Gold Award: Helping Mentally Ill People Break the Cycle of Jail and Homelessness
The 2001 Achievement Award Winners
The American Psychiatric Association will honor five outstanding mental health programs in an awards presentation on October 10 at the opening session of the Institute on Psychiatric Services in Orlando. The Thresholds, State, County Collaborative Jail Linkage Project in Chicago, an intensive program for rehabilitation of mentally ill people who have been caught up in the revolving door of homelessness and incarceration, won the Gold Achievement Award in the category of small community-based programs. In the category of large academically or institutionally sponsored programs, the Community Research Foundation of San Diego won the Gold Achievement Award for its short-term residential treatment (START) program, which provides a cost-effective alternative to hospitalization for individuals experiencing acute psychotic episodes. Each of the programs received a $10,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals.
Certificates of significant achievement were awarded to Baltimore Mental Health Systems, Inc., for its two capitation programs; to the mental health division of the Community-University Health Care Center in Minneapolis; and to the Multnomah County Early Childhood Mental Health Program in Oregon.
The winning programs were selected from among 75 applicants by the 2001 Achievement Awards board, chaired by Michael Silver, M.D., of Providence, Rhode Island. The awards have been presented annually since 1949.
People who have severe schizophrenia, depression, bipolar disorder, or other mental illnesses are often arrested for reasons unrelated to criminal intent. When they leave jail or prison, they are not prepared to build a life on their own, making it likely that they will soon be back in jail. The Thresholds, State, County Collaborative Jail Linkage Project in Chicago is an innovative, intensive program for mentally ill people who have been caught in this revolving door of homelessness and incarceration. The project represents a unique approach based on the premise that often jail or even hospitalization does little or nothing to help mentally ill people and may even make their problems worse. Thresholds helps nonviolent people who have mental illnesses that are treatable with medication to live on their own with support from staff and people in similar situations. The staff provide a wide array of services to help these individuals meet their daily needs.
In recognition of its achievement in the rehabilitation of this population, the Collaborative Jail Linkage Project was selected as one of two winners of the Gold Achievement Award for 2001. The award is presented annually by the American Psychiatric Association to recognize outstanding programs for mentally ill and developmentally disabled persons. It includes a $10,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals.
The collaborative jail project was selected in the category of small, community-based programs. The winner of the award for large academically or institutionally sponsored programs is described in a separate article on page 1383. The awards will be presented on October 10 during the opening session of the Institute on Psychiatric Services in Orlando, Florida.
The collaborative jail project is just one of several innovative programs supported by Thresholds, a private, nonprofit psychiatric rehabilitation center that manages 25 service locations and 75 housing developments in Chicago and its outlying suburbs for people who have a mental illness. With a current operating budget of $42 million, Thresholds serves more than 6,000 people a year. Jerry Dincin, Ph.D., has been the executive director of Thresholds for the past 36 years and also serves as director of the jail project. Dr. Dincin is a founding member of the International Association of Psychiatric Rehabilitation Services and was instrumental in introducing and expanding the Bridge Model of assertive community treatment in Illinois. The Bridge Model uses an intensive team approach that provides long-term, comprehensive, and integrated services. Several agencies around the world have replicated the Bridge Model with great success, but the collaborative jail project marks the first time it has been applied specifically to the jailed mentally ill population.
Providing a unique service to a neglected population
With cuts in health care and public assistance in recent years for people with low incomes, people who have mental illnesses are even more likely to end up on the streets, where arrest for minor offenses is almost unavoidable. These individuals are also at risk of being victims of violent crime and of developing various health problems that are common among people who live on the streets.
According to statistics from the U.S. Department of Justice, about 283,000 people who are incarcerated on any given day in the United States are known to have a mental illness. The rate of mental illness in the jailed population is four times greater than that in the general population. The Cook County Jail in Chicago has become, by default, the largest psychiatric facility in the state of Illinois. At least 10 percent of the facility's 10,000 detainees are on psychiatric medications. Because the jail is overcrowded, prisoners must be released every day, whether they are ready or not, to make room for new arrivals.
The jail's purpose is social control, not treatment, so most of the detainees who have a mental illness receive very little follow-up after they are released. They are usually released in the middle of the night in an unfamiliar neighborhood and given only the name of a city clinic that has a long waiting list. Depending on how long the person has been incarcerated, his or her former housing and possessions may well have disappeared. Any existing social contacts are often angry and disappointed with the individual. Social Security payments and personal funds may have been interrupted as a result of mandatory delays for reinstatement. The person is left to deal with requirements of release such as probation appointments, restitution, social services, and further court-mandated follow-ups—difficult tasks for anyone, but especially for someone who has a mental illness. Dealing with the mental illness itself is always a low priority in the scramble for survival.
When Thresholds started its jail project as a pilot program in October 1997, using solely its own financial resources, no specific aftercare programs for this population existed. The Thresholds jail project initially employed three caseworkers to serve a clientele of 30. A year later, the project received funding from the Illinois Department of Mental Health in recognition of its proven results and cost savings to the state. The program now serves 68 people—referred to as members—at any given time. The program had a budget of $691,645 in 2000, of which $546,305 was contributed by the state and $120,340 by individuals and private foundations, including the Roger Brown Foundation, the Lloyd A. Fry Foundation, and the Chicago Community Trust. The team has grown to include ten direct care staff and a part-time weekend case manager as well as an administrative support person, a consulting psychiatrist, and a program supervisor.
An intensive program for meeting individual needs
Thresholds counselors work with a representative of the Illinois Office of Mental Health and personnel from an affiliate of the Cook County Bureau of Health Services to identify potential members for the jail project. Generally, each member has a history of state inpatient psychiatric hospitalizations and incarceration—the average member has had 12 hospitalizations and has been arrested 35 times. Most members have been estranged from their families for many years.
Thresholds counselors visit the members in jail and accompany them to court, sometimes even securing early release into their custody. Once the member is out of jail and participating in the Collaborative Jail Linkage Project, he or she is expected to take any prescribed medication, to work with a psychiatrist, and to nominate Thresholds as a payee. Thresholds then finds the person an apartment on the north side of Chicago, usually in a single-room-occupancy hotel.
Thresholds staff visit members regularly in their homes to provide case management and to monitor medication compliance. They spend a considerable amount of time developing relationships with landlords and the police department to help build community support and to enlist additional "eyes" for monitoring the care of the program's members. If a member is missing, they will scour the streets to find that person at any time of the day or night. Visited often, even during the holidays, members form close personal relationships with Thresholds counselors. Counselors also spend time talking to members about health, friendships, and other aspects of their lives and organize outings in the Chicago area. Thresholds counselors are on call 24 hours a day. They have an intense passion and dedication to working for the program.
The staff do not carry individual caseloads; instead, a multidisciplinary team approach is used to share responsibility for all the program's members. This team approach promotes flexibility in meeting the day-to-day needs of members and enhances continuity of care. Someone is always available in the event of an emergency. Each staff member has a pager so he or she can be contacted directly during the evening, at night, or during the weekend.
The consulting psychiatrist, Mark Amdur, M.D., plays a crucial role, overseeing the progress of each member's psychiatric illness and providing treatment whenever necessary. He will usually drop everything to see a member. This flexibility is imperative for ensuring proper use of medications in this challenging population. It is important that members see the psychiatrist within hours of their release, because, being unmedicated, they are at risk of decompensation.
Service and treatment plans for individual members are tailored to the severity of the illness. Special emphasis is placed on helping the member identify the reasons for past treatment failures. The member's lifestyle is examined, hospitalization and jail records are studied, and compromises are reached as a means of altering damaging patterns of behavior. Thresholds staff gather information on the exact locations of members' personal hangouts so that they can be located when treatment is necessary. Members' homes, a Thresholds' office cafeteria, and even the city streets have served as venues for visits with the psychiatrist or other Thresholds staff members.
Thoroughness and tenacity in the face of a member's apathy, resistance, or return to old habits is a distinguishing characteristic of the program. By being available and persistent, Thresholds staff are able to convey to the members the importance of psychiatric medications. After a member has been with the program for a year, these less conventional methods of encouraging medication compliance are usually no longer necessary, because the member has gained firsthand experience of benefits of medication: success in avoiding arrest and hospitalization.
A cost-effective program with proven results
Although one might assume that such an intensive program would be costly to administer, the jail linkage project is in fact much less expensive than the alternatives. Keeping a person in jail costs about $70 a day, on top of the costs of arrests and bookings. One day in a public psychiatric hospital costs taxpayers about $500. In contrast, the jail linkage project costs only around $26 a day.
Data on the program were collected and analyzed by an independent research team from Loyola University under the direction of Arthur J. Lurigio, Ph.D., chair of the department of criminal justice at the university. The study compared the number of jail days and arrests for the first 30 members of the Thresholds, State, County Collaborative Jail Linkage Project, the number of days spent in the hospital, and the number of psychiatric hospitalizations before and after they were accepted into the program. The number of jail days dropped from 2,741 in the previous year to 469 during the year of involvement with Thresholds, a reduction of more than 80 percent. The number of days in psychiatric hospitals decreased from 2,153 to 321—a dramatic decline of 85 percent.
Despite the relatively small number of participants in the program, the savings are enormous compared with the alternatives of institution use. In the one-year study period, the total savings in jail costs was $157,000, and the total savings in hospital costs was $917,000, as determined from the 2000 budget of the Cook County Jail and conservative estimates of hospital costs from the Illinois Office of Mental Health.
Most of the members report being happy and healthy for the first time in years. A close, family-like atmosphere between members and staff is evident. "They're not just a support team, they're your friends," said Ms. E, age 50, who became a member of the program after being arrested in September 1999 for knocking a Dutch tourist to the ground. Ms. E had assaulted the young woman deliberately so that she would be put in jail, which she saw as preferable to living on the streets. "It was getting cold—I knew I had to do something," she said. Thresholds team leader Susan Doig convinced a judge to release Ms. E after a jail stay of only six weeks. Ms. E said, "My face would just light up every time I saw Susan come to visit me in jail. She is so laid-back, such a good person. Nothing shakes her up."
A model for the future
Since the advent of the Collaborative Jail Linkage Project, several other organizations have entered the field. Yet the Thresholds project remains unique. Most programs are time limited, concentrating on providing services immediately before or after sentencing. Thresholds is distinguished by its long-term approach: members receive services for as long as they need them. And few programs are as comprehensive as the collaborative jail project, which provides 24-hour access to staff, immediate psychiatric care, connections to housing and a support network, and, eventually, vocational training and education through other Thresholds programs. Through the assertive community treatment model, the program helps to eventually link members with their local community mental health programs. Although the jail project targets some of the most problematic, treatment-resistant people, more than 90 percent of its members are now housed in the community, some for the first time in decades.
Thresholds staff have been approached by mental health centers wanting to establish similar programs in other U.S. cities and in the United Kingdom, Mexico, and Canada. The staff have also been invited to speak at meetings throughout the United States and have published articles about the collaborative jail project in mental health and criminal justice journals.
Beyond the many individual success stories, the most significant contribution of the program has been its proven effectiveness in serving a group of people who were once considered "beyond help." Programs across the United States and abroad now have a model to replicate, hopefully creating a legacy that will eliminate the perpetual cycling through the criminal justice system. Thresholds staff hope that the Collaborative Jail Linkage Project and similar programs will eventually receive additional funding so that the thousands of individuals who could benefit from such programs are able to participate.
