BY CATIA SHARP
James Boyd set up camp for his last time in the foothills of the Sandia Mountains, where you can see all of Albuquerque laid out before you under the sunset. Unfortunately, he was camping without the requisite permit. James had been homeless for a long time.
James was shot to death by the police when they arrived on a nuisance call; the public land he was camping on abutted one of the wealthiest neighborhoods in Albuquerque. “The system”—the labyrinth of social programs designed to help those who can’t help themselves—failed James. It also failed the responding officers, who were ill equipped by that same system to handle problems more appropriately handed to social workers or psychiatrists. Conceptually easy solutions to this problem, like mandating that police wear body cameras, are common discussion points. But perhaps the conceptually easy fix is not a fix at all. Maybe the underlying problem that led to James’ untimely death—a convoluted network of uncoordinated agencies often working at odds with each other—can only be solved with a complex and nuanced approach.
“We’re asking cops to do too much in this country . . . . Every societal failure, we put it off on the cops to solve. Not enough mental health funding, let the cops handle it . . . . Policing was never meant to solve all those problems.” – David Brown, Dallas Police Chief
James spent his adult life homeless—cycling between sleeping on the street, homeless shelters, jail, and psychiatric hospitals. This has led some news outlets to villainize him as a lifelong criminal. However, his upbringing provides a small window into the vicious cycle that led to his demise.
Born in Oregon, James ended up in foster care. He endured violent abuse from his father and was allegedly sexually abused in foster care. Foster care is meant to protect the most vulnerable children; instead, it destabilized James’s life. He ended up in New Mexico as a teenager, where he spent two years in juvenile detention and another seven years in adult prison. When it became clear as a young adult that James struggled with mental illness, he was not treated but instead incarcerated, where his mental health further deteriorated. By the time he exited institutions as an adult, he was 25 years old and severely mentally ill. With an unstable mental state and without work experience, he became homeless.
Does “the system” have a unified conscience, a collective will? Is that will nefarious?
More accurately, one might attribute the multitude of failures by various social programs that plagued James Boyd to “silos” of government—a bureaucracy too big to coordinate outcomes on a single case. I argue that the system ought to have both a collective conscience and the machinery to move people like James Boyd to treatment and stable living, rather than pushing them to the fringes of society and wondering why they end up dead. I will highlight an alternative future system, one compassionately mindful of how to truly enhance safety, health, and well-being in communities.
How Jails Took Over Mental Health Care
In Albuquerque, James’s death kicked off an awakening to the hidden reality that jails are our largest mental hospitals. People with behavioral health challenges (the combined term for mental illness and substance-use disorders) who are homeless often have run-ins with the police. They might get in trouble for “trespassing” (sleeping in an enclosed ATM because it is cold outside); “public indecency” (urinating in public because store bathrooms are for customers only); or even panhandling, which is an arrestable offense in some cities. These types of minor offenses are often referred to as “crimes of homelessness.”
Those arrested might also have a mental health crisis, including extreme emotional disturbance or agitation. Or they might have a severe drug addiction, which is often a way to self-medicate untreated mental illness. Police are the ones we send to respond to these problems, whose underlying causes are not criminal in nature. The police have a choice: bring the person to a homeless shelter that is typically full; bring the person to a hospital, where they likely won’t be admitted unless they are considered “a danger to themselves or others”; arrest them and take them to jail, even when the officer knows that they are not a criminal, because the jail at least provides some mental health care; or leave them on the street, suffering. Given the constraints, the police most frequently opt for the last two.
This is how jails have become our largest mental hospitals: People with behavioral health disorders get arrested due to poverty and sickness, not lives of crime. An Urban Institute report in 2006 found that more than 60 percent of people in local jails and over 50 percent of people in state prisons are living with some type of mental illness, while 15 percent of jail inmates were homeless in the year before incarceration and 54 percent of homeless individuals report having spent time in a correctional institution. The historical basis for this situation is threefold.
1. In response to inhumane conditions and enabled by advancements in antipsychotic drugs, a national de-institutionalization movement aimed to reduce the use of mental hospitals. In 1963, the United States codified the massive downsizing of mental institutions in the Community Mental Health Centers Act, which established a very strict standard for admittance to a mental hospital—the same standard that now presents the limiting barrier to police drop-offs. In its place, a continuum of community-based mental health care was supposed to support stable living for those with mental illness. But this continuum was never funded.
2. Widespread access to preventive mental health care through insurance is recent and incomplete. It wasn’t until the passage of the Affordable Care Act (ACA) in 2010 that full “mental health parity” was required of all commercial insurance plans: plans must now cover behavioral health services with the same restrictions as physical health—discrimination is not tolerated. But despite mental health parity, urgent care for psychiatric illness remains restricted by the high standards for payment imposed by insurers including Medicaid. The ACA also expanded health insurance coverage to low-income, non-elderly adults without children—those like James Boyd. In the states that expanded Medicaid access to childless adults, outpatient preventative behavioral health care may now interrupt the downward spiral James faced.
3. The war on drugs swept a large number of people—disproportionately people of color—into the criminal justice system, which increased the prevalence of substance-use disorders in the corrections system, increased the number of homeless formerly incarcerated individuals, and failed to address substance use as a disease in need of health care.
Jail administrators across the country are beginning to take notice. The Albuquerque jail has been called the largest mental hospital in New Mexico. But jails are inherently un-therapeutic. While the jail is required to provide a minimum level of physical and behavioral health care to those in custody, the environment is stressful and upends lives. Being separated from support networks of family and friends, having prescription medications interrupted, being subjected to social environments inside of prisons, going through stressful court proceedings, and living in unsanitary conditions all facilitate one’s decline in mental health in prison and jail. Further, jail causes unemployment and homelessness by disrupting inmates’ ability to go to work or pay rent and presents a barrier to regaining employment and housing upon release.
“The System Functions Exactly as Intended”
By dramatically underfunding a community-based continuum of behavioral health care, we have created a systemic problem. Police and jails are left with a burden of care for which they are ill equipped—not to mention that jails are expensive treatment settings. The average state prison costs $31,286 per bed for a year.
There is, however, bipartisan support for reversing this trend to save money, reduce systemic inefficiency, and treat people more humanely. In the following sections, I highlight three promising approaches to creating a unified conscience in the criminal justice system. These three are often not performed in tandem, but I argue for a more synergistic approach.
“Money, people, programs – those are all tools. In the end, you need strategy, you need structure. Design thinking starts to teach us that sometimes the thing you thought was going to be the barrier actually isn’t.” – Leah Garabedian, Senior Manager for Justice, Harris County, Texas, Budget Management Department
Sequential Intercept Model
One method for orienting disparate actors toward the common goal of reducing recidivism is the Sequential Intercept Model, developed by Drs. Mark Munetz and Patricia Griffin and propounded by the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal government’s behavioral health agency. The idea is to map the pathways people take through various criminal justice agencies, identify the points at which individuals might be diverted out of the criminal justice system and into more appropriate care settings like public housing or mental health facilities, and implement programs to do just that.
Jurisdictions as diverse as Boston, Denver, and Harris County in Houston, Texas, among others, are using sequential intercept mapping. In Harris County, for example, community leaders are using this tool through the Criminal Justice Coordinating Council and their mental health subcommittee, which highlights the siloed nature of criminal justice systems. The subcommittee comprises the district attorney (an independently elected county-level official), a local judge, a major at the sheriff’s office (another independently elected county-level department), representatives of the county government, and court system administrators from both county and state courts. Each of these government entities is independent from the others; there is no requirement that they all work together or even agree on a common goal for their collective “system.” But they have chosen to collaborate to create a collective conscience for helping their most vulnerable.
The Harris County subcommittee mapped the system, and the first problem they identified was the one confronting police: limited options for helping a person with severe behavioral health problems. Once they identified this problem, the remedy was clear and simple: provide a behavioral health service for people who aren’t sick enough to go to the hospital. The subcommittee’s first project became the Harris County Assessment and Recovery Center (HARC), still in development phase. HARC will provide 24/7 access to health, mental health, and substance-use disorder triage and stabilization services, plus other “wrap-around” services like housing support during the day. This type of “diversion” from jail, as leaders in the field refer to it, is the first step in breaking cycles of recidivism for people with behavioral health needs who should never have ended up in the criminal justice system in the first place.
Other options for addressing the same problem include training police officers to recognize and respond better to mental illness, and even hiring clinical staff to go out on calls with officers.
This mapping requires data on the flow of people through “the system.”
The Data-Driven Justice Initiative, run by the Arnold Foundation and the National Association of Counties, is a model for generating valuable data. For example, existing administrative datasets include 9-1-1 call records, jail information-management systems, and court records. Many jurisdictions are now connecting these separate data sets and analyzing them to identify the highest frequency users of criminal justice services to help pinpoint points of intervention.
Bernalillo County in Albuquerque, New Mexico, has embarked on a journey to use data to make system-level changes in the wake of James Boyd’s death, with the help of the Government Performance Lab at the John F. Kennedy School of Government at Harvard University and the University of New Mexico’s Institute for Social Research. The county used data from the Albuquerque jail to identify the individuals most frequently booked into the jail in order to find out whether there is a relationship between frequency of booking and severity of behavioral health diagnosis. It turns out, unsurprisingly, that the more bookings an individual has, the more likely they are to have serious mental illness. It also turned out that those with more bookings are more likely to be people of color.
The Data-Driven Justice Initiative provides the resources to more governments seeking to copy Bernalillo County and match data across government silos. Another member of Data Driven Justice, the Middlesex County Sheriff’s Office in Massachusetts, will work with 21 police departments to map the local criminal justice system, something that can’t be done without collaboration between municipal governments.
But these types of data analyses are, as yet, imperfect when it comes to fully mapping “the system.” For example, the jail information-management system in Bernalillo County does not collect an individual’s homeless status. Further, attempts to link criminal justice data to health data, like that on emergency room visits, frequently run into patient privacy challenges.
Ultimately, the purpose of this data analysis is to better inform the management of each component of the criminal justice system, as well as community-wide management of “the system” itself, toward the ultimate goal of reducing recidivism while increasing physical and behavioral health treatment among those who shouldn’t be criminalized in the first place.
Jail management is a critical step in redirecting this flow of people through the system. For those who cannot be diverted to treatment before they make it to jail, the Middlesex County Sheriff’s Office is also strengthening its behavioral health services in hopes of making jail time an opportunity for recovery. For example, the Medication-Assisted Treatment and Directed Opioid Recovery program provides cutting-edge opioid addiction treatment to prisoners. Although numerous studies have found this type of treatment to be the most effective for opioid addiction, it is still not available in many jails.
Finally, preparing people to exit a jail is critically important. Bernalillo County is building a Reentry Resource Center through which all discharging inmates will pass. This will be a dramatic departure from prior practice, when people were often discharged to a downtown street corner in the middle of the night, without transportation or housing and certainly without any plans for health care access. The Reentry Resource Center will correct this by not only providing a warm, secure facility where people can wait for rides but also by having social service providers ready to connect them to services in the community that could prevent further recidivism while they await transportation. Bernalillo County will also plan ahead by providing better access to psychotropic medications to discharging inmates to cover their transition home.
These changes to existing institutions can start to create a system that moves people toward stable, healthy lives as an alternative to recidivism.
Toward a Systemic Strategy
These models are taking hold in different jurisdictions but not always in tandem. To create a system with a collective conscience, sequential intercept mapping cannot be done without being informed by rigorous data analysis; meanwhile, data analysis is only as good as its application to systemic mapping, and systemic mapping is only useful when used to identify new interventions.
People like James Boyd end up arrested and in jail largely due to systemic failures that deteriorate their health. If the idea of the corrections industry is to correct criminal conduct, then these people have ended up in the wrong place. What they truly need is health care delivered by a system of government entities that cohesively sum up to more than their constituent parts. Local governments are stepping up to meet this challenge, starting to build a collective conscience in a unified system. But the hard work has only just begun.
Catia Sharp is a second-year master in public policy student at the John F. Kennedy School of Government at Harvard University. She previously worked in state and local government performance improvement, including with the Harvard Kennedy School Government Performance Lab in Bernalillo County, New Mexico, on a behavioral health project.
Photo credit: Thomas Hawk on Flickr
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