Shay Jacobson, RN, MA, NMG, LNCC, CNLCP

Martha M. Kern


George was in luck. He boarded the train to go visit his Mom in the nursing home when a bit of good fortune presented itself to him like a dollar bill on the sidewalk. There, a few seats up, was a ticket someone had left behind. George had not yet purchased a ticket, so this was like winning a small prize.

George walked over to the empty seat and took the abandoned ticket.

And then he was arrested.

The police officer was in plain clothes. He saw George avail himself of the “free” ticket and arrested him on a misdemeanor charge of theft.

George is developmentally disabled and mentally ill. Even a casual conversation with George reveals that his ability to make consistently sound decisions is somewhat limited by his illness. He functions well on a day to day basis but occasionally makes mistakes like this one.

The police booked George and noted with great interest that he had a history of petty crimes. It appeared that George might even wind up in the penal system like countless other individuals whose mental illnesses render them vulnerable to bouts of poor judgment, especially in the company of opportunistic, persuasive individuals pretending to be friends.

If George went to jail, he would contribute to this startling statistic: The Department of Health and Human Services estimates that 700,000 people with active symptoms of mental illness are jailed every year.

How on earth has this number climbed so high, and what can we do about it?

A Brief History of Mental Illness in the United States
There was a time in recent history when scores of mentally ill persons were housed in asylums and state hospitals. Most of these institutions are now closed.

The push to close the institutions stemmed from mistreatment, abuse and other human rights issues. Few would argue the reality of these horrors, nor the need for change. Where asylums utterly failed in some ways, though, they succeeded in others – they operated as their own self-contained communities, complete with housing, on-site medical professionals, therapists, work programs, social activities and psychotropic medications.

When these institutions were closed, both the failures and the successes came to an end. Professionals and government agencies collaborated to form community-based mental health treatment programs. These are not 24-hour hospital settings, but rather come-and-go centers where freedoms – and risks – are far greater. It is infinitely more difficult for professionals in these community settings to recognize when a person is not taking their medication.

It is also true that community settings allow for relatively easy access to alcohol and drugs; in an underfunded, understaffed world where there are not enough professionals to meet the needs of the mentally ill, alcohol and drugs can quickly become a means of self-medicating and making oneself feel better in the absence of other options.

Where the Criminal Issues Occur
Mental illness that is not well managed can lead to severe symptoms such as hallucinations, delusions and acting-out behaviors; these behavior problems can lead to criminal acts being committed by people with mental illness. Many of these offenses, like George’s, are non-violent and directly related to the poorly managed illness.

It comes as no surprise that jail or prison offers little chance for improvement in the prisoner’s mental illness. Many of these people are not as “tough” as other prisoners and they suffer abuse and exploitation in the penal system. Their symptoms often escalate and, upon return to the community, they may be exhibiting behaviors that are worse than those that contributed to their criminal issues in the first place.

George and others like him also find themselves befriended in the community by people who recognize an opportunity for gain, influence and manipulation. Perhaps due to inadequate social connections, the mentally ill can sometimes be talked into carrying drugs, shoplifting and otherwise bending to the peer pressure exerted by “friendly” people they meet in the community.

And sometimes they just have an idea, like using an abandoned train ticket that leads to a messy and largely unwarranted interaction with law enforcement. This is not to suggest that those with mental illness or other disabilities should be given a pass when it comes to petty crime; instead, we suggest that jail is not the only option. It is, in fact, the worst idea when it comes to non-violent offenders.

Diversion from Jail
The basic idea behind Criminal Diversion is to keep persons with mental illness out of the criminal justice system both now and going forward.

Prisoners in general tend to re-offend and go back to jail, and this is a particular problem for the mentally ill. Estimates show that more than half of the persons with mental illness in jail have had three of more prior sentences.

Diversion works by diverting the individual to other interventions when they have been arrested and are headed for jail. The end result is to shorten the duration of any time behind bars, or to help get them released from jail into alternate arrangements.

Consider the case of Jeremy, a schizophrenic whose disease is controlled by medication.   Sometimes, though, Jeremy is influenced by friends in the community, and he fails to comply with his group treatments, stops seeing his doctors and stops taking his medications. Jeremy then becomes subject to hallucinations and voices commanding and compelling him to shoplift. He is arrested for shoplifting, sentenced and sent to jail. A diversion could be implemented at a number of points in the process, such as:

  • When Jeremy is first picked up by the police, before he is sent to jail;
  • When Jeremy comes before the judge for sentencing;
  • When Jeremy’s case is heard for parole;
  • When brought to the court’s attention by Jeremy’s attorney, who may be the State’s Attorney.

A diversion plan can be presented to the criminal justice authorities that plead Jeremy’s case. It would include a presentation of issues related to Jeremy’s diagnosed illness, symptoms, recommended treatment, and issues and barriers impacting treatment compliance. Most important, the plan would provide details as to how obstacles could be minimized or set aside by use of the particular diversion plan under consideration.

Often what a person with mental illness needs to comply with their plan of treatment is the consistent supportive guidance of another person. A successful diversion program must include this very important facet. Private practice diversion plans tend to feature a highly customized approach to client care, thus enabling these clinicians to offer the kind of one-to-one support and coaching necessary to encourage consistent use of prescribed medications, adherence to therapy session schedules, and maintenance of personal care routines. The client can reside at home, keep some semblance of privacy, and reach a level of wellness comparable to that achieved in a group home setting.

For persons who have their own resources to contribute, the private-practice model of diversion offers an individualized, structured and personalized style of intervention with a high rate of proven success. This approach provides value for the individual, the family and community, and is an ideal means for financially-secure clients to access positive outcomes.

George and Jeremy are good people. They can live relatively steady lives and comply with medication regimens, given an opportunity to avoid the penal system and benefit from the services of a private practice care manager who can coach them along and help coordinate the day-to-day details of life. Their families love and support them, of course, but the lifelong rigors of managing mental illness can strain those precious relationships.

Mental illness can impose its own roadblocks and limits; no therapeutic benefit can come of the even profounder limits imposed by prison. A good diversion plan works, and is a welcome alternative to repeated bouts of incarceration for non-violent crimes.

© Lifecare Innovations