National Council Magazine, 2010 Issue 1

m a g a z i n e
NationalCouncilSharing Best Practices in Mental Health & Addictions TREATMENT
Published by the National Council for Community Behavioral Healthcare
www.TheNationalCouncil.org
Improving Public Safety and Maximizing Taxpayer Dollars
Neal Cash
Ending an American Tragedy
National Leadership Forum for Behavioral Health/Criminal
Justice Services
Human Rights at Home:
Mental Illness in U.S. Prisons and Jails
David Fuller
Where Does the Buck Stop?
Linda Rosenberg
Decriminalizing Mental Illness:
Miami Dade County Tackles a Crisis at the Roots
Judge Steven Leifman, Tim Coffey
Mental Health First Aid Equips Police Officers
to De-escalate Crises
Richard Leclerc
Beyond Bars
Mental Health-Addictions and
Criminal Justice Collaborations
2 0 1 0 , Issu e 1

p.34 From the Field
National Council Magazine is published quarterly by the
National Council for Community Behavioral Healthcare,
1701 K Street, Suite 400, Washington, DC 20006.
www.TheNationalCouncil.org
Editor-in-Chief: Meena Dayak
Specialty Editor, Mental Health-Addictions and
Criminal Justice Collaborations: Mohini Venkatesh
Editorial Associate: Nathan Sprenger
Editorial and advertising queries to
Communications@thenationalcouncil.org or
202.684.7457, ext. 240.
PDF available at www.TheNationalCouncil.org
NationalCouncilM A G A Z I N E
2 What Happened to Me, Not What Was Wrong With Me
Tonier Cain
4 Editorial Improving Public Safety and Maximizing Taxpayer Dollars
Neal Cash
6 Human Rights at Home: Mental Illness in U.S. Prisons and Jails
David Fuller
8 Ending an American Tragedy: Addressing the Needs of Justice-Involved People
with Mental Illnesses and Co-Occurring Disorders
National Leadership Forum for Behavioral Health/Criminal Justice Services
14 Behavioral Health and Criminal Justice Collaboration:
Interview with Linda Rosenberg
18 Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots
Steven Leifman, Tim Coffey
24 Jails and Prisons, Our New Mental Asylums
Interview with Pete Earley
26 Reducing Justice Involvement for People with Mental Illness: Strategies that Work
Interview with Fred Osher
28 Funding for Behavioral Health and Criminal Justice Programs
Henry J. Steadman, Samantha Califano
30 Back to Basics: Evaluating Opportunities to Serve the Justice-Involved
Population in Community Behavioral Health
John Petrila
32 Advocate to Give Youth a Second Chance: Juvenile Justice and Delinquency
Prevention Reauthorization Act
Mohini Venkatesh
34 FROM THE FIELD
Center for Health Care Services, Centerstone, Citrus Health Network,
Community Partnership of Southern Arizona, Community Psychiatric Clinic,
Chrysalis, Hands Across Long Island, John Eachon Re-entry Program,
The Kent Center, Mental Health Center of Denver, MHMR Tarrant County,
River Edge Behavioral Health Center, River Oak Center for Children,
Seacoast Mental Health Center, Spanish Peaks Mental Health Center,
Wayne State University Project CARE
52 Double Tragedies: Speaking Out Against the Death Penalty for People
with Mental Illness
Ron Honberg
54 Reinstating Medicaid Benefits: Life in the Community after Incarceration
Alex Blandford
56 Incarceration and Homelessness: Breaking the Tragic and Costly Cycle
Andy McMahon
58 Mental Health First Aid Equips Police Officers to De-escalate Crises
Richard Leclerc
62 E-learning in Corrections: Viable Training Option in a Tough Economy
Diane Geiman
64 Member Spotlight
National Council 2010 Awards of Excellence Honorees
Beyond Bars
Mental Health-Addictions and
Criminal Justice Collaborations
National Council Magazine, 2010, Issue 1

4 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
Beyond Bars
Iam a 41-year-old African American woman who
has been in and out of prison multiple times; I
am a mental health consumer who’s been hospi-
talized many times; and I have been in so many
substance abuse programs, I can’t even name
them all. Most important, I am a trauma survivor.
During every incarceration, every institutionaliza-
tion, every court-ordered drug treatment program,
it was always the same: I was always treated like a
hopeless case.All people could see was the way I
looked or the way I smelled. It wasn’t until I finally
entered a recovery-oriented, trauma-informed
treatment program a little more than four years
ago, where I felt safe and respected, that I could
begin to heal.
As a young child, I had a belief system that I was
nothing and that I would never amount to anything.
I thought that the men whom my mother enter-
tained, who touched and hurt me, did it because
something was wrong with me and I deserved it.
I thought that my mother abused me and didn’t
love me because I was a bad child.My eight broth-
ers and sisters needed me to protect them. I had
to keep the men from hurting them, like they hurt
me; I only wished my mother loved me enough to
protect me.
I spent a long time living with no hope and finding
no help in the different systems I entered. Every
time I went into jail or prison, I asked for help, but
I was told that it was a jail, not rehab.When I was
leaving, they said,“See you when you come back,
we’ll hold your cell for you.” No one ever said, “I
hope you make it this time.”
When I was admitted to mental health units, I was
told that I had several diagnoses, and I always
asked, “How do you know? I’ve been up smoking
crack for 7 days.” They never allowed the street
drugs to get out of my system before they evalu-
ated me. I also went to many substance abuse
programs — at one, I was raped by a counselor;
others used a “tear you down and build you back
up”model,but I was broken down enough already.
Even in school, where I was teased because of the
way I smelled, no one asked about what was hap-
pening to me.
I have also been secluded and restrained several
times. I am a victim of neglect and abandonment,
and one of the worst things that you can do to
someone with this type of history is to put them
into a seclusion room. When that door was shut,
the flashbacks of my mother’s abuse and aban-
donment began. When they’d come later with a
tray of food, I had been triggered, and so I pushed
the tray away from me, but then they restrained
me.I was a rape victim,and this restraint triggered
me even more. I was also always overmedicated.
It’s hard not to lose hope under those circum-
stances.
Then, after 19 years of drug addiction, alcohol-
ism, homelessness, going in and out of prison (83
arrests and 66 convictions), mental health insti-
tutions, and substance abuse programs, I finally
found the help that I needed to heal. Someone
finally asked me“What happened to you?”instead
of “What’s wrong with you?”
I was in prison and pregnant, and I was terrified
that I was about to lose another child: I had al-
ready had four kids taken from me,and I could not
survive losing another. I was told about a program
that would help me heal from my trauma, recover
from my addictions, treat my mental illness, and
let me keep my baby with me. Well, I didn’t know
how they were going to manage all that,but I knew
I had to give it a try.What did I have to lose?
The first thing my therapist said to me was
“Everything that happened to you as a child, hap-
pened to you; you didn’t do it to yourself,” and
I believed her because her tone was gentle and
not judgmental. Then we began the work, and I
had to remember and talk about every time I was
touched and assaulted as a child. I talked about
my issues with my mother,how she never loved me
What Happened to Me,
Not What Was Wrong With Me
Tonier Cain, Consumer Advocate
Tonier Cain is a featured
“In My Own Words” speaker at
the 2010 National Council Conference,
March 15-17, Disney World, Florida.
www.TheNationalCouncil.org/Conference
“
Tonier Cain has spoken nationally on trauma,incarceration,
and recovery. She has served as a member of the
Protection and Advocacy for Individuals with a Mental
Illness Council. She has also worked as a case manager
and director of advocacy services for a private nonprofit
in Annapolis, Maryland. She is the team leader for the
National Center for Trauma Informed Care, which provides
consultation, technical assistance, and training to
revolutionize the way in which mental health and human
services are organized, delivered, and managed while
furthering the understanding of trauma-informed practices
through education and outreach. Ms. Cain is the subject
of “Healing Neen,” a documentary based on her life as
she moved through multiple systems of care.

NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 5
and never protected me. I began to heal because I
started to understand that I am an adult now, and my
mother’s lack of love for me, and men’s abuse of me,
is a reflection of who they are; it’s not about who I am.
Then my therapist told me that we had to start talking
about my children, and I shut down. I asked her how
I could talk about something that gives me so much
pain and suffering every day of my life: How do you
heal from having four kids walking the earth when you
don’t know how they’re doing, what they look like, or
who they are? She said, “You do; you just don’t do it
by yourself,” and she was there with me, for weeks of
crying and rocking, as I allowed myself to remember
them and grieve them.
In that program, I felt safe for the first time.The walls
had pictures and positive quotes on them.We had our
own rooms with nice colors. No one was screaming
“medication time”at us or secluding or restraining us.
I was asked every day, “How are you feeling today?”
Everybody there was trained in trauma, which meant I
could talk to any staff member at any time, and they
would listen. For the first time in my life, I felt like a
person, a human being, and not like the monster I
had been treated as in the past. I felt hope. Oh, what
a difference it makes when someone asks,“What hap-
pened to you?” instead of “What’s wrong with you?”
Once I was able to start healing from the trauma in
my life, my belief system changed from “I am nothing”
to “I am somebody, and I can be anything I want in
this world.” All of the earlier treatment and informa-
tion that people had tried to give me for years had
only reached the surface; it didn’t get down to the
foundation of my problems and needs. Since getting
trauma treatment in a safe, trauma-informed setting,
however, I have been able to heal. I make better deci-
sions. I have a healthy, beautiful child whom I simply
adore and who is securely attached to me. I do not
have the desire to use drugs or alcohol.I am no longer
on medication. I am now an advocate in the streets
where I once lived, used drugs, and was raped and
beaten.I am now a national spokesperson on trauma,
I am a homeowner, and I sit on several boards.
Five years ago, I was taking hits of crack, in a mental
institution, and in and out of prison. Everyone then
thought that I would spend the rest of my life going
in and out of prisons and mental institutions or that I
was going to die in the streets.They were wrong.
Where there’s breath, there’s hope, and for me it be-
gan with respectful, individualized trauma treatment.”
Every time I went into jail or prison, I asked for help, but I was
told that it was a jail, not rehab. When I was leaving, they said,
“See you when you come back, we’ll hold your cell for you.”
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Editorial
Community behavioral healthcare’s role in pre-
venting crime and increasing public safety is
one of our country’s best-kept secrets. And that’s a
shame.
A few months ago, news reports focused on a third
straight year of decreased crime rates across the
United States, surprising law enforcement officials
and other experts who predicted just the opposite,
given the high rate of unemployment and the eco-
nomic recession. In previous periods of economic
stress, crime rates increased.Yet preliminary statis-
tics for 2009, released by the FBI in late December,
showed that rates for all types of crime had again
decreased from the year before.
As analysts struggled to explain this anomaly,few to
none mentioned the role of community behavioral
health services.Yet many of us in the field know how
important our efforts have been in this regard — and
how much more we can accomplish.
Community behavioral healthcare serves as an
important partner for the criminal justice system,
whether by providing treatment which prevents be-
haviors that could bring people into contact with
law enforcement; training officers in how to deal
with people with mental illness who are in crisis;
or preventing recidivism by ensuring continued and
coordinated treatment for people involved with the
justice system, leaving the justice system, or both.
In these difficult financial times, it is especially
important that our systems recognize and embrace
their interrelatedness and work together to maxi-
mize public resources. At the same time, we must
educate the public about how effective behavioral
health treatment reduces crime, avoids expensive
incarceration,helps people remain in or re-enter the
community as contributing citizens, and enhances
the quality of life of everyone in the community.
As reported in the National Leadership Forum on
Behavioral Health/Criminal Justice Services Report
featured in this issue, the interface between our
systems often is frayed, if it exists at all. Yet there
are pockets of excellence around the country that
provide models for collaboration and cooperation,
with promising results in both individual outcomes
and taxpayer savings — examples are featured in
the From the Field section of this issue.Representa-
tives of the Center for Mental Health Services’ Na-
tional GAINS Center visited some of these pockets
of excellence in fall 2009, including those operated
by the Community Partnership of Southern Arizona.
Collaboration Is Key
As a community-based nonprofit organization, CPSA
has a large stake in the quality of life and public
safety of the communities it serves — more than 1
million people across five counties. Our work helps
prevent crime, reduce recidivism, and divert people
with mental illness and substance use issues from
incarceration into less expensive, and more effec-
tive, community-based treatment.
CPSA, the regional behavioral health authority over-
seeing publicly funded care in southernArizona,has
sought creative ways to collaborate with the crimi-
nal justice system.We’ve learned that:
>> Any cross-system program or strategy must be
built on a firm foundation of mutual respect and
understanding and on relationships that both
grow out of and are nurtured by the collaboration.
>> Planning needs to be deliberate and incremental,
with both short- and long-term common goals.
>> Processes, strategies, and results should be
monitored and evaluated, and improvements
should be made on the basis of findings.
>> Communication, including sharing and celebrat-
ing results, should be structured and ongoing.
>> Collaborations must be cost effective and sus-
tainable, even in tough times. This is supported
by the mutual advocacy and identification of
new opportunities that evolve out of collabora-
tive relationships, further strengthening commit-
ment, and magnifying the impact of strategies
and programs.
This is basic community development.It can be slow
and at times frustrating, but CPSA’s experience has
demonstrated that it is worth it — and that no sub-
stantive and lasting change can happen without it.
CPSA began this journey in the late 1990s by form-
ing a work group of behavioral health and criminal
justice stakeholders in Tucson/Pima County that
sought to identify systemic strategies to decrease
the time people with a mental illness were inap-
propriately incarcerated.This group evolved into the
current Forensic Task Force, which meets quarterly
and includes representatives of the court system,
law enforcement, jails and corrections, local behav-
ioral health providers, crisis services, attorneys, the
veterans’ hospital, and other community stakehold-
Neal Cash, President and CEO, Community Partnership of Southern Arizona, and Member, Board of Directors, National Council for Commu-
nity Behavioral Healthcare
Improving Public Safety and Maximizing Taxpayer Dollars
Community Behavioral Healthcare’s Best-kept Secret
Neal Cash is president and
CEO of the Community Part-
nership of Southern Arizona,
the regional behavioral health
authority contracted by the
state of Arizona for funding
and oversight of the public
behavioral health system in
five counties. He has a bach-
elor’s degree in psychology
from Syracuse University and a master’s degree in rehabilitation
counseling from the University of Arizona. He is a member of
the National Leadership Forum on Behavioral Health/Criminal
Justice Services of the National GAINS Center.
Participants in the mental health court
experienced a 50 percent overall reduction in subsequent
criminal charges in the 2 years after being in the program.

ers. The task force, along with collocated behavioral
health and criminal justice staff, provides the founda-
tion and framework for all strategies and programs.
Most of CPSA’s efforts in this collaboration have fallen
into two areas: diversion programs and service coordi-
nation via information sharing (see article, p. 37).
CPSA also helped to establish Arizona’s first mental
health court in 1999 in Tucson and has founded ad-
ditional mental health courts in the Pima County Su-
perior Court and Consolidated Justice Court. It also
developed a formal mental health collaboration with
every other limited-jurisdiction court in Pima County
(six in total). CPSA has developed relationships and
tools to allow swift identification of members who
have been arrested and appropriate, real-time shar-
ing of information while protecting confidentiality.
These relationships and tools expedite communica-
tion between the community behavioral health treat-
ment provider and the jail’s treatment provider,ensur-
ing that members receive support in navigating the
criminal justice system while maintaining coordina-
tion of care.
Most recently,CPSA has established an InitialAppear-
ance program, which involves community behavioral
healthcare staff participation.This program has signif-
icantly decreased the likelihood that a CPSA member
will be detained in the jail system. CPSA has also be-
gun training forensic peer mentors to provide support
and advocate for members involved with the criminal
justice system and is again offering crisis intervention
training to law enforcement in southern Arizona.
Participants in the mental health court experienced a
50 percent overall reduction in subsequent criminal
charges in the 2 years after being in the program.The
most recent annual figures for CPSA’s diversion pro-
grams in Tucson City Court and Pima County Justice
Court show graduation rates of 97 percent and 92
percent, respectively — a total of 627 CPSA members
who avoided incarceration and had charges dropped.
“Many people were skeptical about mental health
court,”noted the Hon.NanetteWarner,Judge of Supe-
rior Court, Division 20, in a recent letter,“but with the
leadership and the commitment from CPSA,it became
a reality and allayed all concerns...The result has been
fewer people with mental illnesses falling through the
cracks. They have escaped the revolving door of the
criminal justice system and are now experiencing
meaningful recovery and success for the first time in
their lives. There are innumerable people who have
graduated from mental health court, even people the
professionals thought would not be successful.”
Current Conditions Demand Creativity
Collaborations are especially critical now.Federal and
state governments face historic budget shortfalls, just
as expenditures on corrections across the country are
nearing a staggering $70 billion annually, according
to the Bureau of Justice Statistics. Some states are
releasing inmates early, and many are increasingly
relying on community supervision as an alternative to
expensive incarceration.
At the same time, publicly funded behavioral health
services — the very resources that can help ensure the
success of these alternative justice approaches — are
in grave danger of being cut.
With states struggling to cut costs and few lawmak-
ers willing to consider new revenue sources,the result
could be a mad, self-defeating scramble for funding
among different systems and stakeholders. Alter-
natively, our industry’s proactive engagement with
criminal justice could create collaboration instead of
chaos and lead to thoughtful changes and strategies
that result in real improvements at both the systems
and individual levels — not only to make the best
use of dwindling dollars but to create stronger, more
efficient, more effective, and more humane systems
in the long run.
The status quo is being shattered by fiscal realities.
We can seize this opportunity to create partnerships
with criminal justice and to educate decision makers
and the public about community behavioral health-
care’s critical role in the safe diversion and release of
people with substance use issues and mental illness.
We can make real connections between community
behavioral healthcare and criminal justice. And by
promoting our accomplishments to the larger com-
munity, we can emphasize our contribution to public
safety.
Expenditures on corrections
across the country are nearing a staggering
$70 billion annually. Some states are
releasing inmates early, and many are
increasingly relying on community
supervision as an alternative
to expensive incarceration.At
the same time, publicly funded
behavioral health services —
the very resources that can
help ensure the success of
these alternative justice
approaches — are in grave
danger of being cut.

Beyond Bars
“Mr. Chairman, Ranking Member Coburn, and dis-
tinguished members of this Subcommittee, it is an
honor to provide testimony before this body. My
purpose in testifying is to bring to light some of the
experiences people with mental illness encounter
when they enter the criminal justice system and to
expose the inhumane treatment they receive. I have
also included information on how this travesty in
human rights can start to be corrected.
With the ability of hindsight, I can say I started
to experience depression at an early age. The first
twinge of it was in elementary school at the time
of Martin Luther King, Jr.’s assassination. I can re-
member thinking, “The people in this country will
never change. If they could kill a man as good as
him what chance do I have?”These thoughts were in
the context of experiencing racism through my en-
tire life, from times visiting family in the rural south
as a young child to going to a majority white school
in my native New York from elementary through high
school. I think now, and feel seven years old is too
young to feel hopelessness, especially in a country
that has as much as this country.
When I was seventeen I experienced my first arrest.
New York City’s Rikers Island at that time was called
the “gladiator school” by local youth. I was arrested
for illegal gambling because I had betted a few
dollars on some numbers and was caught near the
“number spot.” Honestly, I used to bet to get a thrill
because even at that age, it was hard for me to feel
joy or happiness like other young men, so I used to
fill that void with thrill seeking and other non goal-
producing behaviors like drugs and alcohol use.This
charge was considered a misdemeanor in New York
City [and] State.
In the few days it took for me to post bail I experi-
enced suicidal thoughts and was actually stabbed
by another inmate for the jacket I was wearing. I
was afraid to go to the clinic because I knew they
would put me in isolation on suicide watch and I felt
punished enough.
When I became eighteen years old, things were
not getting better for me. I was abusing drugs like
heroin and crack cocaine. My family did not know
what to do. I was trying to outrun someone I could
never outrun, myself. By the time I was twenty-one
years old,I had been arrested several times for drug
possession/sale and gambling. I was using a large
amount of drugs and got caught in a drug den dur-
ing a police raid. I was facing a lot of time and was
scared to death. My family found me a good attor-
ney who eventually got the charges dismissed and
suggested that I seek drug treatment. I went to a
long-term drug treatment facility in NewYork State.I
did not like being there,but I thought maybe I could
get help with the problems I had been experiencing.
I told my counselor I thought I had more than just
a drug problem — that I felt sad and lonely pretty
much all the time no matter what I did. I also told
him I thought about ending my life quite a bit.When
he heard this, he warned me that if I mentioned
that again I would be discharged from the program
and sent to a mental hospital. I never mentioned it
again. I graduated from the program after a year,
went back home,picked up drugs again in less than
two weeks, and was back in the street like nothing
ever changed.
Through the next twenty years, I went back and
forth to jail. My ability to function was slowly, but
steadily, declining. I was arrested at least twenty or
thirty times in that time period. I served sentences
from ten days to one year.The first six to ten times I
would ask my lawyer or the staff in the jail for help
with the issues I had, I got the same answer every
time — that is if they bothered to answer; that either
I went to drug treatment or the mental hospital. I
knew one or the other by itself would not work, so I
gave up asking for help from the system.
Towards the last few years of my suffering, I ex-
perienced my first hospitalization for psychiatric
reasons; it was after my first suicide attempt. I was
there for a couple of months. I went to therapy, and
I was put on medication. It helped; I became stable
and was discharged from the hospital. I did not
have stable housing when I was discharged. I was
referred to a“¾ house”to live and it was worse than
living on the streets, so that is what I did. I ended
up not taking my medication, not participating in
therapy, and quickly re-offended.
When I went to jail the next time I didn’t stand up
for the count. I was written up and put into punitive
segregation (“the box”). In segregation, I was put in
a cold, dark, barren cell — no TV, no books — where
the environment exaggerated my symptoms and I
even experienced some new ones like audio hal-
Testimony of David Fuller, Certified Psychiatric Rehabilitation Practitioner and Forensic Peer Specialist; a Person with a History of Incarcer-
ation and Psychiatric Disability, before the United States Senate Committee on the Judiciary, Subcommittee on Human Rights and the Law,
Hearing on “Human Rights at Home: Mental Illness in US Prisons and Jails,” September 15, 2009.
Printed with permission
of David Fuller
Human Rights at Home:
Mental Illness in
U.S. Prisons and Jails
This cycle would
repeat itself many more
times: get out, no place to live,
stop taking my medication,
use drugs, become suicidal,
then go back to jail.

lucinations. The officers were verbally and physically
abusive.There was no point in making an official com-
plaint because the officers would just abuse you more
and nothing would ever be done about it.
This cycle would repeat itself many more times: get
out, no place to live, stop taking my medication, use
drugs, become suicidal, then go back to jail. I remem-
ber I“caught a ticket”in jail one time and before they
could send me to the box I tried to hang myself in my
cell,my cellmate found me before the officers did and
untied the sheet. He did not tell the officers because
he knew what would happen.I wept in my cell the rest
of the night; I was discharged after two days.
There were fights with other inmates almost every
time I went to jail. Because of my depression, I would
appear to be an easy victim and some of the other
inmates would try to steal my food. Most of the time
I would win the fight, but lose the battle for my self-
esteem and self-respect — fighting for food like a
common animal.
“There is no HIPAA in jail” because there is really no
privacy in regards to your psychiatric care. Either you
are on the “Mental Observation Unit” with all the stig-
ma and dangers that implies, or you are living in gen-
eral population where every time you go for medica-
tion or need to see the doctor it is announced through
the cell block. When you are getting your medication
you are on a line with a hundred other inmates and
inmates going back and forth on the other side of the
hall. People are buying and selling medication and
other illicit drugs. Everybody pretty much knows what
the other person is getting.When you go to the“clinic”
to see the doctor you have to wait for hours on end
and once again, everybody knows what you are there
for. You can hear staff talking about other patients
when you are meeting someone about yourself, so
you think about whether they talk about you when you
leave, so you do not share much and do not get the
help you need.
For 28 years of my life, I struggled with depression
and then later [posttraumatic stress disorder]. I used
hard drugs most of this period and it seemed like I
was always going in and out of jail. Violence was al-
ways around me.Through my periods in jail and being
homeless I have been stabbed and shot.I was abused
by the very people and system that were supposed to
be helping me, and keeping me safe. I did not have
access to the services I needed; I was alienated from
friends and family. I felt isolated and alone. I dwelled
in hopelessness, shame, guilt, and fear of the future.
I believed God had abandoned me and things would
never change.
I turned down treatment a few times in the past when
I was in jail before because I was never offered a
place [where] I could address my psychiatric disabil-
ity and my drug addiction at the same time, in the
same place.I had been through treatment many times
for one or the other at different times and it seemed
to never work for me.
I am happy to say things did change. The last time I
was incarcerated I was offered an opportunity to par-
ticipate in a Mentally Ill/Chemically Addicted — resi-
dential treatment rather than stay in jail. It turned my
life around. I was able to be around people who had
similar experiences and I did not feel so alone. I talk-
ed to people like me who had recovered and [were]
on their way to happy, productive lives. For the first
time in a long time, I had real hope for the future.
I learned I had to be honest,open-minded,and willing
to do the footwork in order to recover. I had to take
responsibility for my life. I gained a relationship with
a higher power that I choose to call God. I confronted
my fears and insecurities and made friends with other
people, some like me and some that did not have
the same experiences as me. I did not use my past
as an excuse to fail; I used it as a source of strength
and truth to move me forward.I learned to love again;
first myself and then others. I learned to forgive. It
set me free.
I went back to work with the help of my peers at the
Howie T. Harp Advocacy Center, a supportive employ-
ment/training center for people with histories similar
to my own, got a place to live, and found someone
special to share my life with. I learned to be a father,
a husband, a citizen — a man!
Eight years ago I never thought I would be able to say
this, but I am happy, joyous, and free.Today, all things
are possible!
Through my years of suffering, the government has
probably spent about one million dollars (not includ-
ing court and law enforcement costs) on incarceration
and treatments that just made my life worse and were
ineffective in diminishing or eliminating the problem.
All my drug use was a desperate attempt to medicate
symptoms that I did not understand and that society
had made me ashamed and fearful to get help for.
All of my arrests were due to my drug use. Why did I
have to be punished so severely, for so long, for be-
ing sick?
Psychiatric disability and substance abuse are chronic
illnesses similar to hypertension or diabetes.The last
time I checked, people with those illnesses were not
being put in jail and shunned by society. People can
live with all of these disorders with proper treatment
and support.
In closing, I encourage everyone to read Ending an
American Tragedy: Addressing the Needs of Justice-In-
volved People with Mental Illnesses and Co-Occurring
Disorders, which I have attached.
I believe this document can point this committee in
the right direction in changing the way services are
given; in a cost-effective and humane way that ben-
efits the community as a whole”
Sincerely,
David L. Fuller
David Fuller, CPRP, a consumer in recovery from psychiatric
disability, substance abuse, and the criminal justice system, is
employed at Kings County Hospital Center in Brooklyn as a peer
counselor who coordinates the Adult Outpatient Walk-In Clinic and
a group facilitator with its Continuing Day Treatment Program. He
is also an outreach and housing coordinator for the Manhattan
Outreach Consortium.As an administrator, service provider, and
independent consultant, Fuller draws on his personal experiences
as a consumer — and his opportunity to overcome many chal-
lenges — to fuel his mission to improve access to services for
people who have been affected by psychiatric diagnoses and who
use the public mental health system. Fuller is also a member of
the National Leadership Forum on Behavioral Health/Criminal
Justice with the National GAINS Center; an advisory board
member of the Peer Integration Project through the Columbia
School of Social Work’s Workplace Center; a guest lecturer at the
Columbia,Adelphi, and New York Universities Schools of Social
Work on trauma and mental health recovery models.
Psychiatric disability
and substance abuse
are chronic illnesses similar to
hypertension or diabetes. The last
time I checked, people with those
illnesses were not being put in jail
and shunned by society.

Beyond Bars
In 1841, Dorothea Dix was appalled by the conditions she observed in Massachusetts jails and
crusaded for more humane responses to the needs of those inmates with mental illnesses. Within
a decade her work was translated into therapeutic state run institutions that traded punishment for
care. Over the next century, without sustained commitment to Dix’s vision for recovery, these facilities
fell into disrepair to the point that today,hundreds of thousands of people with mental illnesses crowd
our county jails and state prisons.
In 1946, Life Magazine published an exposé detailing cruel and inhumane conditions in State psychi-
atric hospitals across the United States.1The article described widespread abuse of patients resulting,
in part, from “public neglect and legislative penny pinching;” and was punctuated by a series of
haunting photographs depicting desolate and shameful conditions under which people with mental
illnesses were being confined, often for years or even decades on end. The author referenced grand
jury reports as well as State and Federal investigations documenting widespread abuses and hazard-
ous living conditions in State institutions. Citing severely inadequate staffing, substandard treatment,
inappropriate use of restraints, and provision of little more than custodial care, the institutions were
described as, “…costly monuments to the States’ betrayal of the duty they have assumed to their
most helpless wards”
Although the population of State psychiatric hospitals continued to grow over the next decade, the
publication of this article, along with similar accounts from other media sources, began to expose
a crisis that had existed largely hidden from public view for far too long. As more light was shed on
the horrific treatment people received in State psychiatric hospitals, along with the hope offered by
the availability of new medications, a flurry of federal lawsuits resulted in court decisions leading to
substantial reductions in the numbers of people housed in State psychiatric hospitals.
Unfortunately, while State hospital beds were shut down by the thousands, the types of comprehensive
community-based services and supports promised as a condition of their closing were never developed.
Combined with changes in sentencing practices, evolution of quality of life ordinances, and restricted
definitions of eligibility for public sector behavioral health services, this has resulted in many individu-
A Report of the National Leadership Forum for Behavioral Health/Criminal Justice Services, Co-chaired by Linda Rosenberg, MSW, President
and CEO, National Council for Community Behavioral Healthcare and Henry J. Steadman, PhD, President, Policy Research Associates; CMHS
National GAINS Center
Ending an American Tragedy:
Addressing the Needs of Justice-Involved
People with Mental Illnesses and
Co-Occurring Disorders
It is my privilege to co-chair the National
Leadership Forum for Behavioral Health/Criminal
Justice Services. Ending an American Tragedy:
Addressing the Needs of Justice-Involved People
With Mental Illnesses and Co-Occurring Disorders
is a working document of the NLF.The report is
designed as both a call to action, focusing on the
crisis in our nation’s jails and prisons — men and
women with mental illnesses and addictions
incarcerated because they didn’t get the treat-
ments they desperately need — and an inspiration
— highlighting the possibilities of effective
services.We are asking leaders in all communities
to come together, pool resources, and work as
one. I’m proud of member organizations that are
already providing such leadership and you’ll find
a small sample of member programs in the “From
the Field” section of this issue. National Council
members are endlessly creative in overcoming
financial, bureaucratic, and cultural barriers and
establishing collaborations that solve community
problems.And we look forward to the growth and
spread of programs and services that offer
productive lives to people with mental illnesses
and addictions as the alternative to incarceration.”
— Linda Rosenberg

als with mental illnesses and co-occurring substance
use disorders repeatedly coming into contact with
the criminal justice system. Our Nation is once again
in the midst of another shameful and costly mental
health crisis that has been allowed to fester and grow,
largely out of public sight. It is a secret of stunning
proportions; in numbers and in harm.
Everyday, in every community in the United States,
our law enforcement officers, courts, and correctional
institutions are witness to a parade of misery brought
on by an inadequately funded, antiquated, and frag-
mented community mental health system that is un-
able to respond to the needs of people with serious
mental illnesses. Each year, more than 1.1 million
people diagnosed with mental illnesses are arrested
and booked into jails in the United States. Roughly
three-quarters of these individuals also experience
co-occurring substance use disorders, which increase
their likelihood of becoming involved in the justice
system. On any given day, between 300,000 and
400,000 people with mental illnesses are incarcer-
ated in jails and prisons across the United States,and
more than 500,000 people with mental illnesses are
under correctional control in the community.
Overthepast50yearswehavegonefrominstitutional-
izing people with mental illnesses, often in subhuman
conditions, to incarcerating them at unprecedented
and appalling rates — putting recovery out of reach
for millions of Americans.
These people are not all the same.They are a hetero-
geneous group.
>> A small subgroup does resemble the State hos-
pital patients of yesteryear, and their presence in
our jails/prisons is one of the most egregious and
disturbing images related to our failed systems of
care. The availability of intensive care models, in-
cluding hospital care for some, is critical.
>> Many other citizens with mental illnesses in our
jails have less disabling conditions and with ac-
cess to appropriate community treatment and
support, will do quite well.
>> A third subgroup includes people with mental ill-
nesses who have traits that are associated with
high arrest and recidivism rates.These individuals
would be best served with good treatment and
supports, which include interventions targeted to
their dynamic risk factors for arrest.
As we attempt to respond to the needs of these peo-
ple and respect the legitimate public safety concerns
of all community members, conditions in these cor-
rectional settings, which are designed for detention
and not therapeutic purposes, are often far worse
than conditions described in the State hospitals of
the 1940s. Moreover, when justice-involved persons
with co-occurring disorders leave correctional institu-
tions, they repeatedly are left adrift only to recycle
through the criminal justice system. Furthermore,
individuals who become involved in the justice sys-
tem often must contend with the additional stigma of
criminal records, which make access to basic needs
in the community, such as housing, education, and
employment, even more difficult to obtain.
This national disgrace, kept hidden for too long,
represents one area in civil rights where we have
actually lost ground.This failed policy has resulted in
a terrible misuse of law enforcement, court, and jail
resources, reduced public safety, and compromised
public health.
These conditions have recently resulted in investiga-
tionsintothetreatmentofpeoplewithmentalillnesses
in institutional settings, only this time the institutions
are correctional facilities that were never intended to
serve as de facto psychiatric hospitals. Over the past
decade alone, the U.S. Department of Justice has
issued findings from investigations of mental health
conditions in more than 20 jail and prison systems
across the United States, with additional investiga-
tions currently ongoing. Equally reminiscent of the
past, among the more pervasive findings from these
investigations are severely inadequate staffing, sub-
standard treatment, inappropriate use of restraints,
and provision of little more than custodial care.
The following excerpts are taken from recent grand
jury and Department of Justice reports:
>> During our tour, we observed inmate JM hitting her
head on the window of her cell and talking with
slurred speech. She was housed in a hospital cell
under suicide watch. She spoke of seeing angels
and said that she was afraid of her cellmate (who
was in the advanced stages of pregnancy) was
trying to harm her. She had been at [the jail] for
approximately one month prior to our visit. JM
stated on her intake form that she had previously
been treated at a mental hospital in Little Rock
and that she had been seen at a local hospital in
January 2005 for seeing ‘spiritual things.’ Shortly
after her admission to [the jail], she was placed
on suicide watch for making statements about
going to sleep and not getting up and ‘not caring
if she was alive or not.’ Her medical record notes
numerous instances of ‘talking wildly’ and ‘talking
to herself.’ She told us that she had a history of
hypothyroidism and told us the names of various
psychiatric medications that she had been taking
before being admitted to [the jail].Throughout our
tour, we could hear JM moaning and crying and at
times screaming. In spite of all this, this inmate
was never evaluated by a mental health care pro-
vider.We were told that she was not started on any
psychiatric medications or sent to the local hos-
pital because she did not have the ability to pay.
>> Inmate M.K. hung herself on January 5, 2003 af-
ter having been admitted on December 4, 2002.
Her record contained the following inmate request
form dated two days before her death on January
3, 2003.The note indicated the following.
‘I need to see the doctor to get my medicine
straightened out. I am not getting my meds
that my doctor faxed prior orders for me, and
I brought in the medication myself and paid
for it. I cannot afford to be treated this way!
Please help me! I need my medicine.’
There is no indication that M.K.received her medi-
cation before her death.
There are no comparable Department of Justice inves-
tigations into a lack of community services, because
there is no constitutional right to community-based
services as there is for persons who are incarcerated.
However, by contrast, there are success stories in the
community.A recent report by the Health Foundation
of Greater Cincinnati offers a number of compelling
personal stories from four Forensic Assertive Commu-
nity Treatment (FACT) Teams they fund.
Clearly, jails and prisons were
never intended as a community’s
primary setting to provide acute
care services to individuals
experiencing serious mental
illnesses. In most cases they
are ill equipped to do so.

Beyond Bars
>> “My housing is a lot better. My Social Security
just got approved today, so I start receiving that
again. They cut it off while I was in prison. I did
18 months in prison. I got [Social Security] back
with the help of [the FACT team]. And they’ve
been helping me with my housing. And that’s a
lot better ‘cause now I can get adjusted to a cer-
tain environment.And I don’t have to worry about
where I’m going to live, one week to the next for
whatever reason.”
>> “Well, I was really in bad shape. I didn’t know
how to go about getting help.The only thing that
I really knew that I had to do was try to care
for myself and my habit. And that’s what leads
to criminal behavior, which limited me on jobs.
I felt like I couldn’t work because of my record.
So,I had to keep being a criminal to support my-
self and my habit. I didn’t know where to go for
help. I didn’t know who to talk to. I was suicidal
all the time.And I really hated myself for all the
feelings and things that I was doing. I had an
apartment but I was evicted because I couldn’t
pay the rent.And then,I was just,like,going from
place to place and sometimes in homeless shel-
ters and sometimes with friends or just wherever.
I was in jail all the time. I just spent two years
in the penitentiary. I’ve been in the penitentiary
3 times and I’ve been in jail probably 30 to 40
times.” The same consumer, when asked about
life after receiving FACT services,reported:“Yeah,
I haven’t had any problems.I work at McDonalds
full-time.”
Clearly, jails and prisons were never intended as a
community’s primary setting to provide acute care
services to individuals experiencing serious mental
illnesses.Inmostcasestheyareillequippedtodoso.
When we look at community-based services,we find
current policies governing the funding and organiza-
tion of community mental health care have resulted
in people with more intensive and chronic treat-
ment needs being underserved or unserved in typi-
cal community-based settings. This is due in large
part to rules and regulations that limit flexibility
in designing service and reimbursement strategies
targeting the specific needs of people with serious
mental illnesses. For example, the Substance Abuse
and Mental Health Services Administration (SAMH-
SA) and the Centers for Medicare and Medicaid Ser-
vices (CMS) are two agencies housed within the U.S.
Department of Health and Human Services (DHHS).
SAMHSA has identified intensive case management,
psychosocial rehabilitation,supported employment,
and supported housing as evidence-based inter-
ventions, consistently yielding positive outcomes for
persons with serious mental illnesses.
However there are several obstacles to using Medic-
aid to pay for these effective services.These include
categorical restrictions on eligibility, which exclude
many people with serious mental illnesses and co-
occurring substance use disorders who have been
involved in the criminal justice system, as well as
fragmentation in coverage for treatment of medical,
mental health,and substance abuse problems.Nar-
row criteria for “medical necessity” and definitions
of covered services that are often not aligned with
what we know about evidence-based practices cre-
ate barriers to more effective service delivery and
recovery outcomes.As a result,there is an increased
demand for services provided in hospitals, emer-
gency settings, and the justice system, contributing
to extraordinarily high costs for local communities,
states, and the Federal government.
Furthermore, new practices have been slow to be
made available to justice-involved persons with
co-occurring disorders. For example, it has now be-
come widely accepted that all services for people
with serious mental illnesses,particularly those with
criminal justice involvement, be trauma-informed.
Among both women and men with criminal justice
involvement, histories of trauma are nearly univer-
sal. Ninety-three percent of 2,000 women and men
in federally funded jail diversion programs between
2002 and 2008 reported at least one incident of
physical or sexual abuse in their lifetime. Sixty-
one percent reported physical or sexual abuse in
the last 12 months. Yet few programs, institutional
or community-based, offer environments that are
trauma informed or trauma specific.
Moreover, a recent study found 31 percent of
women being booked into local jails with current
symptoms of serious mental illness.2This compares
with 14 percent of men.These rates exacerbate the
issues of providing adequate services for women in
predominantly male facilities whose physical plants
and staffing are geared to men.Gender-specific ser-
vices that reflect a trauma-informed culture must
be developed in all institutional and community
settings to respond to the frighteningly high rates
of mental illness among women in contact with the
criminal justice system.
In addition, we know that individuals using mental
health services — often referred to as“consumers”—
have a significant impact on creating recovery-ori-
ented mental health and substance abuse services.
For people involved in the criminal justice system,
forensic peer specialists — those with histories of
mental illness and criminal justice system involve-
ment — can help pave the way for a successful re-
turn to the community.
The ability to effectively design, implement, and
reimburse treatment providers for delivering high
quality services targeting specialized treatment
needs is critical to establishing an effective com-
munity-based system of care for people who expe-
rience serious mental illnesses. In the absence of
what are now seen as essential services for peo-
ple with mental illnesses living in the community,
people will continue to be forced into more costly,
deep-end services in hospitals, crisis centers, emer-
gency rooms, and the justice system.
The result is a recycling of individuals between jails,
prisons, shelters, short-term hospitalizations, and
homelessness — with public health, public safety,
and public administration implications that are
staggering. Now more than ever, as we strive to
provide health care to our most vulnerable citizens,
we must address this serious public health and
public safety crisis. It is high time to be open and
honest about the deplorable conditions that ex-
ist and take steps to address them. We offer four
recommendations for immediate action.
In the absence of what are now seen as essential services
for people with mental illnesses living in the community,
people will continue to be forced into more costly, deep-end
services in hospitals, crisis centers, emergency rooms, and
the justice system.

Beyond Bars
u The President should appoint a Special
Advisor for Mental Health/Criminal Justice
Collaboration.
Currently, there is no fixed responsibility within the
Federal government to promote effective mental
health/criminal justice activities and ensure ac-
countability for the use of public dollars.The Special
Advisor will serve as an advocate and ombudsman
across the wide array of Federal agencies that serve
the multiple needs of justice-involved people with
mental and substance use disorders. One of his or
her tasks will be to implement an immediate re-
view of all CMS and SAMHSA regulations to identify
conflicts and inconsistencies for people with mental
illnesses and co-occurring substance use disorders
— particularly those involved in the justice system.
u Federal Medicaid policies that limit or
discourage access to more effective and
cost-efficient health care services for indi-
viduals with serious mental illnesses and
co-occurring substance use disorders should
be reviewed and action taken to create more
efficient programs.
Congress is encouraged to review Medicaid policies
and take action that will enable states to create
more effective and appropriate programs target-
ing eligible beneficiaries most likely to experience
avoidable admissions to acute care settings. Such
programs should allow states flexibility in designing
and implementing targeted outreach and engage-
ment services, coordinated care management,
and community support services that are likely to
reduce expenditures on deep-end services, and en-
gage people in prevention, early intervention, and
wellness care in the community. Services provided
should reflect evidence-based and promising prac-
tices and should be designed around principles of
recovery, person-centered planning, and consumer
choice. Because of the high rates of co-morbid
health care needs among people with serious men-
tal illnesses and co-occurring substance use disor-
ders, programs should seek to establish more ef-
fective integration of primary and behavioral health
care service delivery system as well.
u All States should create cross-system
agencies, commissions, or positions charged
with removing barriers and creating incen-
tives for cross-agency activity at the State
and local level.
No one system can solve this problem alone.These
cross-system groups or individuals will play a key
role in spanning the different administrative struc-
tures, funding mechanisms, and treatment philoso-
phies of the mental health, substance abuse, and
criminal justice systems. States must make clear
that collaboration is not only possible but expected.
In Montana, for example, the State Department of
Corrections and Department of Public Health and
Human Services jointly fund a boundary spanner
position that facilitates shared planning, communi-
cation, resources, and treatment methods between
the mental health and criminal justice systems.
u Localities must develop and implement
core services that comprise an Essential Sys-
tem of Care:
Recognizing the limited resources often available
and the complexities of the cross-system collabora-
tions required,the eight components of an Essential
System of Care are best approached in two phases.
Phase 1 includes less expensive, easier to mount
services. Phase 2 includes essential evidence-
based practices that are more expensive and more
challenging to implement, but are critical to actu-
ally increasing positive public safety and public
health outcomes.
Phase 1
>> Forensic Intensive Case Management
>> Supportive Housing
>> Peer Support
>> Accessible and Appropriate Medication
These four services are the ones we believe are
minimally necessary to break the cycle of illness,
arrest and incarceration, and recidivism.We believe
these services — described in brief below — can
be implemented quickly, cost-effectively, and with
positive results. However, these services can only
be effective if the programs that provide them are
structured and staffed by people who understand
and are prepared to address trauma as a risk fac-
tor for both mental health problems and criminal
justice involvement.A trauma-informed system that
features trauma-specific interventions can help en-
sure public health and public safety and transform
individuals’ lives.
Forensic Intensive Case Management (FICM) is
designed for justice-involved people with multiple
and complex needs and features services provided
when and where they are needed. FICM focuses on
brokering rather than providing services directly,
making it less expensive than ACT. For a brokered
service model to be effective, communities must
have adequate and accessible services to which in-
dividuals can be linked.What makes these services
“forensic” is “criminal justice savvy,”3 that is, pro-
viders understand the criminal justice system and
the predicaments of their clients involvement in it.
Supportive Housing is permanent, affordable hous-
ing linked to a broad range of supportive services,
including treatment for mental and substance use
disorders. Supportive housing can significantly de-
crease the chance of recidivism to jails and prisons
and is less costly on a daily basis than jail or prison.
Unfortunately, affordable housing is in short supply
in many communities,and ex-offenders with drugre-
lated offenses often have trouble securing public
housing assistance. Housing for ex-offenders must
balance the needs for supervision and the provision
of social services.
Peer Support services can expand the continuum
of services available to people with mental and
substance use disorders and may help them engage
in treatment. Forensic peer specialists bring real-
world experience with multiple service systems and
an ability to relate one-on-one to people struggling
to reclaim their lives. The practice of consumer-
driven care — as exemplified by the involvement of
mental health consumers in service design,delivery,
and evaluation — is at the heart of a transformed
mental health system.
Accessible and Appropriate Medication supports
continuity of care for individuals with mental ill-
nesses whose treatment often is disrupted when
they become involved in the criminal justice system.
They may not receive appropriate medication in
Recommendations
for Immediate Action

jail or prison or adequate follow-up when they return
to the community. It is imperative that people with
mental illnesses and co-occurring substance use
disorders have access to the right medication at the
right dosage for their condition, as determined by the
individual together with his or her clinician.
Phase 2
Clearly, the Phase 1 services are necessary, but not
sufficient. Services that support the Essential System
of Care include several evidence-based practices for
people with serious mental illnesses. These services
may be more expensive or difficult to implement than
the four listed above, but we encourage States and
communities to move toward development of these
services by codifying them in policy, supporting them
in practice, and rewarding their implementation.
Phase 2 services include:
>> Integrated Dual Diagnosis Treatment, which
provides treatment for mental and substance use dis-
orders simultaneously and in the same setting
>> Supported Employment, which is an evidence-
based practice that helps individuals with mental ill-
nesses find, get, and keep competitive work
>> Assertive Community Treatment (ACT)/ Foren-
sic Assertive Community Treatment (FACT), which
is a service delivery model in which treatment is pro-
vided by a team of professionals, with services deter-
mined by an individual’s needs for as long as required,
and
>> Cognitive Behavioral Interventions Targeted to
Risk Factors specific to offending, are a set of in-
terventions, well researched within both institutional
settings and community settings, that have a utility
when extended to community treatment programs.
This list of evidence-based and promising practices is
illustrative but not exhaustive. Clearly, however, there
is much that can be done to help people with mental
and substance use disorders avoid arrest and incar-
ceration and return successfully to their communities
after jail or prison. We acknowledge that in difficult
financial times, new dollars may not be available.
However,though new money is not always required for
systems change, new ways of thinking are.
To meet the public health and public safety needs
of our communities demands a fully collaborative
campaign involving both the behavioral health and
criminal justice systems. Neither system can continue
business as usual. The criminal justice system needs
to do an adequate job of screening, assessing, and
individualizing responses to detainees and inmates
identified with mental illness. The behavioral health
system needs to refine and deliver evidence-based
practices with an awareness of its responsibility to not
only improve the quality of life of its clients,but to ad-
dress interventions to factors associated with criminal
recidivism in these clients and to more directly involve
clients as partners in a recovery process that recog-
nizes the community’s public safety concerns.
Prime examples of this Essential System of Care have
been developed within the CMHS TCE Jail Diversion
program since 2002. San Antonio, TX, has become a
national model with a highly integrated system of care
that reflects strong behavioral health and criminal
justice partnerships that have resulted in a central-
ized police drop-off that directly links persons to case
management, medications, housing, and peer sup-
port. A medium-size city that has built a comprehen-
sive, integrated system around an existing community
mental health center is Lincoln, NB.These are but two
examples of successfully moving entire communities
forward via a jail diversion program to achieve Phase
1 services and move towards Phase 2 implementa-
tion. These goals are achievable even in today’s eco-
nomic tough times.
We must move toward a day when people with men-
tal and substance use disorders receive the effec-
tive community-based interventions they need and
deserve, and jails and prisons no longer are forced
to serve as primary, de facto treatment facilities. We
know what works to address successfully the needs
of people with mental and substance use disorders
who come in contact with the criminal justice system;
now we have to DO what works. The time for action
is now!
National Leadership Forum Members
Thomas Berger
Vietnam Veterans of America
Sandra Cannon
Ohio Department of Mental Health
Neal Cash
Community Partnership of Southern Arizona
David Fuller
Manhattan Outreach Consortium
Robert Glover
National Association of State Mental Health Program
Directors
Gilbert Gonzales
Bexar County Mental Health Authority Center for Health
Care Services
Richard Gowdy
Missouri Department of Mental Health
Jennifer Johnson
San Francisco Office of the Public Defender
Hon. Steve Leifman
Special Advisor on Criminal Justice and Mental Health to
Florida Supreme Court
Stephanie LeMelle
New York State Psychiatric Institute, Columbia University
Department of Psychiatry
Ginger Martin
Oregon Department of Corrections Transitional Services
Division
John Morris
The Technical Assistance Collaborative
Fred Osher
Council of State Governments Justice Center
Linda Rosenberg*
National Council for Community Behavioral Healthcare
David Shern
Mental Health America
Henry J. Steadman*
Policy Research Associates, CMHS National GAINS Center
Carol Wilkins
Corporation for Supportive Housing
B. Diane Williams
Safer Foundation
Dee Wilson
Texas Department of Criminal Justice
Sharon Wise
The Gregory Project of Washington D.C.
*Co-chair of National Leadership Forum
To meet the public health and public safety needs
of our communities demands a fully collaborative
campaign involving both the behavioral health
and criminal justice systems. Neither system can
continue business as usual.

Interview
Linda Rosenberg, MSW, President & CEO, National
Council for Community Behavioral Healthcare, shares
her thoughts about the current status of treatment for
justice-involved individuals with mental illness and ad-
diction. Committed to supporting the efforts of member
organizations to address the problems of their communi-
ties, Rosenberg has positioned the National Council to
promote the expansion of community based alternatives
to incarceration. Prior to her position at the National
Council, she served as the Senior Deputy Commissioner
for the New York State Office of Mental Health, during
which time she oversaw the state’s services for justice-in-
volved individuals,implementing a network of jail diversion
programs including New York’s first mental health court.
National Council: What challenges exist in serving
justice-involved people with mental illness and addic-
tions?
Linda: There are many challenges in connecting jus-
tice involved consumers with services. We’re talking
primarily about people with little money or power and
they may have little or no interest in mental health or
addictions treatment services. They’ve not found ser-
vices useful or relevant and often dislike programs that
are highly structured. Our job at the National Council
is to identify member organizations that have devel-
oped successful services for this population and then
to facilitate the member to member spread of these
programs.
National Council: New York has an assisted outpa-
tient treatment law — what is the controversy behind
such laws?
Linda: Some view these laws as victimizing — blaming
— people with mental illness. In a perfect world, court
ordered treatment would be unnecessary but in our
world the combined power of the court and treatment
can mean successful community living for consumers
that would otherwise be in and out of hospital or jail.
Assisted Outpatient Treatment must be carefully used
but when all else fails it can connect people to vital
services. But AOT alone isn’t enough — a full array of
community services including housing, effective treat-
ments, work supports, and general medical care must
be available and accessible. Unfortunately passage of
AOT is often a political reaction to an unfortunate inci-
dent — a law is passed with no financing of the services
that are critical if we’re going to keep both individuals
with mental illnesses and our communities safe.
National Council: As a state official in New York,
you were a strong supporter of the state’s first mental
health court. What benefits do such courts bring to
providers and the individuals they serve?
Linda: I’ve seen mental health courts and to an even
greater extent, drug courts, emerge as a powerful
means through which people access care. In many
places the court begins with a judge who has personal
and/or professional interest in behavioral health is-
sues. Mental health and drug courts aren’t meant to
be applied broadly — these courts are alternatives for
people with serious mental illnesses and addictions
that are on the way to jail or prison.And like AOT, there
must be seamless connections to the full continuum of
treatment and support services.These problem-solving
courts give individuals with serious behavioral health
disorders a unique opportunity to engage with a judge
around their needs.The courts provide alternatives to
people with mental illnesses and addiction — offering
services instead of time behind bars.
National Council: How can states move forward in
creating programs for justice-involved persons in this
era of budget cuts? What role do community providers
play?
Linda:Change is often incremental in our very complex
world but it looks like we’ve reached a tipping point in
regard to diversion and re-entry. Policy change is often
driven by a convergence of ideas and money. States
are in tremendous economic distress and can’t con-
tinue to build new jails and prisons or support grow-
ing numbers of incarcerated individuals. At the same
time it’s becoming clear that treatment and services
works and are less expensive alternatives. Look at the
President’s budget proposal – growth in financing of
alternatives to criminal justice involvement. This is an
area where there is both new money and potential for
re-investment of dollars currently directed to incarcer-
ation.And as always leadership is essential — excited
by the possibilities, local leaders emerge, enlist others
in their vision, and the money follows.
National Council: How does the justice-involved
population “fall through the cracks?”
Linda: The falling through the cracks problem is not
unique to justice-involved individuals. Every time we
create a new program or service to keep people from
falling through the cracks, we are creating another
crack for someone to fall through.The system has got-
ten so rich and so complicated — multiple programs
and services, most under different corporate auspices
and each with its unique rules and operating practices
— that it’s difficult to navigate it.A person’s treatment
is run by one organization, their housing by another,
their employment supports by another — and getting
all these organizations on the same page and at the
same table becomes nearly impossible. It is very, very
difficult to coordinate services.
National Council:What can be done to support co-
ordinated treatment?
Linda: I think in the end we need a system where one
organization/person is responsible. If everyone is re-
sponsible, then no one is responsible. The buck has
to stop somewhere and I think it needs to stop with
an organization that gets an adequate pot of money
and ensures that the consumer gets the services they
need and want.With adequate financing, clarity as to
what treatments and services are effective and the de-
livery of those interventions, use of health information
technology, and the ongoing measurement of simple
outcomes — hospitalization, incarceration and home-
lessness — we can coordinate care and go a long way
toward supporting successful community tenure. That
doesn’t mean that all justice-involved people will have
a straight trajectory to recovery. Some people will be
hospitalized and some might be incarcerated or be-
come homeless. We can do better but challenges will
remain.Our jobs are to address the challenges,always
exploring new approaches and refining our efforts to
improve lives.
Mohini Venkatesh serves as the staff policy liaison to the
National Council for Community Behavioral Healthcare’s
network of associations throughout the states, conducts federal
legislative and policy analysis on an array of issues, and man-
ages political engagement activities including an annual Hill
Day in Washington, DC. She received a masters in public health
from Yale University and a BA in psychology from the University
of Massachusetts-Amherst.
Nathan Sprenger supports the National Council’s public rela-
tions and marketing efforts, leads the social media activities,
maintains the website, and serves as editorial assistant for
National Council Magazine. He has a masters degree in public
communication from American University in Washington DC.
Linda Rosenberg, MSW, President & CEO, National Council for Community Behavioral Healthcare, Interviewed by Mohini Venkatesh,
Director, Federal and State Policy and Nathan Sprenger, Marketing and Communications Associate — National Council for Community
Behavioral Healthcare
Behavioral Health and Criminal Justice Collaboration:
There must be a single point of
accountability. If everyone is respon-
sible, then no one is responsible.”

VIVITROL...
there when they need it.
For the treatment of alcohol dependence
VIVITROL is a registered trademark of Alkermes, Inc.
©2010 Alkermes, Inc.
All rights reserved VIV 981 B January 2010 Printed in U.S.A.
www.vivitrol.com
Please see brief summary ofViViTrol Prescribing informaTion,
including boxedwarning,onThe nexT Page.
Naltrexonehasthecapacitytocausehepatocellularinjurywhengiveninexcessivedoses.
Naltrexoneiscontraindicatedinacutehepatitisorliverfailure,anditsuseinpatientswithactiveliver
diseasemustbecarefullyconsideredinlightofitshepatotoxiceffects.
Themarginofseparationbetweentheapparentlysafedoseofnaltrexoneandthedosecausing
hepaticinjuryappearstobeonlyfive-foldorless.VIVITROLdoesnotappeartobeahepatotoxinatthe
recommendeddoses.
Patientsshouldbewarnedoftheriskofhepaticinjuryandadvisedtoseekmedicalattentionifthey
experiencesymptomsofacutehepatitis.UseofVIVITROLshouldbediscontinuedintheeventofsymptoms
and/orsignsofacutehepatitis.
VIVITROLisadministeredasaglutealintramuscularinjection.Inadvertentsubcutaneousinjectionof
VIVITROLmayincreasethelikelihoodofsevereinjectionsitereactions.VIVITROLmustbeinjectedusing
thecustomizedneedleprovidedinthecarton.Becauseneedlelengthmaynotbeadequateduetobody
habitus,eachpatientshouldbeassessedpriortoeachinjectiontoassurethatneedlelengthisadequate
forintramuscularadministration.VIVITROLinjectionsitereactionsmaybefollowedbypain,tenderness,
induration,swelling,erythema,bruisingorpruritus;however,insomecasesinjectionsitereactionsmaybe
verysevere.Injectionsitereactionsnotimprovingmayrequirepromptmedicalattention,includinginsome
casessurgicalintervention.
Considerthediagnosisofeosinophilicpneumoniaifpatientsdevelopprogressivedyspneaandhypoxemia.
InanemergencysituationinpatientsreceivingVIVITROL,suggestionsforpainmanagementincluderegional
analgesiaoruseofnon-opioidanalgesics.Alcoholdependentpatients,includingthosetakingVIVITROL,
shouldbemonitoredforthedevelopmentofdepressionorsuicidalthoughts.Cautionisrecommendedin
administeringVIVITROLtopatientswithmoderatetosevererenalimpairment.
ThemostcommonadverseeventsassociatedwithVIVITROLinclinicaltrialswerenausea,vomiting,
headache,dizziness,asthenicconditionsandinjectionsitereactions.
1. VIVITROL [full prescribing information]. Waltham, MA: Alkermes, Inc; May 2009.
*Eligibility for co-pay assistance: Offer not valid for prescriptions purchased under Medicaid, Medicare, or any federal
or state healthcare programs, including any state medical or pharmaceutical assistance program. Offer not valid
in Massachusetts. Void where prohibited by law, taxed or restricted. Alkermes, Inc. reserves the right to rescind,
revoke or amend these offers without notice.
indicaTion1
VIVITROL®
isindicatedforthetreatmentofalcoholdependenceinpatientswhoareabletoabstain
fromalcoholinanoutpatientsettingpriortoinitiationoftreatmentwithVIVITROL.
PatientsshouldnotbeactivelydrinkingatthetimeofinitialVIVITROLadministration.
TreatmentwithVIVITROLshouldbepartofacomprehensivemanagementprogramthatincludes
psychosocialsupport.
imPorTanT safeTy informaTion for ViViTrol1
VIVITROLiscontraindicatedinpatientsreceivingopioidanalgesicsorwithcurrentphysiologic
opioiddependence,patientsinacuteopiatewithdrawal,anyindividualwhohasfailedthenaloxone
challengetestorhasapositiveurinescreenforopioids,orinpatientswhohavepreviouslyexhibited
hypersensitivitytonaltrexone,PLG,carboxymethylcelluloseoranyothercomponentsofthediluent.
VIVITROLpatientsmustbeopioidfreeforaminimumof7-10daysbeforetreatment.Attemptstoovercome
opioidblockadeduetoVIVITROLmayresultinafataloverdose.Inprioropioidusers,useofopioidsafter
discontinuingVIVITROLmayresultinafataloverdosebecausepatientsmaybemoresensitivetolower
dosesofopioids.PatientsrequiringreversaloftheVIVITROLblockadeforpainmanagementshouldbe
monitoredbyappropriatelytrainedpersonnelinasettingequippedforcardiopulmonaryresuscitation.
For more information, call toll-free
1-800-VIVITROL (1-800-848-4876, ext. 2).
Tell Your Patients About Our
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Upto6monthsofmedicationwith
potentiallynoout-of-pocketcosts*

BRIEF SUMMARY See package insert for full Prescribing Information.
INDICATIONS AND USAGE: VIVITROL is indicated for the treatment of alcohol dependence in patients
who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with
VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration.
Treatment with VIVITROL should be part of a comprehensive management program that includes
psychosocial support. CONTRAINDICATIONS: VIVITROL is contraindicated in: • Patients receiving
opioid analgesics (see PRECAUTIONS). • Patients with current physiologic opioid dependence (see
WARNINGS). • Patients in acute opiate withdrawal (see WARNINGS). • Any individual who has failed
the naloxone challenge test or has a positive urine screen for opioids. • Patients who have previously
exhibited hypersensitivity to naltrexone, PLG, carboxymethylcellulose, or any other components of the
diluent.
WARNINGS: Hepatotoxicity
Eosinophilic pneumonia In clinical trials with VIVITROL, there was one diagnosed case and one
suspected case of eosinophilic pneumonia. Both cases required hospitalization, and resolved after
treatment with antibiotics and corticosteroids. Should a person receiving VIVITROL develop progressive
dyspnea and hypoxemia, the diagnosis of eosinophilic pneumonia should be considered (see ADVERSE
REACTIONS). Patients should be warned of the risk of eosinophilic pneumonia, and advised to seek
medical attention should they develop symptoms of pneumonia. Clinicians should consider the possibility
of eosinophilic pneumonia in patients who do not respond to antibiotics. Unintended Precipitation of
Opioid Withdrawal—To prevent occurrence of an acute abstinence syndrome (withdrawal) in
patients dependent on opioids, or exacerbation of a pre-existing subclinical abstinence syndrome,
patients must be opioid-free for a minimum of 7-10 days before starting VIVITROL treatment. Since
the absence of an opioid drug in the urine is often not sufficient proof that a patient is opioid-free,
a naloxone challenge test should be employed if the prescribing physician feels there is a risk
of precipitating a withdrawal reaction following administration of VIVITROL. Opioid Overdose
Following an Attempt to Overcome Opiate Blockade VIVITROL is not indicated for the purpose of
opioid blockade or the treatment of opiate dependence. Although VIVITROL is a potent antagonist with
a prolonged pharmacological effect, the blockade produced by VIVITROL is surmountable. This poses
a potential risk to individuals who attempt, on their own, to overcome the blockade by administering
large amounts of exogenous opioids. Indeed, any attempt by a patient to overcome the antagonism by
taking opioids is very dangerous and may lead to fatal overdose. Injury may arise because the plasma
concentration of exogenous opioids attained immediately following their acute administration may be
sufficient to overcome the competitive receptor blockade. As a consequence, the patient may be in
immediate danger of suffering life-endangering opioid intoxication (e.g., respiratory arrest, circulatory
collapse). Patients should be told of the serious consequences of trying to overcome the opioid blockade
(see INFORMATION FOR PATIENTS).There is also the possibility that a patient who had been treated with
VIVITROL will respond to lower doses of opioids than previously used. This could result in potentially
life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc.). Patients
should be aware that they may be more sensitive to lower doses of opioids after VIVITROL treatment is
discontinued (see INFORMATION FOR PATIENTS). PRECAUTIONS: General—When Reversal of VIVITROL
Blockade is Required for Pain Management In an emergency situation in patients receiving VIVITROL,
suggestions for pain management include regional analgesia or use of non-opioid analgesics. If opioid
therapy is required as part of anesthesia or analgesia, patients should be continuously monitored in an
anesthesia care setting, by a person not involved in the conduct of the surgical or diagnostic procedure.
The opioid therapy must be provided by an individual specifically trained in the use of anesthetic drugs
and the management of the respiratory effects of potent opioids, specifically the establishment and
maintenance of a patent airway and assisted ventilator. Depression and Suicidality In controlled clinical
trials of VIVITROL, adverse events of a suicidal nature (suicidal ideation, suicide attempts, completed
suicides) were infrequent overall, but were more common in patients treated with VIVITROL than in
patients treated with placebo (1% vs. 0). In some cases, the suicidal thoughts or behavior occurred after
study discontinuation, but were in the context of an episode of depression which began while the patient
was on study drug. Two completed suicides occurred, both involving patients treated with VIVITROL.
Depression-related events associated with premature discontinuation of study drug were also more
common in patients treated with VIVITROL (~1%) than in placebo-treated patients (0). In the 24-week,
placebo-controlled pivotal trial, adverse events involving depressed mood were reported by 10% of
patients treated with VIVITROL 380 mg, as compared to 5% of patients treated with placebo injections.
Alcohol dependent patients, including those taking VIVITROL, should be monitored for the development of
depression or suicidal thinking. Families and caregivers of patients being treated with VIVITROL should be
alerted to the need to monitor patients for the emergence of symptoms of depression or suicidality, and to
report such symptoms to the patient’s healthcare provider. Injection Site Reactions VIVITROL injections
may be followed by pain, tenderness, induration, swelling, erythema, bruising or pruritus; however in
some cases injection site reactions may be very severe. In the clinical trials, one patient developed an
area of induration that continued to enlarge after 4 weeks with subsequent development of necrotic tissue
that required surgical excision. In the postmarketing period, additional cases of injection site reaction
with features including induration, cellulitis, hematoma, abscess, sterile abscess and necrosis have been
reported. Some cases required surgical intervention. VIVITROL is administered as a gluteal intramuscular
injection. An inadvertent subcutaneous injection of VIVITROL may increase likelihood of severe injection
site reactions. VIVITROL must be injected by the customized needle provided in the carton. Alternate
treatment should be considered for those patients whose body habitus precludes a gluteal
intramuscular injection with the provided needle. Patients should be informed that any injection site
reactions should be brought to the attention of the healthcare provider (see INFORMATION FOR PATIENTS).
Patients exhibiting signs of abscess, cellulitis, necrosis or extensive swelling should be evaluated by a
physician. Renal Impairment VIVITROL pharmacokinetics have not been evaluated in subjects with
moderate and severe renal insufficiency. Because naltrexone and its primary metabolite are excreted
primarily in the urine, caution is recommended in administering VIVITROL to patients with moderate to
severe renal impairment. Alcohol Withdrawal Use of VIVITROL does not eliminate nor diminish alcohol
withdrawal symptoms. Intramuscular injections As with any intramuscular injection, VIVITROL should
be administered with caution to patients with thrombocytopenia or any coagulation disorder (e.g.,
hemophilia and severe hepatic failure). Information for Patients Physicians are advised to consult Full
Prescribing Information for information to be discussed with patients for whom they have prescribed
VIVITROL. Drug Interactions Patients taking VIVITROL may not benefit from opioid-containing medicines
(see PRECAUTIONS, Pain Management). Because naltrexone is not a substrate for CYP drug metabolizing
enzymes, inducers or inhibitors of these enzymes are unlikely to change the clearance of VIVITROL.
No clinical drug interaction studies have been performed with VIVITROL to evaluate drug interactions,
therefore prescribers should weigh the risks and benefits of concomitant drug use. The safety profile
of patients treated with VIVITROL concomitantly with antidepressants was similar to that of patients
taking VIVITROL without antidepressants. Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity studies have not been conducted with VIVITROL. Carcinogenicity studies of oral naltrexone
hydrochloride (administered via the diet) have been conducted in rats and mice. In rats, there were small
increases in the numbers of testicular mesotheliomas in males and tumors of vascular origin in males and
females. The clinical significance of these findings is not known. Naltrexone was negative in the following
in vitro genotoxicity studies: bacterial reverse mutation assay (Ames test), the heritable translocation
assay, CHO cell sister chromatid exchange assay, and the mouse lymphoma gene mutation assay.
Naltrexone was also negative in an in vivo mouse micronucleus assay. In contrast, naltrexone tested
positive in the following assays: Drosophila recessive lethal frequency assay, non-specific DNA damage in
repair tests with E. coli and WI-38 cells, and urinalysis for methylated histidine residues. Naltrexone given
orally caused a significant increase in pseudopregnancy and a decrease in pregnancy rates in rats at 100
mg/kg/day (600 mg/m2
/day). There was no effect on male fertility at this dose level. The relevance of these
observations to human fertility is not known. Pregnancy Category C Reproduction and developmental
studies have not been conducted for VIVITROL. Studies with naltrexone administered via the oral route
have been conducted in pregnant rats and rabbits. Teratogenic Effects Oral naltrexone has been shown
to increase the incidence of early fetal loss in rats administered ≥30 mg/kg/day (180 mg/m2
/day) and
rabbits administered ≥60 mg/kg/day (720 mg/m2
/day). There are no adequate and well-controlled studies
of either naltrexone or VIVITROL in pregnant women. VIVITROL should be used during pregnancy only if
the potential benefit justifies the potential risk to the fetus. Labor and Delivery The potential effect of
VIVITROL on duration of labor and delivery in humans is unknown. Nursing Mothers Transfer of naltrexone
and 6β-naltrexol into human milk has been reported with oral naltrexone. Because of the potential for
tumorigenicity shown for naltrexone in animal studies, and because of the potential for serious adverse
reactions in nursing infants from VIVITROL, a decision should be made whether to discontinue nursing or
to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use The
safety and efficacy of VIVITROL have not been established in the pediatric population. Geriatric Use In
trials of alcohol dependent subjects, 2.6% (n=26) of subjects were >65 years of age, and one patient was
>75 years of age. Clinical studies of VIVITROL did not include sufficient numbers of subjects age 65 and
over to determine whether they respond differently from younger subjects. ADVERSE REACTIONS: In all
controlled and uncontrolled trials during the premarketing development of VIVITROL, more than 900 patients
with alcohol and/or opioid dependence have been treated with VIVITROL. Approximately 400 patients
have been treated for 6 months or more, and 230 for 1 year or longer. Adverse Events Leading to
Discontinuation of Treatment In controlled trials of 6 months or less, 9% of patients treated with VIVITROL
discontinued treatment due to an adverse event, as compared to 7% of the patients treated with placebo.
Adverse events in the VIVITROL 380-mg group that led to more dropouts were injection site reactions (3%),
nausea (2%), pregnancy (1%), headache (1%), and suicide-related events (0.3%). In the placebo group, 1%
of patients withdrew due to injection site reactions, and 0% of patients withdrew due to the other adverse
events. Common Adverse Events The most common adverse events associated with VIVITROL in clinical
trials were nausea, vomiting, headache, dizziness, fatigue, and injection site reactions. For a complete list
of adverse events, please refer to the VIVITROL package insert for full Prescribing Information. A majority of
patients treated with VIVITROL in clinical studies had adverse events with a maximum intensity of “mild”
or “moderate.” Post-marketing Reports—Reports From Other Intramuscular Drug Products
Containing Polylactide-co-glycolide (PLG) Microspheres – Not With VIVITROL. Retinal Artery
Occlusion Retinal artery occlusion after injection with another drug product containing polylactide-
co-glycolide (PLG) microspheres has been reported very rarely during post-marketing surveillance.
This event has been reported in the presence of abnormal arteriovenous anastomosis. No cases
of retinal artery occlusion have been reported during VIVITROL clinical trials or post-marketing
surveillance. VIVITROL should be administered by intramuscular (IM) injection into the gluteal
muscle, and care must be taken to avoid inadvertent injection into a blood vessel (see DOSAGE
AND ADMINISTRATION). OVERDOSAGE: There is limited experience with overdose of VIVITROL. Single
doses up to 784 mg were administered to 5 healthy subjects. There were no serious or severe adverse
events. The most common effects were injection site reactions, nausea, abdominal pain, somnolence, and
dizziness. There were no significant increases in hepatic enzymes. In the event of an overdose, appropriate
supportive treatment should be initiated. This brief summary is based on VIVITROL Prescribing Information
(VIV 566C May 2009).
Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses.
Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver
disease must be carefully considered in light of its hepatotoxic effects.
The margin of separation between the apparently safe dose of naltrexone and the dose causing
hepatic injury appears to be only five-fold or less. VIVITROL does not appear to be a hepatotoxin at the
recommended doses.
Patients should be warned of the risk of hepatic injury and advised to seek medical attention if they
experience symptoms of acute hepatitis. Use of VIVITROL should be discontinued in the event of symptoms
and/or signs of acute hepatitis.
Alkermes®
and VIVITROL®
are registered trademarks of Alkermes, Inc.
Manufactured and marketed by Alkermes, Inc.
©2009 Alkermes, Inc. VIV 107C July 2009 Printed in U.S.A. All rights reserved.

Beyond Bars
Judge Leifman Encounters the Challenge
“When I first became a judge,I discovered a situation familiar
to many of my colleagues but seldom discussed outside the
courtroom — a situation that my legal and judicial training
had not prepared me for. Day after day, defendants stood be-
fore me, disheveled and distraught. Most were charged with
relatively minor offenses such as loitering or panhandling.
Some exhibited impulsive behaviors, speaking in pressured,
incoherent sentences. Others were guarded and withdrawn,
appearing to have little understanding of the circumstances
in which they found themselves. Homelessness, substance
abuse, and trauma were symptoms of a larger set of personal
and social factors contributing to their unfortunate and often
repeated involvement in the criminal justice system. These
people of many backgrounds shared one thing in common —
serious and persistent mental illness.
When I first came across defendants experiencing acute men-
tal illness, I followed the lead of my fellow judges by appoint-
ing experts and ordering psychiatric evaluations to determine
their competence to proceed with their court cases.Although
these evaluations tended to be very costly and meant that
defendants would remain in jail for weeks or possibly even
months, the idea of releasing a person in acute psychiatric
distress to the streets with nowhere to live and no supports
seemed a far more cruel response to the situation. I assumed
that once evaluations by mental health experts were complet-
ed and the need for treatment was documented, the mental
health treatment system would step in, if not voluntarily, then
by court order.
Before long, I realized my assumptions were wrong. Even
though I had expert opinions indicating that people were
indeed experiencing severe psychiatric symptoms — and in
many cases requiring immediate hospitalization — state law
prohibited judges presiding over misdemeanor cases from
ordering treatment in the forensic mental health system. In-
stead, the law required people to be released to the commu-
nity on the condition that they participate in treatment, but
there was no mechanism to ensure that treatment,housing,or
any other type of support was actually provided.
Judge Steven Leifman, Special Advisor on Criminal Justice and Mental Health, Supreme Court of Florida, and Associate Administrative
Judge, County Court, Criminal Division, 11th Judicial Circuit of Florida; Tim Coffey, Coordinator, 11th Judicial Circuit, Criminal Mental Health
Project
Decriminalizing Mental Illness:
Miami Dade County Tackles a Crisis at the Roots
Miami-Dade County, Florida houses the largest percentage of people
with serious mental illness (e.g., schizophrenia, bipolar disorder, major
depression) of any urban community in the United States. Roughly
9.1 percent of the population (170,000 adults) experiences serious
mental illness, yet only 1 percent (24,000 adults) receives treatment
in the public mental health system. By contrast, the number of people
accessing mental health services through the Miami-Dade County jail
is staggering. Of the roughly 114,000 bookings into the jail this past
year, it is estimated that as many as 20,000 people with mental
illness required psychiatric treatment during incarceration.
On any given day, the county jail houses approximately 1,200 people
with mental illness receiving psychotherapeutic medications. This
number represents 17 percent of the total inmate population and
costs taxpayers more than $50 million annually.The Miami-Dade
County jail serves as the largest psychiatric institution in the state
of Florida, housing more beds serving people with mental illness
than any inpatient hospital in the state and nearly half as many beds
as there are in all state civil and forensic mental health hospitals
combined.
Sadly, these statistics are not unique to south Florida. Findings from
a recent study suggest that people with serious mental illness are
arrested and booked into jails in the United States more than two
million times annually. Roughly three-quarters of these people also
have co-occurring substance use disorders that increase their
likelihood of becoming involved in the justice system. On the basis
of the most recent population data reported by the Department of
Justice, it is estimated that currently 400,000 people with mental
illnesses are incarcerated in jails and prisons across the country,
and nearly 900,000 are on probation or parole in the community.

National Council Magazine, 2010 Issue 1

National Council Magazine, 2010 Issue 1

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