Jail Diversion: Reduced costs by spending more on mental health


WESTBOROUGH, MA July 6, 2017 Jail diversion is a hot topic across the country. The numbers of persons incarcerated for minor offenses and drug crimes has grown. Many of these individuals have mental illness or drug abuse in addition to their criminality. The interaction between poly-substance abuse or dependence and exacerbation of underlying mental health symptoms is complex. It is the focus of mental health advocates and criminal justice experts nationwide as it pertains to jail diversion and reduced use of force among law enforcement.  In Massachusetts, there is a move away from mandatory minimum sentences for all drug crimes except for those involving the distribution of narcotics. Arguably, the impact on behavioral functioning when persons are gripped with co-occurring illness is a recurrent problem for law enforcement and first responders. I have written about the impact of co-occurring illness such as alcoholism on mental and behavioral health is previously published posts here on Word press Human Behavior (Sefton, 2017). It is difficult to uncover which comes first – the addiction or the diagnosed mental illness and yet they are inextricably linked in terms of the strain on public resources and health risk to those so afflicted. Why is this important?

The importance of treatment for substance dependence and mental illness cannot be understated as violent encounters between law enforcement and the mentally ill have been regularly sensationalized. The general public is looking for greater public safety while at the same time MH advocates insist that with the proper treatment violent police encounters may be reduced and jail diversion may be achieved. The referral infrastructure to provide a continuum of care in this growing population is available in very few places across America.

Models of Care

Yet in places like Bexar County, Texas the county jail population has dropped by over 20 percent as a result of crisis intervention training for police officers and mobile mental health teams to intervene with those in crisis. I have seen this for myself during a visit with the San Antonio Police Department where I rode with two members of the Mental Health Unit – Officers Ernest Stevens and Joseph Smarro. It takes training, medical and psychiatric infrastructure, community compassion, and active engagement with members of the community often left to fly under the radar to effectively reduce the jail population. When necessary those most in need must have 24-hour availability for detoxification, emergency mental health, and access to basic needs such as food, clothing, and medicine. In San Antonio they offer so much more including pre-employment training, extended housing, interview preparation including clothes, and opportunity for jobs.

Behavioral Analysis and Law Enforcement

The unpredictability of behavior in those who carry a “dual” diagnosis has emerged in the criminal justice system when jail diversion programs and treatment options are brought forth raising the specter of frustration over the limitations within the system. Cities everywhere are grappling with how best to intervene with the mentally ill in terms of alternative restitution for drug-related misdemeanor crimes in lieu of mandatory jail sentences that many crimes currently require. Some believe, as much as 20-40 percent of all incarcerated persons suffer with mental health diagnoses and are not getting the treatment they require. To provide a bare bones system would add billions to state and federal dollars spent on the needs of inmates at a time when measurable outcomes for in house care are limited.

In my practice I see many cases of co-occurring pain syndromes with other physical debility such as stroke or traumatic brain injury. Generally the emotional impact of two or more diagnosed illnesses yields a greatly reduced capacity for adaptive coping and puts a great stress on the individual system. The importance of addressing co-occurring substance abuse or dependence is now well recognized and with treatment can result in healthy decision-making, growth in maturity, and greater self-awareness. If legislators have a serious desire to reduce statewide numbers of incarcerated persons a comprehensive plan must be considered for both pre-arrest and post-arrest. Infrastructure for enhanced understanding of addiction and greater treatment options must be explored through a joint public and private initiative.


PRE-ARREST JAIL DIVERSION – No crime committed

If police encounter subjects with a known history of mental illness through their community policing efforts they should return the subject to his family or primary psychiatric caregiver – this might be a physician, physician’s assistant (PA), a nurse practitioner (NP), even a psychologist for immediate crisis intervention. Depending upon the nature of the police encounter such as during the nighttime hours the subject may be transported to a local emergency department for psychiatric evaluation. This model has grown less popular because of the growing wait times in local hospital emergency departments – especially for those suspected of mental illness and tends to make them increasingly agitated. Persons with mental illness are often homeless and come into police contact simply on the basis of panhandling or looking suspicious and out of place in the neighborhood. Often they are reported to police because they are talking to themselves, suspicious, and menacing toward pedestrians making them afraid.

The hospital alternative might be to establish regional psychiatric emergency intake centers available 24-hours daily. At one point states had regional hospitals that have been closed down releasing thousands of institutionalized patients into the community. The plan for de-institutionalization was to provide a neighborhood center at which the patient could continue his or her treatment and receive their needed medication to keep them symptom free.

Minor crime committed

When a crime is committed by someone with known or suspected mental illness such as simple assault, disorderly conduct, or shoplifting the responding police officer’s will have discretion whether to bring forth charges or not in exchange for an alternative disposition that would defer jail time. These are not new concepts. Law enforcement has always had the discretion to arrest or not arrest for many minor offenses. The choice often comes down to the subject demeanor and his response to police officer directives at the time of the encounter. In some cases an officer must arrest such as in the setting of domestic violence, child abuse, or as a result of a felony being committed.

In these cases charges may be brought and held as long as the subject entered treatment or remained abstinent from use of drugs or alcohol – the jail diversion plan. If they failed to follow the terms of their diversion plan the charges would be re-instated and sent to district attorney for prosecution.  The alternative is a revolving door of addiction and petty crime that, at times, will escalate into violent crime. As a society more can be done to reduce criminality and jail diversion through empathic, sensitive treatment options.

Uploading the Rhythms of Life

Cardiac monitoring may be an ‘event’ unto itself

Listening to the fountain in Washington DC

The debate over life and death often focuses on the heart and the brain.  Some believe life ends when the brain ceases all activity – a term called brain death.  Others believe death results when the heart ceases to beat.  In a blog published in January 2014, the mind-body dialogue was discussed by Michael Sefton.  He described the rudimentary force of life as the heart’s beating “which begins and ends with the inimitable squeeze of the cardiac muscle.”  For patients who are being monitored the experience is highly stressful and often evokes fear and dread.

The link between what happens to our body and its effect on our mood and feeling state is well documented.  Just as we must adjust to the early developmental changes of our children so must we adapt our own thinking and lifestyle to the changes brought about by the empty nest.  Events such as having children leave home and head off to college and other events associated with empty nesting require flexibility and adaptation of roles for success.  These important transitions signal an advancing age that sometimes accompanies physical decline in health and body.  With that said it is important to note that many American’s are living healthier lifestyles and thus preserving physical health well into the eighth and ninth decades of life.

“Don’t ever get old”

Retirement was once described as a period of “golden years” and was thought to represent the final stage of one’s life during which the experience of freedom and contentment proffered a whimsical enjoyment of lazy, carefree days.  It meant taking time to share one’s wisdom with those who are younger and pass on the stories of family, culture, and life itself.  This is often not the case and I have had patients suggest that I should never get old.  Retirement is frequently a time of unbearabe loss and despair.

One factor affecting quality of life is the sense of physical well-being.  Retirement sometimes triggers an erosion of physical health and cognitive stamina choking all remaining time with recurring, monotonous doctor’s visits and tests.  In truth, what may be a glorious time is now marred by fear and trepidation about one’s health, financial stability and declining physical longevity.

Poor cardiovascular health is an underlying cause of many chronic disease processes like stroke, diabetes, and auto immune disease.  Heart attack remains among the leading precursors to early death and researchers are racing to uncover treatment options including early identification of those most at risk and life saving surgery to open clogged arteries.  Meanwhile, people should take greater responsibility for their own health by eating better and building exercise into their changing lifestyle.  Things like moderating use of alcohol, 7-9 hours of nightly sleep, and eating plenty of fruits and vegetables become the specter of truth and failure to an ever-growing problem with obesity.  This is an important lesson for young adults to discover but is easier said than done.

The mind-body dialogue is one that matches wits with any great debate.  What are the best methods for identifying ‘problem’ hearts before they reach a penultimate, fibrillating finale?  Some doctors ask their patients to wear special monitoring devices – little boxes attached to the skin that permit the ongoing monitoring of life threatening changes in rhythm.  Patients sometimes wear the monitor for a month or more.  These monitors have the potential to catch irregular heart beats and allow physician’s to see a patient’s electrocardiogram on a minute to minute basis.  The monitor requires that the person wearing the device to upload his data via a telephone line each day sometimes with little to no training.  Each recording represents a cardiac event that the person wearing it is asked to chronicle in terms of action and feeling state when the device is active.  The events are uploaded via telephone land lines in real-time that seems almost tortuous to those bearing the burden of wearing the device.  The rhythms are quickly edited, analyzed and more often than not result in nothing more than a friendly vote of confidence – “you’re all set”.

Event Monitoring

Greater thought and training should be afforded to patient’s wearing event monitors.  As time goes on most patients become accostomed to the vagaries of the heart and the sound it makes – lub dub, lub dub.  The event recordings come in one after another and become part of the month-long survey of heart activity.  Some people call two and three times daily worried that they are having a serious cardiac event.  After 30 days the monitor is turned in for analysis by the cardiologist.  These daily rhythms go on to become the underpinnings of a cardiac care regimen that may offer treatment alternatives that can save a life.  The clinicians go on to new patients and new rhythms and new reports.  But each person who wears a monitor is brought to bear the feelings of their own life force beating in his or her chest sometimes wildly out of control. For those with irregular heart beats it can be 30 days of fear, impending doom, and personal paroxysm that seems to go on forever as skipping beats and palpating rhythms.  And even those with a normal EKG, the fear and worry of not feeling well can be just as agonizing as the beats are uploaded one at a time with not so much as a “job well done” and encouragement to call again tomorrow.

The fundamental appetence for living is shaped by the relationships made during life.  Those relationships that nurture and sustain may extend ones years of viability.  Some believe the force of life is the beating heart.  For without a healthy heart the quality of life may become desultory and life itself may become nothing more than a daily upload of irregular beats on the telephone, in real time.

To read the former blog click on the link below.