Experts say jails and prisons have become the nation’s largest psychiatric facilities. Mass incarceration, poverty and a drug epidemic—coupled with lack of access to treatment—have resulted in criminalization of the mentally ill in a system often unprepared to properly deal with the problem.

Consider these grim statistics from the National Alliance of Mental Health:

  • 25% of people arrested and in the criminal justice system have serious mental illnesses
  • More than 2 million people with serious mental illnesses are arrested annually
  • Over 550,000 people with serious mental illness are in jail on any given day
  • In 2017, incarcerating people with serious mental illness cost the US Government $80 billion and the states $71 billion
  • People with mental illness are 9 times more likely to be incarcerated than hospitalized
  • People with mental illness stay four to eight times longer in jail than someone without a mental illness for the exact same charge
  • 40% of people with serious mental illness will come into contact with the criminal justice system at some point in their lives 

A Judge and a Solution

Enter Judge Steven Leifman, associate administrative judge of the Miami-Dade County Court, home to the largest percentage of people with serious mental illnesses of any urban community in the United States.

Roughly 9% of the population (more than 210,000 individuals) experiences serious mental illnesses including schizophrenia, bipolar disorder or major depression and fewer than 13% of these individuals receive care in the public mental health system. As a result, the county jail now serves as the largest psychiatric facility in the state of Florida.

To address the rising toll and costs from untreated mental illnesses in the criminal justice system, Judge Leifman founded (in 2000) the Eleventh Judicial Circuit’s Criminal Mental Health Project (CMHP) and was recently recognized for this work as the 2018 recipient of the Pardes Humanitarian Prize in Mental Health awarded by the Brain & Behavior Research Foundation.

“We have failed people with mental illness miserably. We have seen homelessness increase, seen shootings of people with mental illness increase, wasted critical tax dollars and have made mental illness a crime in this country,” said Judge Leifman in his keynote speech at the Brain & Behavior Research Foundation’s international symposium in New York City.

Judge Leifman said our country has lost considerable ground over the past 30 years in the way we treat people with serious mental illness. Instead of de-institutionalizing people, we have transferred responsibility to the criminal justice system. “We’ve come full circle,” he admits. “Two hundred years ago, we put people in jail because we didn’t know any better and we’re still doing it.”

He went on to explain that conditions in most jails are often inadequate for treating serious mental illness. “Now not only do people have to deal with the stigma of mental illness, they also have to deal with the stigma of being a criminal which makes it harder to get housing, employment and healthy relationships for a healthy life.”

Judge Leifman put it bluntly: “Our community mental health system, crisis system and laws are antiquated, fragmented and do not reflect modern research and science. They need great reform. I’ve been doing this now for 18 years and one thing is abundantly clear: If we treated people in primary health the way we treat people with mental illness, not only would there be a plethora of civil lawsuits, there would probably be indictments for gross negligence,” he says. “I don’t understand why people aren’t angrier about it. What other illness is it okay to discharge people in the middle of the night, homeless, psychotic, and then arrest them when we don’t provide them with the services they need? Because we know treatment works.”

“This is a shameful American tragedy and it is one that must be reversed,” says Judge Leifman. “If you aren’t touched by the inhumanity of this problem, you should be touched by the financial consequences.” 

Measuring the Impact and the Burden

Judge Leifman describes himself as “the gatekeeper to the largest psychiatric facility in Florida—the Miami-Dade County Jail.” Nowhere does this criminal justice problem play out more tragically than in his district.

In Miami-Dade 197,000 adults and 55,000 children suffer from a serious mental illness—that’s almost three times national average. Currently, 35% of county inmates are on psychotropic meds. “We were spending $500,000 a day—that’s $180 million a year to warehouse people in the county jail,” says the judge.

During his speech, Judge Leifman shared a report compiled by a local university: a list of 97 people in Miami-Dade, primarily men diagnosed with schizophrenia, often accompanied by a substance abuse disorder, and typically homeless contributed the lion’s share of the burden on criminal justice resources. Over a five-year period, these 97 people were arrested an astonishing 2,200 times; spent 27,000 days in county jail; 13,000 days in psychiatric facility or emergency room, and cost taxpayers $13.7 million.

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Judge Leifman notes that the money being spent is being spent in all the wrong places. “The US spends billions trying to restore defendants to competency so they can be tried,” the judge says. “Florida spends almost 25% of its $144 million adult mental health budget to restore competency for 2,500 people. Meanwhile, between 130,000-140,000 people in Florida, who at the time of their arrest had acute mental illness, needed immediate treatment.”

In the past 12 years in Florida there has been a 50% increase in the number of people sent to prison, but the percentage of people with mental health illnesses going to prison has grown by 178%. According to Judge Leifman if nothing is done to stem this flow, Florida will have to build 10 new prisons over 10 years to accommodate this growing population at a cost of $2.5 billion.

“Local officials are at the point where they’re starting to have to decide between building new jails or building a new school or hospital,” he said. “There is something terribly wrong with a society that is willing to spend more money to imprison a person with mental illness than treat them.” 

Creating a Way Out of the Cycle

Under Judge Leifman’s leadership, the Eleventh Circuit ‘s highly-acclaimed CMHP has successfully used alternative and community-based treatment and support services to divert eligible, nonviolent defendants with serious mental illnesses away from the criminal justice system.

The program has three components:

1) Prearrest System. Using crisis intervention team (CIT) policing, police receive a 40-hour training on how to identify people with mental illnesses, how to deescalate a situation, and what can be done to connect them to treatment without arresting them. Miami-Dade now has the largest trained squad of CIT officers in the country, with over 6000 officers. Since 2010 to 2017, in two of the largest squads, 83,427 mental health calls, only made 139 arrests. Total arrests in Miami-Dade County went from 118,000 per year when the project started to 56,000 today. The jail audit was cut in half from 7200 to about 4000 and close one of the county’s three main jails, saving the county, $12 million per year over the past 6 years.

2) Post Arrest Diversion Program. Anybody arrested on a misdemeanor in Miami-Dade County is out within 3 days if they meet the criteria of a serious mental illness, specifically, schizo-affective disorder, schizophrenia, bipolar disorder, major depression, and PTSD. They are transferred to a crisis stabilization unit and because it is considered a criminal hold, they are kept for up to two weeks, instead of the usual 72-hour limit for crisis care in civil Baker Act cases.

This amount of time helps them stabilize and receive the peer support necessary to reestablish relationships and gain the will to accept treatment and take required medications—a will that the often-additional burden of clinical depression caused by the repeated cycle of trauma and arrest may have destroyed.

Cindy Schwartz, director of the CMHP’s Jail Diversion Program told Psycom that the program receives about 300 referrals per year. After being stabilized and upon release from custody into the community, there is a transition phase, including a plan to address the risks and needs, two-weeks of medication, initial appointments with mental health professionals, and where to get refill medications. The program coordinates and links participants to community-based services, such as housing, proper identification, social security disability, Medicaid, and other entitlements and contingency funds, says Schwartz.

Within 2 years of its launch, the recidivism rate for misdemeanants dropped from about 72% to 20%.

3) Competency Restoration Alternative Program. With this success, the program was expanded to nonviolent felonies, such as burglary and drug possession. After being stabilized, defendants remain at the facility undergoing treatment until their court date. Instead of just focusing on restoring competence to stand trial, the Eleventh Circuit set up a system focused on integrating them back into the community.

Once they are stable and healthier, they return to court and if eligible are released and supervised for a year to make sure they are taking medications and participating in treatment. They also receive help finding housing, transportation and jobs. In many cases, the court will drop the charges at the end of the year, helping with long term recovery.

According to data, participants achieved mental competency an average of 52 days sooner and cost 32% less than those who are admitted to a state hospital—reducing the recidivism to about 25% and saved the county about 68 years of jail bed days. 

More Counties Stepping Up

Successful programs like the Eleventh Circuit’s CMHP have dramatically improved public safety, reduced police injuries, saved critical tax dollars, and dramatically reduced shootings and other harm to people with serious mental illness by police. Indeed, defendants aren’t the only ones in the criminal justice system who need mental health support, says Judge Leifman.

Police also have significant mental health problems, including very high rates of PTSD. Proper training on identifying and dealing with people with mental illness has reduced the incidence of shootings of people with mental illness in Miami-Dade by police from about two per month to five or six in eight years.

According to the University of Memphis, more than 2600 local CIT programs now operate in 46 states and Washington, D.C. And more than 450 counties in the US have passed resolutions to join “Stepping Up,” a national initiative to reduce the number of people with mental illness in jails. Stepping Up is a joint effort by the National Association of Counties, the Council of State Governments Justice Center and the American Psychiatric Association Foundation that reaches out to partner organizations, including sheriffs, judges, jail administrators, community corrections officials and treatment providers, “to create innovative and evidence-based practices that better respond to the unique needs of people with mental illnesses who are charged with low-level crimes.”

The initiative helps local authorities develop methods and best practices that work for their communities and remove obstacles to success in key areas of mental health diversion programs.

Untreated mental illness is a community problem that requires community solutions. Because no one person or group created this problem, the solution will not be easy, warns  Judge Leifman. “It has to be done county by county. What worked for my district might not be easily replicable elsewhere even if they want to follow our lead. It’s up to local authorities to make the commitment to putting the resources and the research towards addressing their own community’s criminal mental health needs,” says the judge. 

For More Information

Want to learn more about what you can do to steer people with mental illness away from prisons and toward mental health treatment and services instead? Here, some related links

Last Updated: Mar 5, 2019