Freedom fighters
Innovative programs seek to keep mentally ill out of jail and in treatment

By Ed Fraunheim
January 22, 2001
Photo: Artville

Until August, George lived a six-year nightmare all too common for people with mental illnesses. The 28-year-old suffers from paranoid schizophrenia. Partly because he lacked treatment and partly because treatment can’t always alleviate every symptom, George experienced hallucinations and heard voices. He often lived on the streets of Los Angeles. Periodically, he ended up in jail for theft or cruelty to animals.

After his last arrest, he was transferred to a psychiatric hospital. There, he enrolled in a new program designed to keep people with mental health problems out of jail and help turn their lives around.

The program, dubbed AB 2034 after the California bill that brought it about, has set George up in a halfway house, provided him with treatment and medication, and encouraged him to aim for a job one day in the music business.

"Now I’ve got a place to stay, and I’m going to school and everything’s going great," he said. "If it weren’t for AB 2034, I’d probably be on the street somewhere. I’d be having a hard time. I wouldn’t be focused."

The California program is one of several bright spots nationally in what’s generally a gloomy topic: The way people with mental illnesses often wind up in the criminal justice system. Nurses in emergency rooms, psychiatric hospitals and jails are on the front lines of a battle to provide humane care to this marginal group.

Besides typical challenges on the job– being yelled and cursed at by patients –nurses in the field can find it frustrating to watch clients slip repeatedly through cracks in the mental health care system. Even so, some nurses and other mental health experts see some progress in innovative programs, the way courts and police are starting to treat the mentally ill and even the way nurses are learning to handle psychiatric patients.

Brett Faulkner, RN, a psychiatric nurse working at Northridge Hospital Medical Center in Southern California, said AB 2034 is helping to stem recidivism among the mentally ill. He notices greater sensitivity on the part of police officers who bring psychiatric patients to the hospital in comparison to their comportment in the 1970s, when officers occasionally used excessive force.

Meanwhile, Faulkner’s colleagues have come to care for mentally ill patients more effectively. Nurses have helped reduce the rate of violent outbursts from about 10 percent a decade ago to less than 1 percent by clearly articulating hospital rules and working more frequently in teams.

"Staff used to be assaulted on a regular basis," said Faulkner, a case manager. "It’s declined considerably."

The majority of mentally ill people who are arrested haven’t committed seriously violent crimes, said Avrim Fishkind, MD, medical director of the NeuroPsychiatric Center in Houston. Even though media attention often focuses on people such as John Hinckley, the man who shot President Reagan and White House Press Secretary James Brady in 1981, most of the mentally ill people behind bars, at most, have struck someone without causing serious injury, Fishkind said.

"A lot of it amounts to stealing a candy bar or trespassing or camping out in public or public intoxication," Fishkind said. "Those kind of harmless, quality-of-life crimes."

Even so, more and more people with mental illnesses are ending up in jail, according to the National Alliance for the Mentally Ill. Citing a 1999 Justice Department study, the alliance said 16 percent of all inmates in state and federal jails and prisons– roughly 265,000 people –suffer from schizophrenia, bipolar disorder (formerly known as manic depressive illness), major depression or another severe mental illness. By contrast, the alliance estimates about 70,000 people with severe mental illnesses are in public psychiatric hospitals.

The alliance argues that jails and prisons are poor places to treat people with brain disorders because they can be terrifying to the mentally ill, often lack qualified mental health professionals, frequently punish the mentally ill in ways that exacerbate their disease and usually lack state-of-the-art drugs.

Health officials working in jails dispute this claim. In any event, all sides agree one key is keeping the mentally ill out of jail in the first place. Smart programs already are making a difference. In Memphis, Tenn., for example, mental health experts widely regard a 12-year partnership between the police department, health care providers, people with mental health problems and their families as being among the best ways for police officers to handle the situations that may arise. As part of the partnership, the Memphis Police Department has trained roughly 20 percent of its officers with techniques for handling mental illness emergencies. Members of this Crisis Intervention Team typically spearhead situations in which police are summoned to deal with someone who may be mentally ill. If possible, CIT officers do not arrest the individual in crisis but instead take them to the psychiatric services unit of a regional medical center.

The CIT approach has led to successes such as an arrest rate of just 2 percent (compared to a national average of 20 percent), lower injury rates for officers and the willingness of mentally ill people themselves to call on police, said Lt. Sam Cochran, the CIT program coordinator in Memphis.

If they’ve lost confidence in the mental health system, police officers otherwise might choose to take mentally ill suspects to jail, Cochran said. An officer taking a person with mental health problems to an emergency room for a psychiatric referral may have to wait four to eight hours– time they feel should be spent patrolling. The Memphis partnership has reduced that time to 20 minutes or less.

Nurses involved in the Memphis program play a role not only in making those referrals efficient, but also in diffusing what can be explosive situations.

"They bring on a sense of calm to a crisis episode," Cochran said. "That’s the first step toward coming out of a crisis."

Cities such as Seattle; Portland, Ore.; San Jose, Calif.; Houston and Albuquerque, N.M. have replicated the Memphis CIT model, and numerous others intend to do so.

In Houston, the police department has trained a total of 750 officers. Fishkind said the year-old program already has resulted in 300 to 350 fewer mentally ill people sent to jail per month. Instead, people suspected of mental illness are taken to the NeuroPsychiatry Center, where the psychiatric emergency room is open 24 hours a day, seven days a week. The additional referrals are due partly to a Memphis-like fast turnaround, Fishkind said. Police officers bringing in mentally ill people can walk out the door in a mere 15 to 30 minutes compared to wait times of up to 10 hours.

Nurses connected to the CIT program wear multiple hats, Fishkind said. They assess patients, help arrange their discharge plans and teach patients about medications they must take. The last role is key because people with mental illness can be tempted to stop taking their medication as soon as their symptoms stop– but the illness then will creep back into their life.

"The nurse has a central role in [medication] compliance education," Fishkind said.

One of those nurses is Tina Nwosu, RN. She in turn gives credit to the police officers she works with. After three years in psychiatric nursing, Nwosu said the CIT program has led to improved police officer skills when it comes to the mentally ill.

"I have noticed a more tolerant, respectful and understandable approach by the police who are CIT trained," Nwosu said.

The CIT program is just part of the solution in Houston and the rest of Harris County. For seven years, the county’s Mental Health and Mental Retardation Authority has sponsored a program called New Start, which helps mentally ill people on parole or probation make the transition out of the prison system.

Clients receive services such as housing and food assistance, life-skills classes, health classes, mental health treatment and substance abuse counseling. The latter is vital to a population that can turn to alcohol or other drugs to self-medicate. About 95 percent of the New Start clients are mentally ill and substance abusers.

The program boasts an impressive success rate. Last year, only two of 339 clients returned to prison, said Carson Easley, MS, RN, director of nursing for the Authority.

Nurses in New Start have some authority over the clients, because those who violate a program rule can be sent back to prison. But Easley said the RNs aren’t generally regarded like Nurse Ratched– the cruel psychiatric nurse from the film "One Flew Over the Cuckoo’s Nest." New Start nurses are appreciated, Easley said, which may stem from the way the nurses show respect for their clients even at the level of their attire. Rather than Nurse Ratched’s formal white uniform, New Start nurses wear business clothes.

"We didn’t want to set up the illness model," Easley said. "Clients can see what’s appropriate to wear for the workplace."

New Start is in some ways similar to the AB 2034 program. In the California program, clinicians go into jails and reach out to homeless people to link those with mental illness with treatment, housing, life-skills classes and jobs. Licensed vocational nurses, licensed psychiatric technicians and registered nurses teach classes, visit with clients and make sure they take medications. Initially, clinicians try to meet with clients every day to forge a bond.

Taylor Shelton, LVN, has spent 25 years off and on in the mental health field. She believes this outreach program is light years beyond what typically happens in her state and across the country.

"Most of these people don’t belong in jail," said Shelton, who works for Telecare Corp. "It’s far and away the best approach I’ve seen in my career."

AB 2034 began as a pilot project in 1999, and given the results in Los Angeles County, it’s not hard to see why the California Legislature expanded the program. In the course of a year, the county project worked with 892 individuals, 36 percent of whom came from the jail system, according to the County Department of Mental Health. Only 7.7 percent of clients dropped out, while the number of days clients were homeless fell 61 percent. Troubles with the law also fell dramatically. While 451 of the mental health consumers had been incarcerated at some point during the 12 months prior to their enrollment, just 115 were incarcerated during their enrollment, a 75 percent decrease.

Comprehensive, community-based mental health programs such as AB 2034 and New Start can have impressive track records. Tom Hamilton, president of the Texas chapter of the National Alliance for the Mentally Ill and a member of the board of the Harris County Mental Health and Mental Retardation Authority, said the New Start program and similar projects in Wisconsin and Arkansas have success rates ranging from 80 percent to 93 percent in terms of keeping mentally ill people out of prison.

Why are the mentally ill being jailed so much in the first place? The trend perhaps can be traced in part to an effort to help them. Several decades ago, mental hospitals too easily locked up people against their will. In the late 1960s and 1970s, as more effective drugs became available, those hospitals turned people out with the expectation that new community-based mental health care programs would take up the slack. But the community programs often didn’t fill the gap, in part because of funding shortages.

That left many severely mentally ill people without adequate treatment and supervision. Many stopped taking proper medication, became homeless and prone to delusional outbursts or other publicly disruptive actions that could bring the police to the scene.

Texas is a case in point. State funding for community mental health programs is enough to serve about 150,000 people, Hamilton said. But between 500,000 and 1 million severely mentally ill people live in this state of roughly 20 million people. Some mental health consumers receive treatment through private insurance and Medicaid, but between 250,000 and 500,000 remain untreated, Hamilton said. Many end up homeless and ultimately in jail. As many as 12,000 nonviolent people are in state prisons because of an untreated mental illness, Hamilton estimated.

"This is an artifact of the deinstitutionalization process and underfunding the safety net," he said.

Texas is considering building new prisons, but it makes no sense financially, said Hamilton, the CEO of an oil and gas company. He estimates it costs about $30,000 a year to house and treat a mentally ill person in prison, but only $5,000 to $17,000 to provide them with housing and treatment through a community-based program such as New Start.

The Texas Department of Mental Health and Mental Retardation has asked for an additional $42.5 million next year to bolster community mental health programs, an amount that could serve the 12,000 people in prisons and keep the state from having to build new ones, Hamilton said.

"You can treat people more humanely [in community-based programs]. You can do it and save money," Hamilton said. "It’s much more cost-effective than putting them in prison."

For now, though, many mentally ill people are being treated in prisons and jails. In the city and county of San Francisco, for example, roughly a quarter of the 2,000 or so jail inmates are treated with psychiatric medications or followed by a mental health clinician, estimated Randy Hurst, RN, director of nursing for San Francisco’s jail health services.

Although some jails are accused by the National Alliance for the Mentally Ill of lacking the latest, most effective drugs for mental illness, Hurst said that San Francisco’s facilities provide cutting edge medications such as selective serotonin reuptake inhibitors for depression and the anti-psychotics risperidone and Clozaril (clozapine).

"It makes me feel good that I’ve got at my fingertips the resources to help these people," Hurst said.

Less encouraging is the fact that Hurst also sees many of the same people over and over again. He believes the system is broken for people with mental illness.

"We’re giving them excellent treatment," he said. "But I don’t think they should have to commit a crime to get that care."

The long-term solution, most observers suggest, is more public money spent on treatment programs. That includes reestablishing inpatient facilities, said Kathleen Sheridan, RN. Sheridan, who has spent 13 years as a corrections health nurse and now works for the Multnomah County Health Department in the Multnomah County jails in Oregon, said there has to be a place for mentally ill people to spend time when they experience crises.

What’s particularly hard for her is watching patients leave the jail, as there’s frequently no space in treatment programs or public housing projects.

"They’re starting to shape up a little better, and there are so few places to send them when they get out that they wind up again under the bridge," she said. "There’s very limited continuity of care."

Incarceration and freedom have become perversely twisted for the mentally ill, Sheridan noted.

"Jail can be a pretty safe place for [people with mental health problems],"she said.

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