#HELP A proposal for transitional crisis beds~~

A proposal for transitional crisis beds

by Judge Sol Wachtler

This article relates to a program for transitional living and crisis beds for defendants with mental illness diverted into treatment under court supervision. The focus is the New York city metropolitan area and a large and virtually abandoned psychiatric hospital called Creedmoor. Like thousands of other very large psychiatric hospitals thoughout the nation, Creedmoor was closed in the mid 1970's. At that time, and with the advent of new medications and treatment modalities, it was thought that rather than hospitalize the mentally ill, it would be more advantageous to treat them within the communities on an outpatient basis.

No one anticipated the volume which would result, and we were all disappointed with the lack of treatment and housing resources. In recent years, the criminal justice system in New York City has been inundated with cases involving individuals with serious and persistent mental illness, including severe depression,schizophrenia, bipolar disorder and other conditions. Accurate numbers are hard to come by since there is no routine screening in criminal court, but one recent study estimated that as many as three out of every ten defendants display evidence of serious mental illness. If true, this would mean that upwards of 90,000 mentally-ill individuals enter New York City's criminal courts each year.

Adding to this problem, is the current need and anticipated future demands on the criminal justice system occasioned by the discharge of veterans returning from the Iraq and Afghanistan wars. Deployment of troops as of this date number 1.7 million, and the Department of Veteran Affairs has estimated that up to 25 percent of these veterans are, and will suffer from post-traumatic stress disorder (PTSD).

A great number of these veterans do not seek help, and the Veterans Administration is unable to treat effectively even a fraction of those who do. Many have problems readjusting to civilian life and have entered the criminal justice system for charges ranging from loitering to disorderly conduct, petit larceny and domestic violence. The co-occurring disorders of drug and alcohol abuse also drive many veterans into confrontation with the criminal justice system. Offering treatment, help and rehabilitation to return to the community is not only preferable to incarceration, but it is an obligation which the country owes to them.

Diversion programs
Criminal cases involving the mentally ill are inherently challenging. In all but a few extreme cases (the bar for competence is not high), mentally-ill individuals are found fit for trial and must proceed with their cases. Then the question becomes what to do with these individuals, the vast majority of whom appear in court on misdemeanor cases (more than 80 percent of the criminal court docket in New York City is composed of misdemeanor cases).

Many judges and attorneys have complained that their choices boil down to "brain surgery or band aids." "The options that I have are either jail or no jail," says one criminal court judge. Of course, neither of these options gets to the root of the problem or is likely to prevent a mentally-ill individual from coming back to court again as a repeat offender. As a result, a broad consensus has emerged that the cycle of arrest, prosecution, incarceration, and release is counterproductive for defendants with mental illness, especially those who have not committed serious crimes such as murder, rape, or arson.

In an attempt to forge a new response, criminal justice innovators began looking to community-based treatment programs as alternatives to incarceration. For example, in 1998, the Kings County District Attorney's Office launched a program, Treatment Alternatives for the Dually Diagnosed, offering diversion into mental health treatment for felony and misdemeanor offenders; many also had both substance abuse disorders and a serious and persistent mental illness. Soon, thereafter, specialized mental health courts opened in New York City, first in Brooklyn in 2002, then shortly thereafter in the Bronx (2002), in Queens (2005), and, most recently, in Nassau County (2008). All of these programs provide long-term community-based treatment coupled with close judicial supervision and careful case management. Their goal is both to stabilize mentally-ill individuals and to protect public safety.

While these programs are still relatively new, the early results have been promising, including reductions in re-arrest and hospitalization for participants and reduced costs for the justice system. Better results yet could be achieved if inpatient beds at local psychiatric centers could be made available to these programs for two specific purposes: first, to serve as transitional living beds for program participants who need to be in a safe and therapeutic setting while awaiting placement in long-term supportive housing; and second, to serve as crisis beds for program participants who are already either in long-term supportive housing or living at home while receiving treatment and who are also in a period of crisis and in need of stabilization, but not hospitalization or incarceration.

Transitional housing
Preliminary results from these alternative-to-incarceration initiatives have been encouraging, including mental health courts. Yet there has been a significant brake on their expansion and replication -- namely, the lack of stable and appropriate housing for participants.

To ensure minimal risk to public safety, many diversion candidates need to be placed into residential treatment facilities that can safely accommodate forensic clients. Without them, eligible candidates languish in New York City's Jail, Rikers Island, while waiting for a treatment bed. Some defendants who are eligible for supportive housing must wait in jail more than four months -- twice as long as those who have already have stable housing -- before an appropriate housing placement can be found. This is a serious problem for a program that is intended to be an alternative to incarceration.
Furthermore, several residential mental health treatment programs are reluctant to interview potential clients while they are incarcerated.

New long-term supportive housing units must be created to maximize the effectiveness and cost-efficiency of community-based diversion treatment. To meet the anticipated need among veterans returning from Iraq or Afghanistan Buffalo, New York, recently opened a Veterans Court devoted to those who, as a result of acts propelled by their mental health issues and/or substance abuse addiction, became involved in the criminal justice system.

With existing supportive housing resources scarce, many people turn to family members. Mental health courts and other alternative-to-incarceration programs, such as Brooklyn's program, Treatment Alternatives to Dually Diagnosed Defendants (TADD), will allow participants to live with relatives if such an arrangement does not threaten public safety. Unfortunately, too often those who are under criminal justice supervision arrive at the home of their relatives without benefits in hand. They may promptly become a disruptive factor and a drain on resources.

Even when an individual's housing situation appears to be sound, psychiatric stability is not always easy to achieve. Some people go through unstable periods if they slack off on taking their medications or relapse on illicit drugs or alcohol. And, symptoms of mental illness can worsen even when someone is adhering to a course of treatment and remaining sober.

All too often, participants in mental health courts or other programs offering alternatives to incarceration cycle in and out of hospitals or, worse still, jail. In many instances, participants in diversion programs who either have decompensated, or are on the verge of doing so, may be safely treated and stabilized without incarceration in jail or hospitalization in a secure psychiatric facility.

Crisis beds
A more coherent response to this problem would be a comprehensive housing strategy that: expands the availability of transitional, crisis, and long-term supported housing; promotes housing stability for individuals living with family members; and improves coordination between service providers and criminal justice players.

Such an undertaking cannot be realized overnight. However, as an initial step towards achieving that end, attention should be focused on the following:

Identification or creation of transitional living resources to shorten jail stays.

One transitional housing strategy could designate a small number of existing beds (perhaps a few of the transitional and crisis beds at state psychiatric centers) as resources for people who have been accepted into mental health courts or ATI programs and are awaiting placement in long-term supportive housing programs. Another would be to create a transitional housing resource coupled with specific services to address community supervision and case management for people under court supervision. One possible resource includes apartments or underutilized beds on the campus of a psychiatric center.

Improved access to crisis beds for individuals already in the community under court supervision.

Procedures to facilitate access to existing crisis beds could reduce both hospitalizations and jail remands in situations where a mentally-ill defendant has pleaded guilty and been admitted to a program but is destabilizing and requires more intensive services and supervision.

The New York State Office of Mental Health (OMH) has expressed interest in creating partnerships between the diversion programs on the one hand and a number of its psychiatric centers. These psychiatric centers could provide beds that would serve as both transitional living beds and as crisis beds for participants in mental health courts and other alternative-to-incarceration programs in New York City and adjacent suburban counties.

Pilot project
We have proposed launching a pilot program involving one of these New York State psychiatric centers, Creedmoor. Using Creedmoor as the sole site of the pilot program would allow a more careful evaluation of the program's effectiveness, and would permit the standardization of practices and the development of a complete model that could then be more efficiently replicated elsewhere in the state.

The influx of these new clients at Creedmoor would necessitate the appointment of a forensic coordinator to act as liaison with the courts, the district attorneys, participating case management organizations, and to help coordinate the transportation, placement, and treatment of these short-stay clients. The forensic coordinator will assist the New York State Judicial Institute in training judges could assist John Jay College of Criminal Justice in its efforts to similarly train police officers on how to deal with mentally ill defendants.

We have received assurances of cooperation from the various state and educational facilities and have secured private foundation funding for the hiring of the forensic coordinator. We hope to have ready all of the components of the program by the Fall of 2008.

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