least $100,000 per year from local resources toward the implementation of the project.

In addition, CMHS funds a national Technical Assistance and Policy Analysis (TAPA) Center for Jail Diversion, which assists grantees in planning, establishing, and evaluating their programs and provides technical assistance and resources to other communities interested in developing similar programs.

"The jail diversion program really is a transformational effort," said Neal Brown, M.P.A., Chief of the Community Support Program Branch at CMHS. "What communities such as San Antonio are doing is getting people with mental illness and co-occurring substance abuse disorders out of the criminal justice system and into community treatment programs, giving them opportunities to stay out of jail."

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An Ongoing Problem

"Some of our jails are our largest mental hospitals," said Linda A. Teplin, Ph.D., a public health researcher and expert on mental health and criminal justice issues. She is the Owen L. Coon Professor of Psychiatry and Behavioral Sciences at the Feinberg School of Medicine at Northwestern University. Dr. Teplin has studied the interface between the mental health and criminal justice systems for the past 29 years.

According to the Bureau of Justice Statistics, at mid-year 2004, 713,990 inmates were held in local jails across the Nation, up from 691,301 at mid-year 2003—an increase of 3.3 percent. "Our best guess," Dr. Teplin added, "is that as many as 90,000 of those individuals may have a severe mental disorder." And of those 90,000, many have co-occurring substance abuse disorders as well.

According to the President's New Freedom Commission on Mental Health, the problem is inescapable in nearly every urban community. Ironically, the majority of these individuals have committed only minor offenses such as disturbing the peace. Typically poor and uninsured, these individuals often are homeless and have co-occurring substance abuse and mental disorders. They cycle in and out of shelters, hospitals, and jails, occasionally receiving mental health and substance abuse treatment services, but most likely receiving no treatment at all.

Cost studies suggest that communities (and taxpayers) can save on costs by supporting proven jail diversion programs as an alternative to incarceration.

In Bexar County, according to a December 2004 policy analysis report, an estimated 14 percent of the county's jail population has severe mental illness, and 75 percent have co-occurring substance abuse problems. Many of San Antonio's large homeless population—some 25,000 to 30,000 people—have a mental illness. The Texas CHCS, the county's mental health authority, is spearheading the turnaround for Bexar County in close collaboration with city, county, and state law enforcement authorities in addition to judicial and health care entities.

To be effective, most jail diversion programs coordinate a comprehensive set of services at the community level. The cooperation of all involved agencies helps integrate mental health care and substance abuse treatment, physical health care, and social services, such as housing, food, and clothing.

Programs work to bridge the barriers between the mental health and criminal justice systems and help identify detainees who need mental health treatment and meet the jail diversion criteria. This is done through the initial screenings and evaluations at the crisis triage center, arraignment court, or jail.

Bexar County's diversion program relies on three phases of intervention. The first phase uses Deputy Mobile Outreach Teams and Crisis Intervention Teams to divert offenders with mental illness before they are arrested or booked in the county jail. During the second phase, the program identifies persons with mental illness within the system and makes recommendations for alternatives to incarceration, such as mental health bonds or release to treatment facilities. The third phase focuses on providing appropriate services upon their release from jail or prison.

Deputy Mobile Outreach Teams, composed of county deputies and mental health clinicians, are available for onsite mental health assessments and interventions 24 hours a day, 7 days a week. Their mission is to screen high-risk individuals with mental illness and refer or transport them to the CHCS Crisis Center for further evaluation.

Crisis Intervention Teams are staffed by police officers trained to work with persons with mental illness. Their goal is to respond and to resolve conflict so that individuals with mental illness can be safely transported to the Crisis Center or, if necessary, the jail.

CHCS representatives also make home visits, helping people order their lives through cognitive adaptive training (CAT). CAT involves strategic placement of objects and lists of things they need to do, to keep them on track and taking their medications. "Jail diversion is also about identifying people who need additional supports and helping them maintain their good mental health and reintegrating them into the community," said Mr. Evans.

Paul Eisenhauer gives a presentation at San Antonio's Center for Health Care Services.

The CAT program also employs recovering people with schizophrenia to help gain the trust and participation of persons with mental disorders. Paul Eisenhauer, a 45-year-old man who suffers from the disorder, is doing well. He hasn't heard voices for more than a decade. Early diversion efforts helped him get out of jail and into a state hospital conducting clinical trials of a new antipsychotic medication. Today, he teaches police officers (who used to arrest him) about schizophrenia. "They really want to know what it's like to be schizophrenic," said Mr. Eisenhauer. "One officer came up to me and said, 'A lot of people are scared of schizophrenics,' and I said, 'A lot of people are scared of cops.' "

So how is the San Antonio program doing? Interim results show a significant number of jail diversions and potential savings in criminal justice costs. County officials are optimistic that added costs for mental health care will diminish as the long-term benefits of the program take hold.

"We're creating 'steps up' for people in jail into residential facilities, and we're getting them involved in active treatment and employment skills and starting them looking for housing," said Mr. Evans. And Texas is currently making plans to apply the Bexar County jail diversion model throughout the state.

"What's very impressive about the San Antonio program is the way they brought all these services together—the small providers, the big providers, the county judges, the university, primary health care, and the state legislature," said Mr. Brown. "They are transforming the way mental health services are delivered. And this is exactly what we had in mind with this program—to help bring about this kind of transformation and to change the public's view of people struggling to overcome co-occurring mental illnesses and substance abuse."

SAMHSA will announce the 2005 Jail Diversion Program awards in September. For information about the program, call the TAPA Center at 1 (866) 588-TAPA (8272) or visit the SAMHSA Web site at www.samhsa.gov. 

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