Miami's Model for Decriminalizing Mental Illness in America
America’s jails are filled with people suffering from severe psychological problems. But largely thanks to one judge, Miami found ways to keep the mentally ill out of incarceration and in treatment.
Justin Volpe grew up as part of a small New Jersey community that believed the world was about to end. Its leader, Justin’s grandfather, suffered from the delusion that he was a reincarnation of the Prophet Jeremiah and would soon become one of the rulers of the world to come. But after Justin’s older brother complained about abuse within the group, his family was expelled and Justin went into public school for the first time.
The trauma Justin experienced as a result of the event went unaddressed. In his freshman year in high school, after the loss of his best friend, he started drinking and experimenting with drugs -- marijuana, nitrous oxide, ecstasy, cocaine, LSD. When Justin’s brother arose the morning after Justin’s 19th birthday party and found his brother and friends still up doing drugs, he persuaded Justin to make a fresh start by moving to Miami to live near him.
The year was 2003. Justin ended up working in and around Miami Beach. It was a surreal place -- a place where it was easier to find drugs than a stable job. Eventually, one of Justin’s employers introduced him to crystal meth. “Two hits of that and my life changed forever,” he says.
The combination of crystal meth and Justin’s unaddressed trauma proved to be a toxic pairing. Memories of his grandfather’s teachings began to run obsessively through his mind. Gradually paranoia set in: CIA agents were looking through his trash; container ships were flashing messages to him. He stopped buying food, stopped showering. Eventually, Justin became convinced, like his grandfather, that Armageddon was coming and that he too was a prophet. He stopped sleeping. Instead, he walked the streets aimlessly.
Finally, in April 2007, Justin experienced something that befalls up to 40 percent of people with serious mental illnesses: He was arrested on petty theft charges. In Miami, that meant a trip to the Pre-Trial Detention Center. Justin was identified as someone with a form of schizophrenia and was sent to the psychiatric ward on the ninth floor.
Justin was locked in a cell with a schizophrenic who had stabbed his wife with a pair of scissors. At first Justin couldn’t sleep. Then he was put on suicide watch. An officer came by every 15 minutes, 24 hours a day to tap on the window. Justin had to show his face in response. Now he couldn’t sleep even though he wanted to. One day, a person in the cell next door flipped a corrections officer the bird. “They pulled him out and beat him so bad, it haunts me to this day,” says Justin.
His hellish experiences in the detention center were not unique. In the early 2000s, some 113,000 people were arrested in Miami-Dade County every year. An estimated 20 percent suffered from a mental illness. As a result, at any given moment in time, some 1,700 individuals with mental illnesses were in the county lockup. Until recently, they were housed on the upper floors of the Y-shaped, 10-story detention center, making it the largest psychiatric facility in Florida.
The fact that Florida’s largest mental health facility was -- and is -- a county jail isn’t unusual. The Twin Towers Correctional Facility in Los Angeles is California’s largest psychiatric facility; Chicago’s Cook County Jail is Illinois’. Both incarcerate about 3,000 mentally ill occupants at any given time. State prisons house large numbers of people with mental illnesses too. Indeed, prisons today contain more than 10 times the number of people with mental illnesses than all state psychiatric hospitals combined.
[click_to_tweet]Prisons have 10+ times the number of people with mental illnesses than all state psychiatric hospitals combined.[/click_to_tweet]
That’s partly the result of decisions taken by governors and lawmakers during the most recent recession. Between 2009 and 2012, states cut funding for the mentally ill by slashing spending on so-called behavioral health services by some $4.35 billion, even as demand for those services was rising. Not surprisingly, the number of people with mental illnesses in jails surged. According to the Council of State Governments, jails in this country now report that between 20 and 80 percent of their inmates suffer from a mental illness.
Miami-Dade County has long had a more acute problem than most. By one estimate, more than 9 percent of Miami residents suffer from a mental illness -- a rate that is approximately three times higher than the national average. It also has a large homeless population, most of whom have mental health issues and substance abuse problems. Yet over the course of the past decade, Miami-Dade County has emerged as a national model for how a county can develop strategies to combat the criminalization of mental illness.
Every locality, of course, has behavioral health programs. Some have outstanding programs. But what makes Miami different, says Dan Abreu of Policy Research Associates, a think tank focused on behavioral and mental health issues, is that “they are really moving toward having a continuum of services.” In short, the county is trying to build a comprehensive system. That’s due largely to the efforts of one person, Judge Steve Leifman.
Since joining the bench in 1996, Leifman has pushed police to adopt a pre-arrest diversion program that keeps thousands of people picked up by police agencies across the county out of jail. He’s created a model postbooking diversion program that offers people charged with misdemeanors and second- and third-degree felonies an opportunity to get out of jail and go into treatment. Leifman has also developed a network of case managers and peer specialists to support people with mental illnesses who enter the postbooking diversion program, and worked with researchers, corporations and pharmaceutical companies to develop innovative ways to identify and address the needs of the neediest members of this population.
In addition, he’s been one of the leaders of an effort that has brought the legislature to the brink of passing the first major overhaul of the laws governing treatment of the mentally ill in 41 years, while also convincing the state and county to sign over a 180,000-square-foot facility to serve as a comprehensive treatment center. (View photos of it here.)
Conditions in metro Miami certainly aren’t perfect. For one thing, the U.S. Justice Department continues to monitor the Pre-Trial Detention Center closely. Yet Miami-Dade County’s experience also suggests something hopeful: When local government thinks in terms of systems rather than programs, dramatic improvements can result -- even with a problem as difficult as dealing with people with mental illnesses who encounter the criminal justice system.
Judge Steve Leifman has led the effort to overhaul Miami-Dade County's approach to criminal offenders with mental health issues.
Leifman is one of about 120 judges serving the 2 million people in Florida’s 11th Judicial Circuit, the nation’s fourth largest circuit court. He has been working actively on mental health issues since 2000. But his first exposure to the problems posed by the way government handled people with mental illnesses came much earlier -- in 1973, when he was interning in Tallahassee for a state senator.
“I had grown up in a very nice, sheltered, middle-class family” -- in north Miami Beach -- “and had never seen anything bad in my life,” he says. That changed when the editor of the Miami Herald contacted the state senator in whose office Leifman was working. The newspaper had received a letter from one of its readers claiming that her son was being held inappropriately at the South Florida State Hospital in Broward County. Leifman’s boss asked him to check it out.
When Leifman arrived at the hospital, the staff showed him to the patient’s room. There Leifman found the young man tied to the bed; both his arms and his legs were in restraints. He was enormously overweight: Hospital staff had been injecting him with Thorazine, an antipsychotic medication that caused weight gain. Thorazine had been hailed as a wonder drug when it was released in the U.S. in 1953, and for good reason. Among other things, it significantly reduced psychosis. But the bloated young man strapped to the bed before Leifman was not psychotic. He was autistic.
Leifman was deeply shaken. As he was preparing to go back and brief his employer, an advocate showed up and offered to give him a tour of the hospital. He led Leifman down the hallways. The light grew dimmer, the temperature colder. Eventually they got to a metal cage. The door was open. A guard was hosing feces off several naked men. “It was one of those experiences that you never forget,” says Leifman. “The only thing I could think of while I was standing there was, ‘We treat animals better in the zoo.’”
[click_to_tweet]“We treat animals better in the zoo [than people in mental health facilities].”[/click_to_tweet]
The state senator Leifman worked for was able to arrange for the autistic man’s release. Across the nation, however, scenes like the ones Leifman had witnessed were leading to sweeping changes in the ways state governments handled people with mental illnesses. States were shutting psychiatric hospitals down, as well as other facilities that housed and treated the mentally ill. This process is often called “deinstitutionalization.” The term, however, is misleading. What was really happening was more akin to a transfer -- out of hospitals and into jails. In the mid-1950s, more than 500,000 people were held in state psychiatric hospitals. By the 1980s, that number had fallen to around 70,000. During this period, the number of people with mental illnesses who were arrested and ended up in local jails surged.
Today fewer than 40,000 people with mental illnesses are in state or civil psychiatric hospitals or facilities. Yet last year, 1.5 million people with serious mental illnesses were arrested in about 2 million incidents. Instead of being committed to state psychiatric hospitals, they are sent to jail. Instead of being offered treatment, they are turned into criminals.
By the early 1990s, when he was an assistant public defender in Miami, Leifman was seeing this process every day at work. He and his colleagues had to represent clients who had been arrested, mainly for misdemeanor charges that stemmed from their mental illnesses. Some of these people had once been in the very hospital that Leifman toured as an intern.
In 1994, when Leifman became acting chief of the county court division, he decided to call attention to the problem. He sent out letters inviting the state attorney (who serves the same function as a traditional district attorney for Miami-Dade County), the chief judge and several area police chiefs to a meeting to discuss the issue. Not one replied, and when the day of the event arrived, not a single person came. “I showed up,” Leifman recalls, “and there was nobody there.”
Two years later, in 1996, Leifman was appointed to the bench as a county court judge. Four years after that, he presided over a case that involved parents attempting to require their son -- who suffered from schizophrenia and who was also a Harvard-educated psychiatrist -- to get help. His frustrations with the case inspired him to dig into the problems posed by the intersection of mental illness with the criminal justice system.
At a national conference in Miami, Leifman met Hank Steadman, the co-founder and president of Policy Research Associates. Steadman had federal funding, and after hearing Leifman describe his hopes to tackle this problem in Miami-Dade County, he offered him a grant. Leifman reprinted his old letter on judicial letterhead and sent out another invitation to local stakeholders. This time, people came.
Leifman and his partners decided to use their grant money to engage in what is called “sequential intercept mapping” -- basically, documenting existing services and gaps in programming. The first opportunity they identified was a postbooking diversion program. With one staff person from the county and another staffer from Jackson Memorial Hospital, Leifman launched what he called the Criminal Mental Health Project (CMHP). Initially, it targeted people with serious mental illnesses who had been arrested for misdemeanor offenses, such as trespassing, loitering, petty theft and other quality-of-life charges. These were defendants who typically spent months locked in the Pre-Trial Detention Center awaiting hearings -- four to eight times longer on average than people without mental illnesses.
The postbooking diversion program offered an alternative. To start, people who had been arrested for misdemeanor offenses and identified as having acute mental illnesses would be transported from jail to an offsite crisis stabilization unit, typically within 48 hours of their arrest. After defendants began to receive treatment and regained some clarity, one of the CMHP staff members would visit and offer a choice: If they opted to receive treatment, the program would help them find housing and see that treatment continued. The court would agree to hold open their case, meaning that as long as they complied with the program they would stay out of jail. State attorney Katherine Fernandez Rundle and public defender Carlos Martinez also agreed to cooperate. Rundle encouraged her prosecutors to downgrade or dismiss charges for misdemeanants who completed the program.
If, on the other hand, defendants chose to reject the opportunity to participate in the diversion program, they would return to jail and, if competent, stand trial.
Not surprisingly, seeking treatment proved to be a popular choice. About 80 percent of people offered the chance to participate in the program accepted it. What was surprising was how many people stayed out of the system afterward. An evaluation conducted soon after the program began found that recidivism rates one year out among participants who complete the program was just 20 percent. In contrast, 72 percent of peers who did not participate in the program were back in jail within one year of their release.
The next -- and greater -- challenge was to avoid arresting the mentally ill in the first place. That meant changing the way Miami-Dade’s 36 police departments interacted with people with mental illnesses. Some 175,000 adults in Miami-Dade County have a serious mental illness. Yet only 24,000 of them are receiving treatment in the public mental health system at a given time. As a result, police across the county encounter people with serious mental illnesses on a daily basis. These encounters have often gone poorly. Between 1999 and 2005, police in Miami-Dade County shot and killed 19 people with mental illnesses.
Leifman believed that metro area police could reduce arrests, deaths and injuries by adopting the Crisis Intervention Team (CIT) program developed in Memphis, Tenn., in the late 1980s. The program taught officers how to distinguish between different types of mental illnesses and respond accordingly. It introduced officers to families struggling with mental illnesses and to providers in the community who could offer help.
It’s a model that seems to work. Police departments that adopted it generally saw meaningful reductions in the use of force and in officer injuries. But getting buy-in was difficult. In the CMHP’s first three years of existence, its staff managed to train only about 60 officers a year.
Thanks to better training, Miami’s two biggest police departments have greatly reduced arrests of the mentally ill.
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In 2003, Leifman’s program got a grant from the federal government that allowed it to hire a program director and a handful of additional staffers. Gradually more police departments adopted CIT training. But the single largest police department in the area -- the Miami-Dade police -- continued to resist. Leifman urged the department’s director, Carlos Alvarez (the equivalent of a sheriff in other parts of the country), to sign on. Alvarez told Leifman he’d look into the matter but denied that his part of the county had a problem with mental health arrests.
But Leifman knew that Miami-Dade police were probably dealing with thousands of calls. The two men’s disagreement eventually went public, prompting stories in the local press. In 2004, Alvarez ran for mayor and won. Just months after Alvarez’s election, the county grand jury released a report on the criminalization of mental illness, along with a comprehensive set of recommended reforms.
To Leifman’s surprise, Alvarez embraced all the recommendations and asked Leifman to co-chair a group charged with overseeing implementation of the reforms. “Those recommendations,” Leifman says, “have been the blueprint for everything that has happened since.”
Every police department in the county now offers its officers CIT training. Some 4,500 officers in all have gone through the training. In 2013, the most recent year for which data is available, Miami and Miami-Dade County police responded to 10,626 mental health calls. Prior to CIT, these responses would have resulted in hundreds if not thousands of arrests. But that year those departments made only nine arrests in response. Instead of booking mentally ill offenders into jail, police officers took these people to crisis stabilization centers. The reduction in arrests was so significant that last year the county was able to close one of its five jail facilities.
The CMHP has also assigned four employees to help people going through the postbooking diversion program to obtain Social Security benefits. In effect, says Program Director Cindy Schwartz, this has turned people who were once seen as “these criminals with mental health problems into attractive, paying customers.” The program’s first client was none other than Justin Volpe.
After 46 days in the Pre-Trial Detention Center, Justin was offered the opportunity to leave as long as he agreed to enter the postbooking diversion program. From Justin’s perspective, this was an easy decision. He immediately signed on and was sent to Jackson Memorial Hospital. There he got treatment and got back on medications for his illnesses. Eventually he was placed in an assisted living facility in Opa-Locka. Its costs were covered by the monthly Social Security disability check that Schwartz’s office had secured for him.
But it turned out Justin wasn’t ready to get clean. Within two months, he was living in Liberty City with a woman and her four kids, smoking crack. Eventually, the woman’s boyfriend came home and kicked him out. As Justin began the 10-mile walk back to his assisted living facility in Opa-Locka, he had a realization. “By the time I got home,” says Justin, “I felt physically and emotionally sick. I had had enough.” When his caseworker called, Justin said he wanted to go back to Jackson Memorial. He promised that this time he would comply with the treatment protocols. And he did.
Schwartz realized that Justin needed something else to sustain his recovery -- a job. In November 2007, Schwartz offered Justin a position as a peer specialist. In that role, he would help other postbooking diversion participants discharge from hospitals and jails, help them line up doctors’ appointments and keep track of medications, find housing, make it to drug and alcohol support meetings, and so forth. Justin was shocked -- and doubtful. “You want me to be a county employee?” he asked after receiving the job offer. “But I have a criminal record. I’m also paranoid and delusional.”
“You’ll fit right in,” he was told.
Today, Justin and five other peer specialists spend their days working with people with mental illnesses in the postbooking diversion program. It’s a tough job. Justin doesn’t have a car so he and his clients take the bus to their doctor appointments. He visits his clients frequently, offering them advice and encouragement.
On a late afternoon outing in May, Justin stopped by River Villas, a shabby, eight-unit apartment building in Miami’s Little Havana neighborhood, to check on three clients. Several men sat in chairs outside. One of them was Justin’s client, Kwame, who suffered from schizophrenia, acute paranoia and substance abuse issues. About a year ago, he’d been picked up on a panhandling charge, entered the postbooking diversion program and, after a period of intensive treatment, been transferred to River Villas. He’d been living there for a year.
Justin asked him about a medical appointment he’d missed the previous Thursday. He said he’d help him reschedule and gave him a bus pass so he could get to the appointment. Kwame didn’t have much to say, but considering his acute paranoia (“the most paranoid person I’ve ever met,” says Justin), the fact that he’d shared any details of his life at all was a heartening sign that he was taking his medications. As shabby as his current circumstances were, they were undeniably better than the Pre-Trial Detention Center would have been.
After greeting a few other men in the building, several of whom were CMHP clients, Justin set out for his last visit of the day. Clark, a man with a serious case of bipolar disorder, had also been picked up by police and ended up on the detention center’s ninth floor. Thanks to the diversion program, however, he’d gotten out and made it to a tidy house across the Miami River from the government center. Justin or another CMHP employee stopped by two or three times a week to check on Clark. They frequently went to Alcoholics Anonymous meetings together. After talking briefly about an upcoming meeting, Clark returned to a small room he shared with another man. “He has about three months to go,” says Justin. “Then he will go to independent-type housing” -- most likely an apartment paid for with his disability check.
A program participant named Clark will soon transfer from a group home to independent living.
As for Justin, it was time for him to go home too -- to a house he and his wife had purchased a year ago, and to his 4-year-old son. His success illustrates something important, says Leifman. Namely, this population can be helped. Mental illnesses, he notes, are treated successfully at the same rate as diabetes. With treatment, even acute chronic cases can be ameliorated.
Leifman ticks off the statistics that back up his assessments of his program’s success: The county has reduced recidivism among participants in the misdemeanor diversion program from 72 percent to less than 20 percent. And the felony diversion program -- the one that Justin was part of -- is maintaining a recidivism rate of only 6 percent for those that successfully complete it, which most do. That program alone has saved Miami-Dade County around 35 to 40 years of jail time.
Already, Leifman is focused on the next next steps. Earlier this year, both houses of the legislature passed bills (shaped by Leifman and other advocates) that would have overhauled Florida’s mental health laws. But before the two versions could be reconciled, the House unexpectedly ended its session -- to avoid legislation that would have expanded access to Medicaid. Leifman is hopeful the legislature will get it done during its next session.
Leifman’s program has also acquired an old seven-story forensic jail that’s been closed since 2007. Workers have begun converting it into a model mental health facility. (View photos of it here.) The plans call for a triage area, a central receiving room, a crisis unit for people who need treatment immediately and a short-term residential program. Leifman wants there to be a courtroom where judges can do bond hearings so that people who get arrested on misdemeanors can get out and get treatment. He would also like the facility to include a primary health unit and possibly a dental clinic. The funding for many of these programs has yet to be identified, but Leifman is confident that it will come.
“Treatment works; recovery is real,” he says. When the 180,000-square-foot building is converted, it will be a central piece in a comprehensive system. It will, Leifman says, “be the first of its kind in the country, a true diversion facility with all the essential elements.”