A SAMHSA Research Initiative Assessing the Effectiveness of Jail Diversion Programs for Mentally Ill Persons

The number of persons with mental illness in U.S. jails continues to grow (1,2,3,4,5,6). Currently the prevalence of serious mental illness among inmates is about 7 percent, which means that nearly 700,000 persons with active symptoms of severe mental illness are admitted to jails annually (5,6,7). About 75 percent of this population have a co-occurring alcohol or drug use disorder (8). Criminal justice and mental health professionals and advocates have called for diversion efforts to link offenders with mental illness to community-based services to break their continued cycling through the criminal justice, mental health, and substance abuse treatment systems and to reduce the number of people with mental illness in jails (1,9).

Jail diversion generally refers to specific programs that screen detainees in contact with the criminal justice system for the presence of mental disorder; they employ mental health professionals to evaluate the detainees and negotiate with prosecutors, defense attorneys, community-based mental health providers, and the courts to develop community-based mental health dispositions for mentally ill detainees. The mental health disposition is sought as an alternative to prosecution, as a condition of a reduction in charges, or as satisfaction for the charges, for example, as a condition of probation. Once such a disposition is decided on, the diversion program links the client to community-based mental health services.

In a recent survey, 34 percent of U.S. jails indicated that they had some type of formal diversion program for mentally ill detainees (2). However, in a follow-up telephone survey, only 18 percent of the jails that claimed to have such interventions actually had programs that fit the definition provided above. After researchers visited these sites, their final estimate was that only about 50 to 55 true jail diversion programs for mentally ill detainees exist nationwide.

When the major diversion programs were examined, five key elements were associated with the programs that were perceived to be most successful. First, all relevant mental health, substance abuse, and criminal justice agencies were involved in program development from the start. Second, regular meetings between key personnel from the various agencies were held. Third, integration of services was encouraged through the efforts of a liaison person, or "boundary spanner," between the corrections, mental health, and judicial staff. Fourth, the programs had strong leadership. And fifth, nontraditional case management approaches were used. These approaches relied on staff the were hired less for their academic credentials and more for their experience across criminal justice, mental health, and substance abuse systems. The bottom line was that program effectiveness depended on building new system linkages, viewing detainees as citizens, and holding the community responsible for the full array of services needed by the detainees.

Outcomes of jail diversion programs

Although jail diversion programs appear to have widespread support, few outcome studies have systematically examined the effectiveness of diversion programs using client outcome data. The literature offers little information on whether current programs benefit the targeted recipients in terms of symptom stabilization, reduced jail time, higher levels of community adjustment, and stable participation in community mental health services. Torrey and colleagues (1) noted that there was not enough evidence about the comparative effectiveness of alternative approaches to jail diversion to recommend one approach over another. Rogers and Bagby (9) argued that without good outcome data, recommendations about diversion appear to reflect individual clinicians' opinions rather than any standardized format for decision making.

Since these calls for research were issued, three modest outcome studies have been published. Lamb and colleagues (10,11) studied both a prebooking jail diversion program and a postbooking, court-based program in Los Angeles County. Deane and colleagues (12) conducted a national mail survey of police departments in the U.S. to identify various types of law enforcement and mental-health-based strategies for handling mentally ill persons and to determine the availability of jail diversion programs. This group of researchers subsequently conducted an in-depth analysis of two of the most innovative prebooking jail diversion programs operating in the U.S. (13).

Lamb and colleagues' study of the prebooking diversion program (10) sought to determine whether emergency outreach teams composed of police officers and mental health professionals could assess and make appropriate disposition decisions for psychiatric crisis cases in the community, including situations involving a threat of violence or actual violence. The study included a six-month follow-up of all referrals to the specialized outreach teams. Sixty-nine subjects encountered by the teams were placed on involuntary 72-hour holds; 80 were transported to hospitals, and 73 were actually hospitalized. Only two subjects were taken to jail.

The researchers concluded that the teams benefited from shared access to mental health and criminal justice records in making disposition decisions. The trained police officers provided security, transportation, law enforcement field resources, and knowledge about handling violence. The mental health specialists provided knowledge about mental illness and experience in diagnosis, crisis evaluation, and interacting with psychiatric patients. Overall, the teams increased the percentage of mentally ill persons who had access to the mental health system.

The study of the prebooking diversion program by Borum and associates (13) included two diversion sites—the community service officer program in Birmingham, Alabama, and the crisis intervention team in Memphis, Tennessee. The Birmingham community service officer program is a police department-based program staffed with in-house social workers. The Memphis crisis intervention team is a police-department-based cadre of specially trained officers who handle mental health crisis calls when the police are the first line of response. For comparison, the study included a traditional mental health emergency team—a mobile crisis unit in Knoxville, Tennessee—which is based in the county's mental health department and works with the Knoxville police department.

The diversion programs in the study differed in the backgrounds of the members of the response teams, the settings where they were based, how the teams were trained, and how they handled crises with mentally ill people. The study focused on the extent to which the use of a prebooking diversion program was associated with specialized procedures for managing persons with mental illness and with reductions in their arrests.

The three programs had notable differences, partly due to the program structure and staffing patterns. However, all three showed great promise for diverting mentally ill people from jail, keeping them in the community, and facilitating access to treatment. Across all three sites, only 6.7 percent of the "mental disturbance" calls resulted in arrest. The Memphis crisis intervention team had an arrest rate of 2 percent, which was comparable to that reported by Lamb and colleagues (10) for the prebooking diversion program they studied. In more than half of the encounters examined in all three programs, mentally ill subjects were either transported or referred to treatment; in a third of the encounters, program staff used specialized response procedures to provide crisis intervention or resolve the incident on the scene. Of the three programs, the Memphis crisis intervention team appeared to make the management of crisis incidents easiest on police by offering a no-refusal, 24-hour crisis dropoff center.

Lamb and colleagues (11) examined outcomes from a postbooking diversion program in Los Angeles County that provided mental health consultation to a municipal court. Clinical and forensic records of 96 individuals charged with misdemeanors and referred to a clinical psychologist court consultant for evaluation were studied. Follow-up information was collected one year after arrest on each subject. Poor outcomes were defined as psychiatric hospitalization, arrest, significant physical violence against persons, or homelessness during the follow-up year. Although 54 percent of the sample had a poor outcome, a significantly larger proportion of subjects who were diverted to receive judicially monitored treatment had a good outcome compared with subjects who were not mandated to receive monitored treatment. Also, subjects mandated to receive judicially monitored treatment had significantly better outcomes than subjects referred for treatment, but without court monitoring.

The three outcome studies described here offer some useful information. However, they do not provide adequate data to help answer the questions of a county executive, a sheriff, or some other elected official who asks a diversion program proponent to show how the proposed program will save the county money or keep the streets safer. In the absence of more comprehensive client outcome data and some cost-effectiveness information, the creation of innovative programs to prevent the unnecessary and often harmful incarceration of persons with serious mental illness is severely compromised.

To produce such data is extremely difficult. In real-world settings, random clinical trials are usually ethically impossible or, if possible, are impractical given local politics and the public's fears. Nonetheless, a current federal initiative holds great promise of filling these empirical gaps with information that will help communities in the design, implementation, and operation of both prebooking, police-department-based diversion programs and postbooking, arraignment-court and jail-based diversion programs.

The SAMHSA jail diversion initiative

In September 1997, the Substance Abuse and Mental Health Services Administration (SAMHSA) funded a three-year Knowledge and Development Application on jail diversion. The goal of the Knowledge and Development Application program is to develop new knowledge about ways to improve the prevention and treatment of substance abuse and mental illness, and to work with state and local governments as well as providers, families, and consumers to apply that knowledge effectively in everyday practice. Knowledge Development and Application grants do not provide operating funds for service programs, except as required by the knowledge development activity.

The jail diversion initiative moves beyond the three outcome studies described above in four ways. First, it includes several sites. Second, it is collecting extensive background and outcome data on subjects who are diverted from jail and on comparison subjects. Third, the study subjects constitute a diverse group. About 70 percent of the subjects are expected to be men in their mid 30s, most of whom have a mood disorder or schizophrenia. Their charges are expected to be primarily nonviolent misdemeanors, although a few are expected to have committed nonviolent felonies. Fourth, the jail diversion initiative will gather some cost data. The results will allow more sophisticated answers to the core questions for diversion—what works, for whom, and under what circumstances.

SAMHSA selected nine sites with established diversion programs to assess the effectiveness of the three major types of jail diversion programs—prebooking programs, court-based postbooking programs, and jail-based postbooking programs. The sites qualified for funding by submitting proposals describing strategies to evaluate the relative effectiveness of fully functioning diversion models for individuals with co-occurring serious mental illnesses and alcohol or other drug use disorders. The Research Triangle Institute in Research Triangle Park, North Carolina, was chosen to coordinate the research initiative, and the National GAINS Center of Policy Research, Inc., in Delmar, New York, was chosen to provide technical assistance to the sites to facilitate coordinated services and to assist in reporting the research findings. The nine sites selected for the study are Maricopa County (the Phoenix area) and Pima County (the Tucson area) in Arizona; Hartford, Bridgeport, Stamford, New Haven, and Norwich and New London counties in Connecticut; Oahu and Kauai, Hawaii; Wicomico County, Maryland; New York City; Lane County (the Eugene area) and Multnomah County (the Portland area) in Oregon; Bucks County and Montgomery County, Pennsylvania; and Memphis, Tennessee.

A total of five prebooking programs are included in the research initiative. Prebooking programs in Memphis, Multnomah County, Oregon, and Montgomery County, Pennsylvania, intensively train members of the police force to handle calls that involve an individual with mental health or substance abuse problems. Each site has a 24-hour crisis center with a no-refusal policy that is available to receive persons brought in by the police. A prebooking program in Wicomico County, Maryland, targets women. Two of the three programs in Hawaii that are included in the study have prebooking programs. In Kauai, an informal prebooking program uses community connections to divert seriously mentally ill misdemeanants. In Honolulu, a prebooking program has a staff member who is the single point of contact for police officers; the program creates linkages with community mental health services after subjects are evaluated.

A total of 11 postbooking programs are being studied. Most of the postbooking programs are jail based, although five of the Connecticut programs are court based. In the court-based programs, mental health workers situated in the courthouse identify clients while they are awaiting their hearing and negotiate with the court to develop community-based alternatives to jail.

The jail-based postbooking programs involved in the research initiative include New York City's NYC-LINK program, which uses linkages between planners at the jail and transitional managers in the community to create community-based treatment arrangements for offenders with mental illness. The two postbooking programs at the Arizona sites identify offenders in jail and can refer them to three tiers of diversion alternatives: release from jail with conditions, deferred prosecution, and summary probation.

Lane County, Oregon, has a unique program that involves a psychiatric hospital located near the jail that offers detoxification services. Diversion options in Montgomery County, Pennsylvania, include conditional release with mental health services or dropping of charges once the offender is identified as a current mental health client. A third alternative in Montgomery County is "coterminous diversion," in which police take the offender into custody, then deliver the offender straight to psychiatric treatment and also file charges. This arrangement can result in a variety of dispositions, ranging from dropping the charges to having the offender respond to the charges.

The postbooking program in Honolulu begins when detainees are transported from holding cells in the local precincts to the courthouse in the early morning, where they are seen by a case coordinator who determines before arraignment whether diversion is appropriate.

Each of the nine sites will conduct a process and outcome evaluation of its jail diversion programs. The process evaluation focuses on a detailed description of the pre- or postbooking interventions at each site, a description of each subject's exposure to the intervention, and a description of the community context of the interventions and how it changes over time. Both self-report and record-based data will be used.

The Research Triangle Institute is managing the cross-site cost-outcome evaluation. For the cross-site study, a common design and interview protocol were developed for interviews with subjects at baseline, three months, and 12 months. A quasiexperimental nonequivalent comparison group design was adopted due to the serious difficulties involved in conducting true experiments with random assignment of subjects to jail and nonjail statuses.

The general hypothesis that will be tested in the cross-site study is that diversion from jail to community mental health and substance abuse services will reduce negative outcomes such as recidivism, poor psychosocial functioning, and psychiatric hospitalizations while increasing the quality of life of mentally ill detainees. The relative effectiveness of pre- versus postbooking diversion will also be assessed.

A cost-effectiveness analysis will be carried out to determine the cost savings to the criminal justice system; the benefits to the individuals who are diverted, in the form of improved individual outcomes; and the benefits to society as a whole, in the form of decreased costs due to a reduction in criminal victimization and property crimes and increased employment of diverted subjects. Comparisons of costs and effects will be made for pre- versus postbooking programs as well as for both types of diversion programs versus incarceration.

Discussion and conclusions

Diversion programs are thought to be among the most effective ways to integrate an array of mental health, substance abuse, and other support services to break the cycle of repeated entry into the criminal justice and mental health and substance abuse treatment systems by persons with mental disorders. However, as noted, very few systematic outcome studies that address the effectiveness of jail diversion programs have been conducted. Thus far no research has systematically examined which types of programs work best for whom. We do not know which are the most effective programs and which are the most appropriate for certain communities and for certain groups of detainees.

Available research findings suggest that at least two core elements are necessary for diversion programs: aggressive linkage to an array of community services, especially those for co-occurring mental health and substance use disorders, and nontraditional case managers. However, we have not determined whether diversion programs are more effective than high-quality jail-based programs at accomplishing the goals discussed above.

Major goals for mental health diversion programs include the avoidance or the reduction of jail time for detainees who are inappropriately confined, an overall reduction of recidivism rates, and continuing linkage of these detainees with comprehensive community-based services that recognize their high rate of co-occurring mental illness and substance use disorders. The SAMHSA research initiative on jail diversion offers great promise of providing the kind of data local communities need to plan, build, and defend these essential programs.

At present, no definitive model for organizing a criminal justice-mental health diversion program exists. In addition, little is known about which types of programs are effective for detainees with co-occurring disorders or whether programs actually benefit the targeted recipients, especially in terms of symptom stabilization, reduced jail time, higher levels of community adjustment, and stable participation in community mental health and substance abuse services. The SAMHSA jail diversion Knowledge and Development Application is expected to provide data that can be used to answer these pressing policy and clinical questions.

Dr. Steadman is with Policy Research Associates, Inc., 262 Delaware Avenue, Delmar, New York 12054 (email, [email protected]). Ms. Deane is with the New York State Police Academy in Albany. Dr. Morrissey is with the Cecil G. Sheps Center for Mental Health Services Research at the University of North Carolina in Chapel Hill. Dr. Westcott is with the Division of Knowledge Development and Systems Change and Ms. Salasin is with Community Support Programs at the Center for Mental Health Services in Rockville, Maryland. Mr. Shapiro is with the Division of Practice and Systems Development at the Center for Substance Abuse Treatment in Rockville, Maryland. This paper is part of a special section on mentally ill offenders.