To the Editor: The department of mental health of Riverside County, California, has had the equivalent of an outpatient program operating within the main county jail since early 1988. Clinical staff of the program respond to requests for assessment and treatment from sheriff's department personnel, the inmates themselves, and inmates' families. Mental health staff also monitor inmates felt to be potentially suicidal or homicidal and evaluate those with more serious psychiatric illnesses for transfer to a secure inpatient setting in the county hospital.
In line with national statistics, at any one time approximately 10 to 15 percent of the inmates are severely mentally ill (1). Many of these inmates would be better served outside the jail setting (2). Consequently, in 1995 mental health staff designed a diversion program in collaboration with the other major players, including the sheriff's department, the district attorney's office, the public defender's office, the probation department, and representatives of the superior and municipal courts.
Successful diversion of people with serious mental illnesses goes beyond just keeping them out of jail. Some of the most challenging cases are clients who tend to come to the attention of the police regularly. Many have other major problems besides their mental illness, such as poor housing or actual homelessness and marginal employment skills. They are typically well known to the mental health system and have a history of very poor treatment compliance or blatant refusal of services. Many also suffer from serious substance abuse. Further, many offenders with mental disorders are at high risk of committing other offenses, particularly if their mental illness is untreated.
Any potentially successful program aimed at diverting offenders from jail would have to offer strong and consistent support and management. With this in mind, the program's design called for evaluation and assessment, presentation of options for diversion to the court, intensive case management services, individual and group therapy, and medication management and referral to day treatment programs when appropriate.
Referrals to the diversion program are inmates with severe and persistent mental illness who have committed misdemeanors but have a minimal history of violence. They must agree to comply with treatment and to follow program regulations. They must have at least a nine-month sentence to ensure treatment continuity, stability, and program effectiveness.
From the program's inception on February 22, 1996, through October 31, 1998, a total of 180 clients were referred, 37 were accepted, and four were on a waiting list. Thirteen had successfully completed the program and were living in the community. Four clients left the program without approval and had not been found, and nine had their outpatient status revoked.
Over the course of almost three years of the program's operation, we have found that certain clients are better candidates for diversion than others. Our failures include those with poor motivation to change their lifestyle, repeated previous treatment failures and medication noncompliance, inability to adjust to limits and structure, little or no community support (family, friends, or previous employment), and serious substance abuse. For these clients, a more structured, longer-term setting, though not a correctional one, would seem to be a better choice.
For those who successfully completed the program and were discharged from the court's jurisdiction, several factors stand out: acknowledgment that previous methods of adaptation were self-destructive and nonproductive, the ability and determination to commit to sobriety and an ongoing recovery program, and the capacity to adopt new skills and coping mechanisms to deal with and express feelings.
Dr. Seide is adult services manager for the Riverside County Department of Mental Health in Riverside, California.