Prison and Jails: Hospitals of Last Resort by Heather Barr

11/26/03 12:24 AM

Prisons and Jails: Hospitals of Last Resort

The Need for Diversion and Discharge Planning for Incarcerated
People with Mental Illness in New York
By Heather Barr
The Correctional Association of New York is a non-profit policy analysis and advocacy
organization that focuses on criminal justice and prison issues. It is the only private entity in
New York State with legislative authority to visit prisons and report its findings to policy
makers and the public. The Urban Justice Center (formerly the Legal Action Center for the
Homeless) is a not-for-profit agency which works on behalf of poor and marginalized New
Yorkers through a combination of direct representation, systemic advocacy, community
organizing and education. The agency houses five projects which, respectively, work for and
with: the homeless and the marginally housed, poor people with mental illness, survivors of
domestic violence, lesbian and gay youth, and welfare applicants and recipients. Heather Barr
is a Soros Justice Fellow and an attorney with the Urban Justice Center's Mental Health
Project. She advocates on behalf of people with mental illness in New York's criminal justice
system. Copyright © 1999, the Correctional Association of New York and the Urban Justice
Center. All rights reserved.

Acknowledgments
Many people provided invaluable assistance in compiling and editing this report. First and
foremost, thanks are due to the Center on Crime, Communities and Culture at the Open
Society Institute, which funds Heather Barr's work through its post-graduate fellowship
program.
Thanks to Robert Gangi, Executive Director of The Correctional Association of New York,
and the Correctional Association's Board of Directors for taking on this project and devoting
so much attention to it. Dr. Nahama Broner of the NYU School of Social Work and Dr.
Stacy Lamon of the NYC Department of Mental Health were of enormous help in finetuning the substance of the report. Carol Bernstein Ferry, a Correctional Association board
member, and Jennifer Wynn, Director of the Correctional Association's Prison Visiting
Project, were excellent editors. Ruth Groebner, a law intern at the Urban Justice Center, was
of great assistance with research and editing.
This report is the product of a number of meetings of an advisory board composed of
independent experts in the field and Correctional Association board members. Everyone
involved gave generously of their time and knowledge. This project would have been
impossible without the help of the following advisory board members:
Gail B. Allen, M.D., Director of Substance Abuse Services, St. Luke's Roosevelt Hospital*
Nahama Broner, Ph.D., Research Director, NYU/SAMHSA Jail Diversion Research Project
Ralph S. Brown, Jr., Esq., Chair of the Correctional Association Prison Visiting Committee*
Amanda M. Burden (and her colleagues David Connolly and John Megaw), Center for Court
Innovations*
Constance P. Carden, Esq., Supervising Attorney, New York Legal Assistance Group*
Michelle Des Roches, CSW, Program Director, Times Square Consortium Outreach Team
Carol Bernstein Ferry, Correctional Association board member
John Gresham, Esq., Senior Litigation Counsel, New York Lawyers for the Public Interest
Patrice Kanada, Research Associate, Center on Crime, Communities and Culture
Stacy Lamon, Ph.D., Criminal Justice Consultant to the New York City Commissioner of
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Mental Health
Dori Lewis, Esq., Senior Supervising Attorney, Legal Aid Society -- Prisoners' Rights
Project Trish Marsik, CSW, Facility Director, Citizen's Advice Bureau -- The Living Room
Evelyn Mielke, Core Member, NAMI-NYC Metro Criminal Justice Support Group
Marjorie Rock, Dr.PH, Associate Professor, NYU School of Social Work
James D. Silbert, Esq., Silbert, Hiller & Sena, LLP*
Barbara H. Stanton, Center for Human Environments, CUNY*
Heather Barr thanks everyone at the Urban Justice Center, especially Marlene Aksen, Sue
Batkin, Ray Brescia, Ruth Groebner, Doug Lasdon and Ann Vermes, for their help and
moral support. Cover design by Sally Liu.
Cover design and copying kindly provided by the law firm of Shearman & Sterling. Special
thanks to Janet Casiano, Kit Chau, Bonny Forrest and Sally Liu at Shearman.
* These individuals are also Correctional Association board members.

EXECUTIVE SUMMARY
Have jails and prisons replaced hospitals for New Yorkers with mental illness? Increasingly,
theanswer is yes. Deinstitutionalization and the closing of psychiatric hospitals, the rise of
managed care, the growth of prisons and jails, and punishment of "quality of life" crimes
have contributed to the incarceration of thousands of people with mental illness in New York
City and New York State. This paper examines the scope of the problem and recommends
strategies which, if implemented, would lead to a far more humane and sensible system. In
such a system, seriously mentally ill minor offenders would be diverted to treatment rather
than sent to jail, and prisoners requiring mental health services would be able to continue their
treatment as they moved between correctional facilities and the community. These strategies
have the potential to be safer and cheaper for the community while providing better care for
people with mental illness.
The central premise of this paper is that people with mental illness rarely belong in jail and
prison. Diversion and discharge planning are the only humane responses to illegal activity by
people with serious mentall illness, and we believe that these responses have far greater
potential than traditional law enforcement approaches to stop the "revolving door" and lead to
real rehabilitation for mentally ill offenders. The goal of this paper is to serve as a catalyst for
change.
On any given day, there are close to 8,000 people with mental illness in New York's prisons
and jails. Fifteen to 20% of city jail inmates are mentally ill; 7 to 8% of state prisoners are.
Some of these people are serving long sentences in the state prison system; many others
spend short periods of time at Rikers Island on relatively minor misdemeanor charges. In
1997, 15,000 New York City jail inmates were treated for serious mental illness and more
than 33,000 required mental health services.
People with mental illness in New York's prisons and jails are marginalized in many ways.
Prior to incarceration, very few were employed; most relied on public benefits or had no
income. The vast majority received Medicaid or had no insurance at all. They are
predominantly poor people of color and are disproportionately female. Most people with
mental illness in New York's jails and prisons, like the correctional population generally,
struggle with substance use. Finally, an overwhelming number of inmates with mental illness
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are homeless: On any given day, there are about 1,100 homeless mentally ill people in New
York City's jails.
New York's current practices in dealing with people with mental illness in the criminal justice
system are neither efficient nor humane. People with mental illness who have committed
minor offenses, and desperately need treatment, are simply incarcerated. New York has no
effective mechanisms, legal or informal, to divert offenders with mental illness into mental
health treatment and out of the criminal justice system. While incarcerated, people with
mental illness are victimized and segregated, learn institutional behaviors, lose contact with
their families and community mental health treatment providers, and lose their housing,
income and insurance.
During their incarceration, most people with mental illness receive basic mental health
services, but when their release date arrives they are usually discharged with no referral to
community treatment, no income, insurance, or housing -- none of the support they need to
remain in treatment, maintain their psychiatric stability and stay out of trouble. This failure to
create a continuum of care has many harmful consequences for the ex-inmate and the
community. The burden of housing the person and dealing with the return of psychiatric
symptoms falls on the city shelter system. The task of treating uninsured, acutely ill exinmates taxes the city's hospitals and emergency rooms. Finally, ex-offenders with mental
illness who receive no discharge planning are likely to reoffend, thereby creating both
financial and social costs for their communities.
By offering woefully insufficient diversion and discharge planning to criminal defendants and
prisoners with mental illness, New York fails to stop the "revolving door" of repeated
hospitalizations and incarcerations. Not only does this failure set people up to reoffend, it also
squanders what may be a rare opportunity to intervene in the course of an individual's illness.
Involvement in the criminal justice system offers a window of opportunity for even a
treatment-resistant person with mental illness to get help. All of society benefits when we take
these opportunities to assist people.
The recommendations outlined in this paper fall into three distinct areas: 1) mechanisms to
divert criminal defendants with mental illness into mental health services; 2) strategies to
create a continuum of care for people with mental illness as they move between the criminal
justice system and the community; and 3) the components necessary to provide
comprehensive discharge planning and help ex-offenders with mental illness reintegrate into
the community.
This paper recommends:
DIVERSION
Divert people with mental illness instead of arresting them. 1) Direct 911 calls involving
people with mental illness to specially trained police. Police can be taught to do crisis
intervention rather than arrest. 2) Provide easier access to psychiatric hospital beds for police
and courts. Acutely ill offenders can be hospitalized, not arrested, if beds are available. Divert
misdemeanants with mental illness into community mental health services. 1) Make mental
health screening, diversion and crisis beds available at arraignment. The arraignment process
can offer a unique mental health intervention point. 2) Complete 730 (competency) exams in
misdemeanor cases within 48 hours. Incompetent misdemeanants can move quickly out of
the criminal justice system. Develop alternative to incarceration programs for people with
mentally illness. 1) Enhance existing ATI programs with mental health services and create
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new mental health ATI programs. Mentally ill felony offenders can succeed in formal mental
health ATI programs.
CONTINUUM OF CARE
Build links between jail and community treatment providers. 1) Train community mental
health workers to track clients in the criminal justice system. Community workers can learn to
be advocates within the criminal justice system. 2) Create mechanisms to connect jail-based
mental health services to the community. Continuity of care can be built into jail-based mental
health care.
DISCHARGE PLANNING
Link inmates with services before release. 1) Provide pre-release discharge planning to all
mentally ill jail and prison inmates. Correctional mental health staff can smooth the transition
back to the community. Ensure immediate access to essential services following release. 1)
Provide immediate access to medications and treatment. Releasees can be guaranteed the
treatment they need to succeed. 2) Expedite benefit approval/recertification. Releasees can be
insured that their immediate survival needs will be met. 3) Refer mentally ill ex-offenders to
supportive housing or specialized shelter programs. Programs can provide shelter and support
to ex-inmates with mental illness. 4) Create specialized mental health parole/probation
programs with low caseloads. Community supervision officers can help ex-inmates avoid reoffending.

Glossary of Abbreviations
The following terms are written in full at first mention and abbreviated thereafter throughout
the paper.
ACT assertive community treatment
ADA assistant district attorney
AMI Alliance for the Mentally Ill
ATI alternative to incarceration
CIT Crisis Intervention Team
CNYPC Central New York Psychiatric Center
C-PEP Comprehensive Psychiatric Emergency Programs
CPL Criminal Procedure Law
DHS New York City Department of Homeless Services
DMH New York City Department of Mental Health, Mental Retardation, and Alcoholism
Services
EDP emotionally disturbed person
FY fiscal year
HRA New York City Human Resources Administration
HHC New York City Health and Hospitals Corporation
ICP intermediate care program
MHU mental health unit
MICA mentally ill chemical abuser
MOU mental observation unit
NGRI not guilty by reason of insanity
OMH New York State Office of Mental Health
SSD Social Security Disability
SSI Supplemental Security Income
WEP Work Experience Program
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I. INTRODUCTION
A. A Case Study
James1 grew up in Brooklyn in a middle class family where he was the oldest of three
children. He was a junior in college studying engineering when he was hospitalized for the
first time and diagnosed with paranoid schizophrenia. He has been in and out of hospitals
dozens of times since then. His family took care of him for years, but eventually his parents
died and his siblings left the city.
After James lost contact with his family, his condition deteriorated. He lived in a single room
occupancy hotel for several years, paying his rent with disability benefits. In the early 1990s,
James was sent to prison after breaking the window of an appliance store and injuring a
police officer. While in prison, James took Thorazine every day and functioned relatively
well, but when he left prison he had no way of getting his medicine and he'd lost his disability
benefits and his room.
Today James is homeless. He sleeps in a park, eats out of garbage cans, panhandles and
drinks malt liquor to help him cope with the voices he hears in his head. He does not see a
psychiatrist; he has neither benefits nor insurance.
James hears things other people do not. He hears agents from the FBI planning to capture
him, kidnap him and hurt him. He often talks back to the voices he hears.
One day James is standing on a busy corner arguing loudly with the voices in his head and
waving his arms for emphasis. He is blocking pedestrian traffic and a police officer tells him
to move along. James looks at the police officer and sees one of the FBI agents coming to get
him. He flails his arms, hitting the officer and knocking him down.
James is arrested and charged with disorderly conduct, assaulting a police officer and
resisting arrest. Assaulting an officer is a felony. James spends several hours at the nearby
precinct, several more hours at Central Booking, several more hours in a pen below the
courthouse, several more hours in a pen behind the courtroom, and finally, about 30 hours
after hitting the police officer, James meets his lawyer.
The lawyer knows immediately that there is something wrong with James. Thirty hours of
moving from one cage to another have not helped James collect himself. He is disheveled
and smelly and detoxing from alcohol; he is barefoot, talking loudly to himself, and there is a
cut and a bruise on his face where another prisoner punched him for being too noisy.
James's lawyer asks him what happened. The details are sketchy, but James manages to
explain that he didn't mean to hit the police officer. The lawyer considers asking the judge to
have a psychiatrist examine James to determine whether he is competent to assist in his own
defense.2But the lawyer knows that getting the results of this examination could take weeks -much longer than the sentence will be if he can get James the chance to plead guilty to
disorderly conduct or even a misdemeanor assault.
At arraignment, the assistant district attorney assigned to the case is amenable to lowering
the charges. She has reviewed the paperwork and agrees with the defense attorney that
James probably did not mean to hit the police officer. She, like the defense attorney, can tell
just by looking at James that he has psychiatric problems.
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James is offered the opportunity to plead guilty to misdemeanor assault and receive a
sentence of 10 days of community service. The defense attorney tells James it's a good deal
and he should take it. James pulls himself together enough to get through the procedure of
pleading guilty. His defense attorney tells him where and when to go for the community
service and, as an afterthought, suggests that James see a doctor and get some medicine.
James agrees to everything and walks out of the courtroom barefoot into a cold rainy night.
He still has no benefits or insurance or any idea where he might find a doctor, if he wanted
one. He loses the piece of paper with the information about community service almost
immediately. He goes back to the park where he usually sleeps. He does not show up for
community service. Three weeks later, James is found sleeping in the entrance foyer of a
building on a snowy night. He is arrested for trespassing and the judge wants to send him to
jail because he didn't do his community service last time.

B. A Case for Change
James is an example of a stigmatized and rapidly growing group of people -- people with
mental illness who are or have been involved in the criminal justice system. An important
threshold question is what the term "mentally ill" means. For the purposes of this paper,
"mentally ill" does not include everyone who has been or could be diagnosed with a mental
disorder. This paper is concerned with people who have serious mental illnesses -- illnesses
(other than substance use), such as schizophrenia and bipolar disorder, which substantially
impair their daily functioning -- and who require ongoing psychiatric treatment and
supportive services in order to function in the community.3
Across the country, attention is finally being paid to the problem researchers describe as "the
criminalization of mental illness" and "transinstitutionalization" -- the movement of people
with serious mental illness from community psychiatric hospitals into jails and prisons.4 The
incarceration of thousands of people with serious mental illness is having tragic consequences
nationwide, and nowhere more so than in New York.
On any given day, there are approximately 7,680 people with mental illness in New York
State's jails and prisons. 5 At least 2,850 of those are in the New York City jail system, making
Rikers Island, de facto, the state's largest psychiatric facility.6 Fifteen to 20% of New York
City jail inmates are mentally ill.7 In 1997, 15,000 New York City jail inmates were treated
for serious mental disorders.8 Twenty-five percent of New York City jail inmates receive
some sort of mental health services -- a total of about 33,325 people per year.9 Seven to 8%
of the 70,000 inmates in New York's state prisons are mentally ill, and 15,000 to 20,000
mentally ill state prisoners are released to New York City each year.10
Police, courts, jails and prisons are not adequately prepared to deal with a woman who stands
in traffic yelling at voices she hears in her head, or a man who stalks a celebrity thinking she
is his wife. Police are much more likely to arrest people with mental illness than the nonmentally ill.1 1 Once arrested, mentally ill people in New York are incarcerated longer and
have less access to alternative to incarceration programs than non-mentally ill offenders.12 As
a result, even mentally ill people charged with minor misdemeanors can end up spending
significant time in jail. While incarcerated, they receive limited psychiatric care or none at all.
Any psychiatric treatment they were receiving in the community is disrupted. When inmates
with mental illness are released, they are generally not referred to mental health services or
benefits or housing and are likely to end up in jail again as a result. This is the cycle that has
criminalized mental illness and made jails and prisons New York's new psychiatric
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institutions.
People with mental illness who are or have been incarcerated are perhaps the most
marginalized people in New York. They suffer the stigma and consequences of both mental
illness and criminality; they are predominantly poor and of color, and they are often battling
substance use and additional problems including homelessness and illnesses such as
tuberculosis and AIDS. They are cut off from mental health services available to nonoffenders, and their psychiatric problems isolate them from advocates for "normal"
defendants and prisoners.
The vast majority of people with mental illness in the criminal justice system are not
dangerous and are not incarcerated for long. With New York City's increasing punishment of
"quality of life" crimes, more people with mental illness than ever, particularly the homeless
mentally ill, are charged with misdemeanors.13 They spend days, weeks or perhaps months in
jail,14 then return to the community needing help reintegrating into society, remaining
psychiatrically stable and staying out of trouble. People with mental illness sentenced to
upstate prison terms are not gone forever either. Most prisoners are eventually released, and
70% of state prisoners return to New York City.
These problems are not unique to New York City or New York State. Nationwide, as many
as 13% of jail inmates suffer from severe mental disabilities.15In many jurisdictions, jails have
become the primary treatment provider for poor people with mental illnesses. In state and
federal prisons, the situation is the same: An estimated 10% of the nation's prisoners, a total of
about 122,000 people, are seriously mentally ill.16 The total number of people with serious
mental illness in jails and prisons nationwide is estimated at almost 200,000.17 While this
population and the problems it poses have received significant national attention recently,
finding solutions remains uncharted territory.18 Clearly, innovative treatment and intervention
models are needed, and a successful local model is likely to be replicated across the nation.
There are three obvious ways to help people with mental illness who are involved in the
criminal justice system. One is to divert them from the criminal justice system into mental
health treatment. A second is to offer discharge planning that helps them gain access to
treatment and other services they will need after they leave prison or jail.
An important third way to help people with mental illness in the criminal justice system is to
improve conditions and mental health services inside jails and prisons. While addressing the
changes that need to be made within correctional facilities is beyond the scope of this paper,
this omission should not be seen as an endorsement of the current treatment of incarcerated
people with mental illness in New York.
Another limitation of this paper is its focus on New York City. We do not intend it to be a
comprehensive overview of correctional systems or mental health systems statewide. While
the paper's recommendations have some general applicability, they are designed with New
York City in mind, and refer in many cases to New York City government agencies.
The central premise of this paper is that people with mental illness rarely belong in jail and
prison. Diversion and discharge planning are the only humane responses to illegal activity by
people with serious mental illness, and we believe that these responses have far greater
potential than traditional law enforcement approaches to stop the "revolving door" and lead to
real rehabilitation for mentally ill offenders. The goal of this paper is to serve as a catalyst for
change.
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C. Treatment Works
History and research have shown that mental health and substance use treatment works.
Although we are far from being able to "cure" serious mental illness or provide universally
effective treatment, the range, compassion and efficacy of mental health treatment modalities
have improved dramatically in recent years. Researchers have developed new medications
that offer clinicians a greater range of options and that may help patients who did not respond
to or who experienced severe side effects with the previous generation of psychotropic drugs.
New "client-centered" mental health programs, such as psychosocial clubhouses, have
succeeded in engaging people resistant to conventional treatment. A broad array of effective
programs with different levels of care have been developed in both inpatient and outpatient
settings to accommodate patients' individual needs.
The majority of people with mental illness in New York's prisons and jails have substance
use problems. People who suffer from both mental illness and substance use disorders pose a
great challenge to the mental health community. The co-occurrence of these disorders
complicates the patient's prognosis and clinical treatment planning; fragmentation of treatment
programs often adds to the problem. Traditionally, the mental health and substance abuse
fields have been separate and, at times, even antagonistic. The result was often that mentally
ill substance users received treatment for only one of their problems or, at best, received
mental health and substance use treatment from separate providers who did not work together
or even communicate to create a joint treatment plan.
This gap is beginning to close as researchers and clinicians call for integrated mental health
and substance use services that address both problems simultaneously.19 Research has shown
that integrated services are more effective than mental health and substance use treatment
offered separately or sequentially.20 A number of specific integrated treatment modalities have
shown definite promise in treating mentally ill substance users.2 1
The movement toward integrated services, and the research showing the success of this
approach, are enormously important for people with mental illness in the criminal justice
system. Clearly, diverting people with mental illness out of the criminal justice system and
into treatment is not an attractive option if the treatment only addresses one aspect of their
problem. With integrated treatment programs available, however, we have an opportunity to
create real change in the lives of offenders with mental illness by diverting them to
community mental health services or referring them to community treatment following
incarceration.22

D. Potential Cost Savings of Diversion
An obvious question is whether effective treatment costs less than incarceration. In 1996, the
cost of incarcerating an individual in the New York City jail system for one year was
approximately $64,000.23 The comparable cost of a year in state prison was $32,000.24 This
is equal to $175 per day to keep someone in jail and $88 per day in prison. These figures are
for the average inmate, however, and people with mental illness are not average inmates;
inmates with mental illness require far more than their "share" of jail and prison resources, in
the form of treatment, suicide prevention observation and crisis intervention. As a result,
inmates with mental illness substantially inflate average incarceration costs.
In comparing the costs of diversion to those of incarceration, it is important to remember that
incarcerating a person with mental illness does not "save" the cost of providing health and
mental health care to the individual. Health services provided in jail or prison are limited but
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costly. For example, New York City pays more than $115 million a year to provide health
and mental health services to jail inmates.25
Another important element of any comparison of the costs of diversion with those of not
diverting people with mental illness is the costs of processing the case. Long before a person
with mental illness is sentenced to incarceration, taxpayers begin paying the costs of the
police who arrest and process the person; the court pens where the person is held; the defense
attorney who represents the person; the Assistant District Attorney (ADA) who prosecutes
the person; the judges the person appears before, as well as their staff and court officers; the
rent, maintenance and overhead of the courthouse; the jail where the person is detained;
transportation to and from the jail, et cetera. Diverting a person with mental illness out of the
criminal justice system at an early stage, for example prior to arrest or at arraignment, saves
not only the cost of incarceration, but many of these costs as well.
Finally, any cost comparison is incomplete if it does not consider the future fiscal
consequences of the decision to divert or not divert a person with mental illness from the
criminal justice system into treatment. Many of the people with mental illness in New York's
criminal justice system are caught in a "revolving door" that shuffles them repeatedly through
hospitals, jails and shelters at an enormous cost to taxpayers. One authoritative estimate
places the annual cost of serving a seriously mentally ill homeless person caught in the
revolving door of repeated hospitalizations in New York City at about $70,000.26 An
individual passing repeatedly through hospitals and the criminal justice system may cost even
more. If diversion from the criminal justice system into community mental health services
creates an opportunity to engage the individual and provide services that will stop the
revolving door and prevent future hospitalizations and arrests, and the other costs of crime,
for example, injury to victims and property damage, then diversion has the potential to save a
great deal of money in the long run.
It is difficult to quantify the costs of treating a person with mental illness in the community
because the individual may use a variety of mental health services. The question of how
much mental health services cost, and how this cost compares to that of incarceration, has not
been widely studied in the past; currently, a number of jurisdictions have begun to research
the comparative costs of community treatment and incarceration.2 7
It is possible, however, to make some educated guesses about relative costs. A 1997
Wisconsin study of 1,890 severely mentally ill patients found that the average total
expenditure for inpatient and outpatient mental health services per client was $10,995 per
year, or $30 per day.28 Obviously, Wisconsin is a very different setting than New York; it is
also important to note that in this study outpatient services accounted for 53.5% of
expenditures, and the costs of food and shelter for people in outpatient programs were not
borne by the mental health system. This study still stands out as one of the few recent
attempts to quantify the costs of providing a continuum of community services.
Another helpful figure may be the cost of supportive housing. Supportive housing is
permanent housing provided by a social service agency and designed specifically for
mentally ill, often formerly homeless, people. Mental health services including case
management, psychiatry, medication management and counseling are typically provided onsite. The cost of providing supportive housing to an individual in New York City is about
$12,000 per year or $33 per day, considerably less than the $175 per day to incarcerate.2 9
Another model for providing intensive services to seriously mentally ill clients is the
Assertive Community Treatment (ACT) team model. This model works with clients who are
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housed, but who also have great service needs and are not able to access these services
without assistance. An ACT team is a mobile team that works with these difficult or
treatment-resistant clients by bringing psychiatric, case management, drug treatment and
vocational services to the client's home. ACT teams in New York City are currently funded
at approximately $10,000 per client per year.30
A few cautions are necessary when comparing the costs of community services such as
supportive housing and ACT teams to the cost of incarceration. For example, some residents
of supportive housing and ACT clients may also require mental health services such as day
treatment and hospitalization in addition to a $12,000 bed in supportive housing or the
$10,000 ACT team services. Supportive housing residents and ACT clients also generally
create additional costs by receiving benefits which they would not be eligible for were they
incarcerated. With comprehensive on-site services, however, a person with a very serious
mental illness may be able to receive all of his mental health services at his residence and
work toward future employment and independence.
Clearly, more research on the costs of diversion and discharge planning is needed. Any costbenefit analyses should figure in the long-term costs of a person trapped in the revolving
door. It is not adequate to examine how much money is spent or saved in the first six months
or year; we need comparisons of the long-term costs of repeated contact with fragmented
systems versus outcomes for people diverted or discharged to comprehensive, integrated
programs.
Implementation of diversion and discharge planning strategies makes sense from both a
public safety and a humanitarian perspective, even if these programs never save a penny. We
believe research will show, however, that if offenders with mental illness are diverted to, or
linked at discharge with, comprehensive integrated services, these services will stop the
revolving door for many people and save money.

E. Limits of Legal Mechanisms for Diversion
Two sections of the New York State Criminal Procedure Law (CPL) make provisions for
diverting a mentally ill criminal defendant out of the criminal justice system and into mental
health services. These two sections deal with "730 exams"3 1 and verdicts or pleas of "not
responsible by reason of mental disease or defect" (commonly referred to as a NGRI or "not
guilty by reason of insanity" defense).32
Under CPL section 730, a judge who has reason to believe that a criminal defendant may be
"incapacitated" must order that the defendant undergo a psychiatric examination.
"Incapacitated," in this context, means that because of mental disease or defect, the defendant
is unable to understand the proceedings against him or assist in his own defense. A "730
exam" can be requested by a defense attorney or an assistant district attorney, or may be
ordered upon the judge's own initiative.
When a 730 exam is ordered, the case is delayed while the defendant is seen by two
psychiatric examiners. Each examiner makes an independent determination as to whether the
defendant is "fit" or "not fit" to proceed with the case.33 If the defendant is found "not fit" to
proceed and the case is a misdemeanor, the charges will be dismissed and the defendant
hospitalized as a civil patient at a state psychiatric hospital until he is clinically ready for
discharge or is released by a judge under civil commitment laws.34 If the charges are a felony,
a "not fit" defendant will be hospitalized at a state forensic hospital35 until he becomes "fit."
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The 730 process is the only special legal mechanism for dealing with a criminal defendant
with a mental illness, except for the NGRI defense. A NGRI defense is rarely used, however,
because it is expensive and generally requires a defendant to take the substantial risk of going
to trial with little chance of avoiding conviction. Another reason for the limited use of the
NGRI defense is that defendants found not guilty by reason of insanity are not set free; they
are committed to secure psychiatric facilities for indeterminate periods of time. Finally, some
defendants with serious mental illness refuse to permit their defense attorneys to interpose a
NGRI defense, either because they do not believe they are mentally ill or because they prefer
incarceration to long-term hospitalization.
Neither the 730 process nor the NGRI defense comes close to addressing the needs of
criminal defendants with mental illness. Both standards ("not fit" to proceed and "not
responsible") are very narrow; the majority of criminal defendants with mental illness are
found organized and coherent enough to understand the proceeding against them and are,
under New York's standards, legally responsible for their actions. Thousands of these "fit"
and "responsible" defendants are seriously mentally ill, however, and should be dealt with
differently than other criminal defendants, in ways that address their mental health needs.
Another limitation of the 730 and the NGRI provisions is that both are most often used in
cases with very serious charges and neither offers much benefit to the misdemeanor or
"nuisance" offender with mental illness who passes repeatedly through the doors of the
criminal justice system. In misdemeanor cases, even repeat offenders are unlikely to go to jail
for very long,36 so remaining confined pending a 730 exam may constitute a greater
"punishment" than the sentence available through plea bargaining.37 This delay discourages
defense attorneys from requesting 730 exams even when they know their client has serious
psychiatric problems. A NGRI defense is not a realistic option for a misdemeanant either;
preparing to go to trial with a NGRI defense requires time and resources that neither a
defense attorney, a defendant, nor the court is likely to invest in a misdemeanor case.
There is another section of the CPL which, while not specifically concerned with mental
health, can be used to facilitate diversion of criminal defendants with mental illness. CPL
section 390 requires pre-sentence reports in felony cases and permits them for misdemeanors.
A pre-sentence report is a report prepared after a guilty plea or conviction but prior to
sentencing; the report may include a psychiatric examination.38 Should this examination find
the defendant to be mentally ill, the report may suggest treatment options to the judge,
offering the judge a greater range of sentencing alternatives. The judge may sentence the
defendant to treatment, or order the person to go to treatment and defer sentencing while
monitoring treatment compliance. In some cases, a finding of serious mental illness during a
pre-sentence examination may even serve as the basis for vacating a plea on the grounds that
the defendant was not fit to plead guilty. "390 Exams" are being used creatively by advocates
and judges to access treatment for defendants with mental illness, but this, too, is at best a
partial solution. By the time a defendant with a mental illness is seen for a 390 exam, he may
have already spent many months in jail awaiting trial.
The NGRI defense, 730 exams and 390 exams are important acknowledgments by the
legislature that the psychiatric condition of a defendant is relevant to the disposition of
criminal charges. All of these mechanisms, however, focus solely on legal competence and
culpability, not need for treatment or public policy goals such as stopping the revolving door.
As a result, for the vast majority of criminal defendants with mental illness, including virtually
all mentally ill misdemeanants, there is no statutory mechanism for addressing their mental
health needs.

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F. Lack of Alternatives to Incarceration
Progressive thinkers in the criminal justice community have long recognized the need for
forms of punishment other than imprisonment. New York City is home to a number of wellrespected "alternative to incarceration" (ATI) programs, which provide supervision and
services to distinct offender populations. However, not one of these programs targets
offenders with mental illness.
In fact, not only are there no ATI programs designed for this population; people with serious
mental illness are often deliberately excluded from New York City's ATI programs. Lacking
expertise in mental health and the resources to provide intensive services to this difficult
population, ATI program staff are unable to deal with the seriously mentally ill. As a result,
offenders who are otherwise appropriate for ATI programs are screened out.
Offenders with mental illness are good candidates for ATIs. They may have committed the
offenses for which they are charged because of untreated mental illness. As studies have
shown, they are likely to respond well to mental health treatment, so it is possible to
determine what services will help them avoid future criminal behavior. New York City
agencies offer a wide array of mental health services that could be woven into ATI programs.
Offenders with mental illness should have at least as much access to ATIs as the rest of the
offender population.

II. THE INCARCERATED MENTALLY ILL
With diversion from the criminal justice system an option for very few criminal defendants
with mental illness, multiple systems struggle to meet the needs of incarcerated mentally ill
New Yorkers. These inmates not only require expensive mental health services during
incarceration, they also need a great deal of assistance in making the transition back to the
community at the time of their release. This section describes the mentally ill jail and prison
populations and highlights gaps in the continuum of care.

A. The Mentally Ill in New York City Jails
New York City's jail system is composed of 16 separate jails, including "borough houses" of
detention in Manhattan, Brooklyn, the Bronx and Queens, and ten separate jails on Rikers
Island, including facilities for women and adolescents. In 1997, the New York City
Department of Correction had an average daily census of 19,205 inmates and a total of
133,300 admissions throughout the year.39 Approximately two-thirds of city jail inmates are
pretrial detainees, and 90% of the population is male.40 The average length of stay for
detainees in 1997 was 46 days; for sentenced prisoners, it was 37 days.41 Two-thirds of
sentenced inmates are recidivists.42
The structure of mental health services in New York City jails
To serve the approximately 33,325 prisoners per year requiring mental health services,43
including the 15,000 with serious mental disorders, the New York City jail system provides a
broad spectrum of mental health services.44 Although responsibility for supplying these
services rests with the city's Department of Mental Health, Mental Retardation and
Alcoholism (DMH),45 DMH has delegated this duty to the New York City Health and
Hospitals Corporation (HHC), the body that operates the city's public hospitals, to provide
mental health services to jail inmates. HHC, in turn, has contracted with a private hospital, St.
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Barnabas, which since January 1, 1998, has provided the vast majority of mental health
services within the city jails.
Mental health services are provided both to inmates housed in general population and within
segregated Mental Observation Units (MOUs), a Mental Health Center and a Behavioral
Management Unit. Inmates who are not believed to present any risk to themselves or others
are treated in general population. The next higher level of care, for patients who are judged to
require removal from general population, is provided within the nine MOUs -- segregated
mental health treatment units with the capacity to house up to 625 inmates at a time.46
Inmates too ill for the MOUs are sent to the 350-bed Mental Health Center at Anna M. Kross
Center on Rikers Island, where 24-hour, seven-day-a-week psychiatric, medical and nursing
care is provided.47 A 24-bed Behavioral Management Unit at the Bronx House of Detention
works exclusively with unusually aggressive mentally ill men.4 8 This facility brings the total
number of segregated mental health beds in the New York City jail system to 999. During
1997, 192,228 mental health visits were provided to inmates in the city jail system.49 About
two-thirds of mental health visits are provided within the segregated mental health units.50
Patients found to be too ill even for the Mental Health Center are transferred to secure
psychiatric units at three community hospitals -- Bellevue, Kings County and Elmhurst.51
Utilization of these community hospital beds has dropped in recent years, and the number of
beds in these units has been reduced as a result.52 The HHC Office of Correctional Health
Services attributes the reduction in hospital transfers to new treatment initiatives at the Rikers
Island Mental Health Center, including having a psychiatrist review all hospital referrals
before transfer and having a psychiatrist consult with any patient refusing medications.5 3 The
Legal Aid Society of New York City, however, has expressed concern that the community
hospital beds for jail inmates are being inappropriately underutilized in an attempt to save
money.54
Who are the mentally ill in New York City's jails?
Not surprisingly, people with mental illness in the city's jails are marginalized in many ways.
They are overwhelmingly people of color: 50% African-American, 35% Latino.55 They are
disproportionately female: Only 10% of the city jail population are women, but 17% of the
inmates utilizing mental health services are female.56 They are also likely to be unemployed:
In a sample of seriously mentally ill inmates served by the NYC-LINK discharge planning
program,57 28% had never been employed, and only 10% were employed at the time of
incarceration.58 Fully 39% received SSI or SSD (social security disability benefits), 25%
received Public Assistance, and 16% had no income.59 Only 2% had private insurance, while
the vast majority of patients in the sample relied on Medicaid (63%) or had no insurance
(30%).60
People with mental illness in city jails are also likely to have histories of psychiatric treatment
and of substance use. In an HHC Office of Correctional Health Services study conducted in
November 1997, 68% of inmates in the sample had contact with the mental health system
prior to their incarceration.61 While more than half (54%) admitted to histories of substance
use,62 this figure is almost certainly low. Prevalence of substance use among the general New
York City jail population is estimated to be 75-80%,6.3 and there is no reason to expect a
lower prevalence among inmates with mental illness.
It is impossible to talk about people with mental illness in jail and prison without also talking
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about homelessness. In New York City, a 1992 study found that 20% of jail detainees were
homeless.64 In NYC-LINK's first year, 29% of their clients were homeless.65 The higher rate
of homelessness among NYC-LINK clients corroborates another finding of this study -- a
strong association between homelessness and mental illness. Subjects of this study who had
histories of homelessness were twice as likely as the never-homeless to show some indication
of mental illness (50% v. 25%). A 1995 study in New York City found that 43% of
defendants with mental disorders were homeless at the time of arrest.66 These figures show
that while jail is offering emergency shelter for thousands of New Yorkers, it is especially
true for people with mental illnesses. On any given day, there are approximately 3,800
homeless people in the city jails -- more than half as many as the 7,100 in the city's shelters
for homeless adults.67 A rough estimate of the number of homeless people with mental illness
in the city jail system would be over 1,000.68
Few mentally ill people leaving jail receive any discharge planning
When a person with a serious mental illness goes to Rikers Island or one of the city's other
jails, she or he probably receives some form of basic mental health care, including
psychotropic medications as an out-patient in general population, or in one of the segregated
Mental Observation Units. However, many of these people have no insurance or income at
the time of arrest. Many more lose their Medicaid while they are incarcerated. Without
insurance, there is no way for a person with a mental illness to leave jail and continue getting
the medications she or he needs to remain stable.
Inmates with mental illness finishing their sentences at Rikers Island are generally put on a
bus with other prisoners being released that day. Most mentally ill inmates are not given
medications or a prescription to take with them. They are driven to Queens Plaza and
released between 2 and 4 in the morning with three subway tokens.
Even if a person with a mental illness is organized enough to go straight to the welfare office,
there will still be at least a 45-day wait for benefits and, more important, Medicaid.
Temporary Medicaid benefits are theoretically available to qualified applicants immediately,
but in practice the red tape involved in getting a temporary Medicaid card is daunting to even
the most experienced social worker and all but impossible for a disorganized person with a
mental illness in a crisis situation. Finally, a person with a mental illness resourceful and
persistent enough to get a temporary Medicaid card is likely to be unable to find a pharmacy
willing to honor a temporary card.
Without Medicaid or other insurance there is no access to treatment, and the inevitable
happens: The mentally ill ex-offender decompensates,69 acts out, and ends up in a hospital if
he is lucky, but more likely back in jail.
The NYC-LINK Program -- a small step in the right direction
In June 1996, the New York State Office of Mental Health and the New York City
Department of Mental Health, in collaboration with the New York City Health and Hospitals
Corporation, created and funded a discharge planning program for jail and prison inmates
with mental illness, the NYC-LINK Program. The New York City jail component of the
program is currently staffed by twelve jail-based "linkage planners" and eight communitybased "transition support counselors."
The jail-based staff are employed and supervised by the Health and Hospitals Corporation,
while the community-based staff work for a private social service agency, the Federation
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Employment and Guidance Services. Jail-based staff screen and evaluate clients and arrange
for post-release services. After the client is released, the community-based staff assist the
client in obtaining the needed services and follow the client's progress for two years.
Creation of the NYC-LINK Program shows that city and state officials recognize the
desperate need for discharge planning for jail and prison inmates with mental illness.
Unfortunately, it is a relatively small program, which only begins to address the greater need
for discharge planning for all jail inmates with mental illness. As currently funded, the NYCLINK Program is expected to provide discharge planning services to 1,200 inmates per
year.70 With 15,000 seriously mentally ill people, and 33,325 people requiring some kind of
mental health service passing through the jail system each year, this program is providing
services for only about 4% of the individuals who need them -- discharge planning for one in
every 25 inmates with mental illness.

B. The Mentally Ill in New York State Prisons
New York State is home to a large and complex prison system composed of 69 facilities
scattered throughout the state, holding about 70,000 inmates. Although prisons are distributed
statewide, with relatively few located in the New York City area, 70% of state prisoners
come from New York City.
Although a higher proportion of New York City jail inmates are seriously mentally ill than
state prisoners, the prison system is also, for many New Yorkers with mental illness, the
psychiatric hospital of last resort. Last year, New York State prisons treated 6,000 inmates, or
8.7% of the state prison population, for serious psychiatric disorders.71 This figure is
remarkable when compared to the fact that the entire state has only 5,800 adult patients in
public psychiatric hospitals.72 A 1987 study of the New York prison system found that 15%
of inmates suffered from a significant or severe psychiatric disability.73 In a system with
approximately 70,000 inmates, this means that at any given time there are about 10,500 state
prisoners with significant psychiatric service needs.
The structure of mental health services in New York State prisons
The state prison system, like the city jail system, has developed a variety of services to
address the mental health needs of inmates. Mental health services in the state prison system
are provided directly by the state Office of Mental Health (OMH). OMH provides intensive
services at its 202-bed psychiatric center for prisoners, Central New York Psychiatric Center
(CNYPC), and through CNYPC's satellite units at eleven maximum-security prisons
throughout the state.74
Satellite units are segregated units within prisons where inmates requiring short-term acute
psychiatric care are housed in dormitories and solitary "observation cells." The state's eleven
satellite units contain a total of 134 beds. Facilities with satellite units also have Intermediate
Care Programs (ICPs), which provide long-term segregated housing to inmates who, because
of mental illness, are unable to function in general population. ICPs range in size from 29 to
78 beds, and house a total of 526 inmates state-wide.
At present, the state prison system contains a total of 862 segregated beds for inmates
requiring mental health services. Plans are underway, however, to build an additional satellite
unit for female prisoners at Albion Correctional Facility and to expand the capacity of
CNYPC.
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Each of CNYPC's satellite units provides mental health services to other correctional facilities
within a catchment area. CNYPC also operates Mental Health Units (MHUs), which offer
mental health services but do not have segregated beds, at eight facilities.75 Each state prison
is classified by OMH according to the level of mental health services it provides. Level I
facilities offer the most intensive services; Level VI denotes a facility with no direct OMH
services. Inmates' mental health needs are classified according to the same system of levels.
Who are the mentally ill in New York State's prisons?
According to OMH, the psychiatric problems of the prisoners treated in the satellite units are
becoming increasingly severe and complex. "The proportions of persons with a serious
diagnosis, severe and persistent mental illness, and co-occurring alcohol or drug abuse or
both" have been increasing, OMH reports.76 Lengths of stay by prisoners/patients at CNYPC
have also been increasing.77 Ninety-three percent of the inpatients at CNYPC are male, and
the patient population has increased in age over the last 10 years. In 1986, the majority of
patients were under 34; today over 50% of CNYPC patients are between the ages of 35 and
45.78
Mentally ill people leaving prison do not get adequate discharge planning
Approximately 1,500 to 2,000 state prisoners with mental illness are released to New York
City each year,79 and many of these people have no access to mental health services
following their release. They leave prison without employment or benefits or insurance and,
very likely, without anywhere to live. The Department of Correctional Services gives
releasees $40, a bus ticket home, and a list of parole conditions. OMH has a policy of
providing all seriously mentally ill releasees with a two week supply of medication plus a
prescription for an additional two weeks, but it is not clear that all prisoners who need
medications following release are included by this policy, and even those who are will have a
four-week gap between when they run out of medication and when they receive the
Medicaid benefits they need to fill a prescription. For most prisoners with mental illness, this
is the extent of the discharge planning they receive.
Some prisoners, particularly those receiving intensive mental health services, do receive
discharge planning before they are released. OMH has a discharge planner at each satellite
unit and the NYC-LINK program has four transition support counselors working with
inmates leaving state prison. These services are located in Level I and Level II facilities,
however, and do not reach anywhere near all the inmates who need them. Some people with
serious mental illness are able to function better in a highly structured environment than in an
unstructured one. The extreme regimentation of prison, while certainly not therapeutic, may
actually help some inmates with mental illness to maintain a higher level of functioning than
they would be able to manage in the community, thus masking their great need for discharge
planning and support following release. For example, some inmates with serious mental
illness are able to function in Level III or Level IV facilities as long as they get psychotropic
medications. When they near release, however, they are unlikely to be the recipients of scarce
discharge planning resources, because those resources are concentrated in Level I and Level
II facilities.
As a result, advocates in New York City frequently encounter parolees who have been taking
powerful psychotropic medications, such as Thorazine, Haldol or Lithium, for years while
incarcerated, but who are released to the city shelter system without access to medication and
benefits, and thus, no way to continue treatment.
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Even for those inmates who receive discharge planning, there are crucial gaps in the
continuum of care. For prisoners returning to New York City, a wide variety of community
resources is available, including supportive housing and intensive social service programs.
Unfortunately, OMH discharge planners do not seem to have much success accessing these
resources for prisoners nearing release. Discharge planners are handicapped by the great
distance between the facility holding the prisoner and the community he will return to.
Community mental health service providers are reluctant to accept clients who do not have
benefits already in place, and discharge planners at faraway facilities have a difficult time
developing the personal relationships with program staff which often help smooth over such
obstacles. As a result, for state prisoners who receive discharge planning, the discharge plan
is often no different from that of other inmates -- release to one of New York City's
Department of Homeless Services shelters.
Upon entering the shelter system after incarceration, the mentally ill releasee must spend up to
three months being assessed in a general population intake shelter with few or no mental
health services. No information is exchanged between the prison system and the shelter
system, so if the releasee is not obviously mentally ill and does not volunteer that he is
mentally ill, he will not receive mental health services. Often no one is available to assist the
person with mental illness in accessing benefits, insurance and treatment. For a person with
mental illness recently released from the controlled environment of a prison, city intake
shelters can be chaotic and frightening places.
State prisoners usually serve indeterminate sentences, i.e., two to six years, or seven to 14
years.80 Inmates released prior to serving their maximum sentence are supervised by parole
until that maximum date arrives. The purpose of parole is to monitor the ex-prisoner's conduct
in the community and ensure the person remains law-abiding. Parole officers have the power
to impose any number of conditions on an ex-prisoner, such as requiring that the parolee
receive psychiatric treatment or not use drugs or alcohol. For ex-prisoners with mental illness,
a parole officer could be a valuable resource for help in securing benefits, housing and
treatment. OMH has made efforts to train parole officers about mental health issues, but
parole caseloads are high and few officers have the time or expertise to help parolees reinstate
their benefits and obtain mental health services.
Because their parole conditions generally require them to get mental health treatment and to
remain in the shelter, people with mental illness recently released from prison are in an even
worse situation than those released from jail. When they decompensate because they have not
received mental health services, or when they leave the shelter because their mental state is
too fragile for such a difficult environment, they have violated parole and are often sent back
to prison shortly thereafter.

C. Effects of Incarceration on the Mentally Ill
People with mental illness entering the criminal justice system have complex service needs
that incarceration does little to alleviate. In fact, by the time most people with mental illness
leave the criminal justice system, their problems have been exacerbated.
Victimization
People with mental illnesses have difficulty protecting themselves while incarcerated. Jails
and prisons are often harsh, dangerous environments for inmates, and are especially so for the
mentally ill. Common symptoms of mental illness include bizarre and disorganized behavior;
these behaviors make mentally ill prisoners vulnerable. Bizarre behavior often annoys
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correction staff and other inmates and leads to victimization. Disorganization makes prisoners
with mental illness easy prey for aggressive fellow prisoners. Finally, untreated mental illness
may make inmates' behavior erratic, alarming others and at times provoking violent responses
from guards and other inmates.
Institutionalization
Like all prisoners, inmates with mental illness learn institutional behaviors that help them
cope with incarceration but that compromise their successful transition back to the
community. Some of these behaviors may include aggressiveness and intimidation of others
or, conversely, extreme passivity, manipulative behavior and reluctance to discuss problems
with (or "rat" to) authority figures.81 These behaviors create barriers to engagement in mental
health services and treatment. Former prisoners may associate the structure of mental health
treatment facilities, such as hospitals and supportive residences, with prison, and behave
accordingly toward staff and fellow patients.
Segregation
Inmates with mental illness may be punished for disruptive behavior in ways that exacerbate
their illnesses. The standard punishment for disobeying prison or jail rules is "punitive
segregation" -- locking inmates in small single (or occasionally double) cells for 23 hours a
day. Better known as solitary confinement, the punishment prevents contact with the general
population, prohibits participation in programs or prison work, and often denies the inmate
access to reading materials or hygiene products. A person with mental illness who has not
violated rules, but whose presence in general population is deemed by correction officials to
"pose a threat to the safety and security of the facility,"82 will be sentenced to administrative
segregation. Despite the kinder-sounding name, administrative segregation is just as isolating
as punitive segregation and often as restrictive in terms of movement and privileges. New
York correction officials have been known to sentence inmates to punitive or administrative
segregation for years at a time.
People with mental illness are particularly likely to find themselves in punitive or
administrative segregation due to behavior that is symptomatic of their illness.83 For example,
studies in Ohio in the early 1990s found that hundreds of inmates had been placed in
disciplinary cells for no reason other than mental illness.84 "Acting out" psychotic behavior
and even suicide attempts by inmates with mental illness are sometimes treated as discipline
problems; several days after his death, one inmate in a California prison received a
disciplinary write-up for committing suicide.85
The conditions in punitive and administrative segregation create great psychological stress
and can cause symptoms of mental illness to appear even in inmates with no prior psychiatric
problems. Segregated inmates are also at risk for suicide. A recent study examined nine
suicides that occurred within 24 months at an unnamed large metropolitan jail; the author
found that of the nine suicides, eight were segregated from the general population of the jail
at the time of their death.86
The dangers of segregation have been recognized by courts in many prisoners' rights cases.
For example, in 1995 a federal court held that, "Social science and clinical literature have
consistently reported that when human beings are subjected to social isolation and reduced
environmental stimulation, they may deteriorate mentally and in some cases develop
psychiatric disturbances."87 Another federal court, presented with allegations regarding the
misuse of administrative segregation in New York State prisons held that, "A conclusion
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...that prolonged isolation from social and environmental stimulation increases the risk of
developing mental illness does not strike this Court as rocket science."88
Too often, psychotropic medication is the only form of treatment available to prisoners with
mental illness confined in punitive or administrative segregation units. Even though the
Department of Correctional Services requires that a mental health counselor make daily
rounds in special housing (segregation) units, actual contact with individual prisoners, in the
form of conversation or counseling, is infrequent. The cumulative effect of isolation, reduced
supportive services and sensory deprivation will typically leave the inmate with mental illness
functioning at a lower level than before incarceration.
Alienation from family and friends
While incarcerated, people with mental illness lose many of the community contacts that are
essential to their success following release. It is difficult for even the most supportive family
members or friends to maintain contact with an incarcerated person. Rikers Island, where the
vast majority of city jail inmates are housed, is very inconvenient to visit. A trip to Rikers is
likely to take an entire day; when the visitor finally arrives, the inmate may have been taken
to court for the day or transferred to another facility. Visiting state prisoners also poses
challenges. Most state prisons are located hours from New York City, with some as far away
as the Canadian border. To reach these facilities, families take buses from Manhattan on
Friday night, spend Saturday at the prison, then Saturday night on the bus returning to the
city. Under these difficult circumstances, as years of incarceration go by, a prisoner's
connections with family and friends often wither and die. When a released prisoner returns to
the community, with neither discharge planning, transitional services, nor the support of
family and friends, he is likely to reoffend or violate parole, and be returned to prison.
Disconnection from community mental health services
Another vital source of support for people with mental illness is community mental health
services. New York City is home to a broad spectrum of mental health services, ranging from
simple outpatient clinics to 24-hour supportive residences. Many people with mental illness
who are arrested have some connection with a community mental health service provider
prior to incarceration. These people are likely to be receiving treatment, including psychiatric
medication, which is disrupted when they are arrested and incarcerated. Staff at these
programs often wish to maintain contact with the client to ensure that the client is getting
appropriate mental health services or to offer support to the person following release. But a
number of barriers make it difficult for community mental health providers to maintain
contact with incarcerated clients.
When jail-based mental health professionals evaluate a newly arrested defendant at intake, it
is often as if the patient has never before received mental health services. Members of the
jail's mental health staff interview the patient and make informed guesses about the person's
diagnosis and which medications may be helpful; no system exists to facilitate or even
encourage the exchange of information between community treatment providers and jail staff.
Having to "reinvent the wheel" with each incoming patient is frustratingly inefficient and
clinically unsound. Many inmates have a psychiatrist or case manager in the community who
can tell the workers in jail, for example, that the patient's last diagnosis was schizoaffective
disorder and that he has had bad side effect reactions to Haldol and Mellaril and Lithium and
Zoloft, but recently has been doing well on a dose of 15 mg. of Stelazine and 1200 mg. of
Depakote at night plus 1 mg. of Cogentin two times a day.

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As any community mental health worker can attest, it can be exceedingly difficult for an
outsider to locate a client in the city's criminal justice system. The process of finding out
which jail an individual is in is a complicated on requiring multiple phone calls. Once an
inmate is located, it is difficult to even find the names and numbers of whom to talk to in the
individual jails, much less get information regarding an inmate's treatment status. Community
mental health workers who manage to contact a facility where a client is being held often find
that no one staff person is responsible for gathering or relaying information about what
medication the client has been taking or what diagnoses have been made. Defense attorneys,
who could act as liaisons between a community program and the jail, often do not see this as
part of their job or understand the advantages of involving a community mental health worker
in their client's defense. Finally, when an inmate with a mental illness goes to court or is
released it is rare that anyone will notify his community worker -- although it might be useful
for the worker to come to court and essential for the worker to know when the client is being
released and returning to the community program.
All of these barriers lessen the effectiveness of community mental health programs. By
necessitating the duplication of each others' work, these barriers also waste the resources of
both community and jail-based mental health programs. They also jeopardize the mental
health of inmate patients by interrupting their continuum of care.
Loss of housing
Incarceration costs inmates their homes; many mentally ill people are homeless at the time of
their arrest, but far more are homeless by the time they leave jail or prison. Even people
detained for only a few weeks may be evicted during their incarceration; those who are
incarcerated for a year or more will inevitably leave prison homeless unless they have family
or friends who will take them in. Homelessness is a problem for everyone leaving jail or
prison, but people with mental illness are worse equipped than most to take on New York
City's daunting housing market or to navigate the city's shelter system. Stable and supportive
housing is an essential key to successful reintegration into the community for ex-offenders
with mental illness.89
Loss of income and insurance
Most city jail inmates with mental illness depend on Social Security or Public Assistance
benefits for income, and Medicaid for insurance. The longer the period of incarceration, the
more likely it is that these benefits will be terminated; even a short incarceration may lead to
loss of benefits. For example, under New York City's Work Experience Program (WEP),
Public Assistance recipients are required to report to work assignments in order to maintain
their benefits. Missing even a single day of work without a documented excuse leads to loss
of Public Assistance, Food Stamps and Medicaid.90 Additionally, a graduated series of
sanctions that require waiting periods of up to 180 days before the former recipient may
reapply are imposed as penalties for failure to comply with WEP requirements. Therefore, as
a result of these policies, a person with a mental illness who is arrested for a misdemeanor,
such as jumping a subway turnstile, and spends a day or two in the system prior to
arraignment can lose his benefits, insurance, access to mental health treatment and housing.
People incarcerated for months or years always lose their benefits, and they cannot reapply
for benefits prior to release. On the outside, the application process is bewildering even for
people who are not dealing with mental illness and the upheaval of having recently left jail or
prison. For example, to apply for Public Assistance, Food Stamps and Medicaid, an applicant
must first figure out which Income Support Center to go to. The closest Income Support
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Center is not necessarily the right one; Income Support Centers are down-sizing and merging,
and Income Support Centers' overworked staff sometimes tell new applicants that the Center
is not taking any more applications. Once the appropriate center is located, the applicant must
arrive before 9 a.m., complete a complicated application form, present identification and
documentation of rent expenses and/or lack of cooking facilities, and be interviewed by a
caseworker.
The applicant will then be directed to the Eligibility Verification Review office in Brooklyn
Heights for a painstaking interview intended to detect fraud. Then, Eligibility Verification
Review will send the Front End Detection System workers, who carry badges and announce
themselves as "the FEDS,"91 to visit the applicant's house and verify residence. If, after three
visits, the FEDS have not found the applicant at home, the case will be closed.
Under the new welfare-to-work initiatives, many Income Support Centers have become Job
Centers. An applicant who goes to a Job Center will be turned away the first time and sent to
look for a job or other resources.92 Once applicants return to the center and prove that they
have been actively seeking work, cannot find work and have no other resources, they are
permitted to apply for benefits. They must comply with finger-imaging in order to begin the
process. Next they are sent to a center where they must report promptly five days a week and
spend the day looking for a job for 50 days (35 if they have children to take care of) before
they will receive benefits. If a caseworker believes the applicant has a substance abuse
problem, the applicant must undergo substance abuse assessment at a center in Long Island
City. Applicants who indicate that physical or mental health problems limit their ability to
work must report for examination at Health Service Systems in midtown Manhattan.
An applicant who complies with all of these conditions and is deemed eligible for benefits
will, after about 45 working days, receive up to $352 per month in rent and cash monies plus
$120 in Food Stamps and a Medicaid card. People living in shelters, however, will receive
only a "shelter allowance" of $22.50 every two weeks.
Needless to say, this complicated process jeopardizes the chances of a successful transition
for a person with a mental illness returning to the community from jail or prison. Public
Assistance is the only option for a recently released person with a mental illness in need of
money for food and medication. Given the 45-day wait, many are forced to finance their
needs through illegal means. While focused on such basic concerns as how to pay for their
next meal, ex-prisoners with mental illness are not likely to be thinking about how to get a
new Thorazine prescription. The barriers to obtaining benefits and insurance following
release from incarceration may be the single greatest cause of decompensation and recidivism
among mentally ill ex-offenders.
D. Costs and Consequences of Inadequate Discharge Planning
The lack of discharge planning has tragic consequences for ex-offenders with mental illness,
who end up psychotic, homeless and destitute. But it also has serious consequences, financial
and otherwise, for the communities and agencies that are left to pick up the pieces.
The burden on city shelters
New York City's Department of Homeless Services (DHS) is the shelter provider for up to
7,584 single adults on any given night. By default, DHS shelters have become the "discharge
plan" for thousands of homeless mentally ill ex-offenders. A recent survey by the Coalition
for the Homeless found that one-third of a sample of men at the Atlantic Avenue Armory had
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gone directly to the shelter from prison.93 Obviously, adequate discharge planning for the
mentally ill, including housing referral, would relieve the shelter system of a great burden.
Short of finding housing for every person in need, however, easier ways exist to create some
continuum of care for ex-offenders with mental illness going to DHS shelters.
Currently, even when mental health workers in jails and prisons know that a soon-to-bereleased inmate with mental illness is going to a city shelter, no mechanism exists to convey
treatment information or to make a formal referral to that shelter. No one at the shelter is
notified that the client will be arriving, and no mental health information is sent to the shelter
prior to the client's release. During intake into the shelter system, each person is asked
questions about psychiatric history. But those who are not obviously ill, if they withhold
information about their psychiatric history and do not identify themselves as needing
psychiatric services, will be put in a general population shelter and will not receive mental
health services.
Many of these shelter clients, having been released from jail or prison with little or no
medication, soon decompensate. They proceed to disrupt the shelter or endanger themselves
until they are hospitalized or rearrested. New York City's shelters are not merely full of
people with mental illness who recently left jail or prison; they are full of acutely psychotic
people who recently left jail or prison.
The costs of over-utilization of hospitals
The other main entity that bears the impact of the lack of discharge planning is hospitals,
particularly public hospitals. With the rise of managed care, health care delivery has changed
drastically in recent years. Health care providers, responding to financial incentives in the
managed care environment, are downsizing inpatient units and attempting to provide the
majority of services through outpatient programs. The New York City Health and Hospitals
Corporation (HHC), the corporation that operates the city's public hospitals, has downsized
from 9,902 psychiatric inpatient beds in 1995 to a projected 8,029 in 1999 -- a 19%
decrease.94
The needs of the 25,000 people with mental illness returning to New York City from the
criminal justice system each year create a serious obstacle to health care administrators' goals
of saving money and promoting outpatient services. People with mental illness released
without medications or discharge planning find that the emergency room is the only place
they will not be turned away for inability to pay. HHC hospitals are particularly affected
because they are required to serve patients regardless of their ability to pay. The result is that
many ex-prisoners with mental illness use costly emergency room services to create their own
continuum of care when they could be better and much less expensively served by referral
and access to outpatient services.
The other great cost to hospitals generated by the lack of discharge planning is that of
preventable hospitalizations. When people with mental illness who require psychotropic
medications to maintain stability are released with no means to continue those medications,
their symptoms inevitably return. As anyone who has encountered a psychotic person on the
street or subway knows, these symptoms can be severe. They may include disorganization,
delusions, hallucinations, an inability to manage such tasks as eating and bathing, and
aggressive or suicidal impulses. For many of these people, decompensation means a return to
the criminal justice system. For the less unfortunate, the result is hospitalization, where
symptoms may be addressed and medications resumed. These hospitalizations, however,
carry considerable costs for taxpayers.
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Many releasees with mental illness who end up hospitalized were psychiatrically stable just
weeks earlier when they left prison or jail. Had they received access to Medicaid, referral to a
community outpatient mental health provider and a sufficient supply of medication to see
them through the transition, many would never have needed hospitalization. They would
have been spared the traumas of decompensation and hospitalization, and hospitals and
taxpayers95 would have been spared the cost of expensive inpatient and emergency services.
The social and financial costs of recidivism
Releasees with mental illness on probation or parole are often required to obtain mental health
services as a condition of maintaining their freedom. When prisoners are released without
access to treatment, they violate this condition the first day by not taking the medications they
have no means to obtain. While most mentally ill probationers and parolees are not returned
to jail or prison simply for not taking medication, a more common scenario is that they
gradually decompensate. Within a week or two, an array of symptoms that had been
controlled by medications during their incarceration resurface. They become disorganized,
delusional, agitated, and/or paranoid. In this state, the mentally ill person is unable to comply
with orders of protection or keep track of appointments with probation or parole officers,
court dates or community service schedules. A new arrest is the result, and the person is on
his way back to jail or prison.
A psychotic and disorganized person is also likely to have difficulty conforming to social
norms. Offenses committed by the mentally ill range from the very minor to the far more
serious. On the minor end of the spectrum are the sort of quality of life offenses that, for
mentally ill homeless people, are the inevitable result of life on the streets. Activities that nonhomeless people perform legally all the time -- drinking a beer, changing clothes, urinating -become crimes when they are done on the street. Other activities that are not legal, but which
people with homes do without detection, such as drug use, are far more likely to lead to arrest
when done on city sidewalks. Arrests for these types of offenses may lead to violations of
probation or parole and serve as the sole basis for reincarcerating an ex-offender with mental
illness.
Other people with mental illness released from incarceration without access to treatment
commit more serious crimes. Although a substantial body of research has shown that people
with mental illness are no more dangerous than the general population,96 a number of recent
studies suggest that there is a relationship between untreated mental illness (especially when
combined with substance use) and violent crime.97 The lesson of these studies is not that
people with mental illness are dangerous and should be confined; the lesson is that all of
society has a stake in ensuring that ex-offenders with mental illness have access to the
services they need. By linking ex-offenders with treatment and services, we can save
taxpayers the cost of processing the same person through the criminal justice system over and
over again. We can save government the cost of treating mental illness in jail.98 We can save
communities financial costs and individuals emotional costs by preventing crime. And,
finally, we can prevent the trauma people with mental illness suffer as they cycle repeatedly
through jails, prisons, hospitals and the streets.

E. Lost Opportunity for Intervention
Mental health clinicians have long recognized that the effectiveness of treatment largely
depends on when it is offered. For example, intervening when someone is young is more
likely to have a long-term impact than intervening later in the course of a mental illness. Even
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for individuals who have been very ill for a long time, who have a co-occurring substance
use disorder or are resistant to accepting treatment, specific occurrences in the person's life
create opportunities for intervention. Hospitalization is one: A stay in a psychiatric hospital
gives the patient the chance to be stabilized, and to work with hospital staff to develop a
discharge plan including services that will facilitate future psychiatric stability.99 The period
following transition from a shelter to permanent housing is another important time for
treatment intervention.100
Similarly, arrest and incarceration present opportunities to break cycles of self-destructive
behavior. Unpleasant as jail and prison are, it is not terribly unusual to hear ex-inmates talk
about jail or prison as having "saved their life." In fact, for some people with serious mental
illness living on the streets, jail- or prison-based services may be the only mental health
treatment they have received in years.
Both diversion and discharge planning can be used as treatment interventions for people with
mental illness in the criminal justice system. When a person with a mental illness is diverted
to mental health treatment rather than to incarceration or community service, the patient may
be more willing to accept needed services because of the knowledge that a judge is
monitoring the treatment and noncompliance will have consequences.101
Discharge planning is an essential follow-up to the mental health services received during
incarceration. If correctional mental health services prescribe medications that control
psychiatric symptoms, it may be the person's first period of psychiatric stability in a long time.
Once stable, the patient may have far better insight about his or her need for treatment and
support services and may be better able to plan for the future. It is a terrible waste to treat,
stabilize and counsel a person with a serious mental illness only to send that person back to
the streets with no way to capitalize on the progress that has been made.

RECOMMENDATIONS
A. Overview
Let us revisit James for a moment and consider how things might have worked out for him in
a more humane system. When the police officer saw James standing on the corner waving his
arms and yelling, the officer could tell James was mentally ill. Imagine if he had training and
experience in dealing with mental illness or had the ability to get a mental health professional
to respond to the scene quickly. The situation could have been defused, James might not have
hit the officer, and there would have been no felony assault charge. If there had been an
agreement between the precinct and a neighborhood hospital, James might have been
hospitalized, not arrested -- a better arrangement for all concerned: James, the police officer,
and society.
Sometimes it is difficult to prevent an arrest, but the mentally ill defendant can still be diverted
out of the criminal justice system. Imagine if James were arrested. Once he arrived at the
court pens, he would have caught the eye of a mental health professional assigned to screen
arrestees. The mental health professional would have spoken to James, taken his psychiatric
history, concluded that he was seriously mentally ill, assessed his service needs, and
discussed these findings with James' attorney and the ADA. With everyone in agreement, the
mental health professional would either have had James transferred to a hospital or, if
appropriate, arranged for James to have a bed that night in a safe shelter. There, backed up by
supportive mental health services, staff could begin working with him the next day to arrange
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ongoing treatment, benefits and permanent supportive housing.
When a person with a mental illness commits a more serious crime, such as burglary, the
range of options is limited by the need to hold the person accountable for his actions.
However, there are still practical ways to accommodate the person's need for mental health
treatment. Imagine James had broken into an appliance store, and imagine that the judge had
the option of sending him to an ATI program where the staff had the expertise and resources
to provide James with day treatment, counseling, supportive services and hands-on
supervision to make sure that he took his medications and stayed out of trouble.
In the absence of an ATI program, imagine if James were sent to prison, but prison mental
health workers were able to have James transferred to a prison in New York City six months
prior to release. There, a discharge planner, familiar with community services providers,
could arrange housing and services that would help James stay out of trouble after his release.
The discharge planner could apply for supportive housing and begin the paperwork to get
James benefits. Using contacts in the community, the discharge planner could arrange for
housing providers to come to the prison to meet James and interview him. Being
psychiatrically stable and having played an active role in developing his discharge plan,
James would be prepared for the interviews and would present himself well and be accepted
for supportive housing.
On the day of his release, James would be met by his new case manager, who would take
him to his new residence. At the residence, he would be able to see a psychiatrist regularly,
receive counseling, have social service staff available 24 hours a day, be assisted in applying
for and maintaining his benefits, participate in therapeutic and recreational group activities,
and get referrals to other services such as day treatment or vocational training.
The following recommendations would make the above scenario a reality. These
recommendations overlap in some areas. For example, if misdemeanants with mental illness
were not arrested, then we would not need to expedite misdemeanor 730 exams. This overlap
is intentional; since no system will work perfectly, the goal of the recommendations is to
provide a road map, or starting points, for designing a truly comprehensive system informed
by what works in other jurisdictions.
Clearly, before implementation of these recommendations, a careful needs assessment should
be conducted to determine how many people need which types of services. Prioritizing needs
and creating demonstration and pilot projects are also critical steps before implementing
sweeping changes. It is encouraging to note that some of the recommendations suggested,
such as expediting 730 exams and providing court-based mental health services, are projects
the city and state have already begun to implement or explore.

B. Diversion
Many of the people with mental illness currently passing through New York's criminal justice
system are appropriate for diversion into community mental health treatment or formal ATI
programs. In the current system, however, mechanisms to divert them do not exist. The
following recommendations show how such measures could be created.
Avoid Arresting People with Mental Illness102
Divert the mentally ill into community mental health services rather than arresting
them.
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People who commit offenses are often identified as being mentally ill at a very early stage in
their movement into the criminal justice system. Currently, however, the identification of an
offender as mentally ill does not trigger specialized mechanisms for dealing with the situation.
Police and 911 operators do not have access to mental health experts able to respond to
emergencies, and police who would like to hospitalize an offender rather than making an
arrest do not have easy access to hospital emergency rooms. The following strategies can be
used to facilitate the diversion of offenders with mental illness before an arrest is made.
1. Direct all "EDP" 911 calls to specially trained police officers.
As a standard procedure, 911 operators inquire about the type of emergency when answering
emergency calls. One of the categories they look for is "EDP" or "emotionally disturbed
person" calls -- police lingo for a person with a mental illness. Unfortunately, once a call has
been identified as involving an EDP, no special effort is made to accommodate that fact.
Police are dispatched and the EDP is dealt with by whichever officer happens to be in the
area -- perhaps with great sensitivity, but perhaps not.103
A far better alternative would be to divert these calls to specially trained units of the police
department that have the ability to respond immediately and the training and expertise to
defuse the situation, assess the EDP and effect a hospitalization, if necessary. The model of a
police crisis intervention team (CIT) was developed in Memphis, Tennessee, in 1988. This
model has been replicated in other jurisdictions104 and could easily be adapted to New York
City.
The Memphis model was developed through a partnership between the police department
and the local chapter of the Alliance for the Mentally Ill (AMI), an organization that offers
support groups and advocacy for people with mental illnesses and their families. Officers
from each precinct, a total of about 15% of the force, join the program voluntarily and receive
40 hours of multidisciplinary training designed to teach them that mental illness is a disease,
not a crime.105 AMI developed the training and offers it at no charge to the city. The training
brings together police, people with mental illness and families of the mentally ill, and gives
officers the opportunity to role-play how they would respond to specific situations. Officers
learn about mental illness and are exposed first-hand to the viewpoints of people with mental
illness. Special emphasis is placed on verbal de-escalation techniques designed to avoid
physical conflict. In addition to the initial 40 hours, CIT officers also receive ongoing
training.
Once trained, CIT officers provide 24-hour, seven-day-a-week coverage in every precinct
while also performing their regular patrol duties. There are currently about 165 CIT officers.
They respond immediately to all crisis calls involving a person with mental illness; the
number of these calls has increased in Memphis by 97% since 1987.106 In 1996, the CIT
received 6,825 calls and transported 3,284 people.107 Since 1989, Memphis police have not
been responsible for the death of any people with mental illness.108 The goal of the program is
to "offer a more humane and calm approach" to these calls and to take most patients to
medical facilities without injury or charges.109 The Memphis CIT program has not only
improved police response to crisis situations involving people with mental illness, but has also
fostered broader sensitivity to mental health issues within the police department, enhanced
trust between families of the mentally ill and the police, and helped forge relationships
between the police department and community mental health service providers.
New York City has many mental health organizations, including chapters of AMI, which
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could be valuable resources in training a special unit of police. This strategy would not only
be an inexpensive way to divert a significant number of people with mental illnesses out of
the criminal justice system, it would also be a significant step toward improving police
relations with the community.
2. Provide easier access to community psychiatric hospital beds for police and courts.
A serious obstacle to the pre-booking diversion of people with mental illness is the perception
by the police that if they try to hospitalize a person with a mental illness rather than arrest her,
they will have to spend many hours sitting in an emergency room only to have the hospital
refuse to admit the patient. This problem can be solved by creating agreements between
police and psychiatric hospitals that make it easier for police to bring a person with mental
illness to the hospital rather than putting the person "through the system." These agreements
would also facilitate the diversion and hospitalization of defendants who display serious
psychiatric symptoms prior to arraignment.
Police/hospital agreements have proven successful as diversion mechanisms in several
jurisdictions. For example, as an adjunct to the Memphis CIT program, the police department
has developed an agreement with a psychiatric emergency room at a local hospital, whereby
officers bringing a person with mental illness to the hospital are ensured a waiting time of no
more than 20 minutes. New York City has, through the C-PEP (Comprehensive Psychiatric
Emergency Programs), made some effort to streamline access to emergency psychiatric
services, but this program needs to be expanded and restructured.
We recommend that C-PEP sites be developed in every public (HHC) hospital in New York
City and that both new and existing C-PEP programs make working with the police a
priority. Police should be guaranteed a "no refusal" policy and a half-hour turn-around time
when they bring a person with mental illness to the C-PEP program as an alternative to arrest.
Each C-PEP program should be responsible for a catchment area of precincts; every precinct
in the city should belong to a catchment area. C-PEP staff should do frequent outreach to
precincts in their catchment area, explaining the program to police, building relationships, and
sensitizing officers to mental health issues.
Divert Misdemeanants into Community Mental Health Services110
Existing community mental health programs can act as alternatives to incarceration.
Many mentally ill defendants are charged with misdemeanors. It is essential that diversion to
community mental health services be an option for these people. If diversion to treatment is
not available to misdemeanants, many people with mental illness will pass through the
criminal justice system repeatedly without receiving help; others will go on to commit serious
crimes before any attempt is made to offer them treatment.
Because of the pressure to move cases quickly, a large number of misdemeanors in New
York City are "disposed of" at arraignment. The defendant receives an Adjournment in
Contemplation of Dismissal or a Conditional Discharge, or a plea is entered and the
arraignment judge imposes a jail sentence, community service or probation, and the case is
over. As a result, mentally ill people charged with misdemeanors must be diverted quickly;
for this large group of cases, slow diversion mechanisms that require the defendant to return
to court repeatedly will not be effective. The only effective way to divert most
misdemeanants with mental illness is to have screening procedures and diversion mechanisms
integrated into the earliest stages of the criminal justice process. Following are several
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suggestions on how to do this.
1. Make mental health screening, diversion and crisis beds available at arraignment.
A substantial number of criminal defendants appear obviously mentally ill at arraignment.111
Anecdotal evidence suggests that judges and lawyers doing arraignments may see as many as
three to five defendants with serious mental illness each shift.112 Many of these people are
charged with misdemeanors and should be diverted from the criminal justice system at
arraignment. A prevalence study would be an essential first step in integrating mental health
services into arraignment courts, but it is clear that a great need exists. The New York City
Department of Mental Health, Mental Retardation, and Alcoholism Services has made
beginning steps toward planning arraignment-based mental health services; this project needs
to move forward.
Diversion of people with mental illness could be effected at arraignment by placement of
mental health professionals in court to assess people believed to be mentally ill. The mental
health professionals would need to be skilled in quick, accurate assessment and
knowledgeable about how to access community services. Such professionals would be
valuable consultants to the court and could facilitate agreements between the ADA and the
defense to substitute treatment for prosecution or create alternative dispositions. The mental
health worker could arrange for hospitalization when necessary and, in cases where the
defendant is mentally ill but does not require inpatient care, develop a plan utilizing
community mental health resources.
Pre-arraignment mental health screening raises some concerns about confidentiality issues,
but these problems could be solved by creating a formal relationship between the mental
health professionals and the defense counsel which would protect confidentiality. To avoid
"net-widening" -- the referral of individuals who need help but whose charges do not justify
continuing court supervision -- court-based mental health staff would also make their services
available on a strictly voluntary basis to individuals being released by the court.
For court-based mental health professionals to divert misdemeanants efficiently, the court
would need to have access to a small number of "crisis beds" -- beds in a supportive
environment that homeless people with mental illnesses could be taken to directly from the
court and where they could remain for a day or two while longer-term services were being
located. The court-based mental health services should have enough staffing so that the
workers can follow up with people who have been diverted, implement the alternative to
incarceration plan, and provide the support services necessary to enforce compliance with the
plan.
Integrating mental health experts into arraignment courts should be a first step toward
comprehensive court-based mental health services. These services should have adequate
personnel and resources to respond quickly and provide assessments and referral assistance to
any court part dealing with a defendant with mental illness, not only in Criminal Court, but in
Supreme Court as well.113 These services would be particularly valuable to the city's
numerous specialized drug treatment and domestic violence court parts that frequently
encounter defendants with mental illness but lack the resources and expertise to fully address
defendants' mental health needs.
2. Complete 730 exams in misdemeanor cases within 48 hours.
As noted, one reason the 730 exam is not an effective diversion tool is that it is underutilized.
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Defense attorneys avoid requesting 730 exams because getting the results may take longer
than the sentence available through a plea bargain. This problem could be alleviated if 730
examinations for misdemeanants were expedited and completed within two business days.
This way, 730 examinations would be requested more frequently, and "not fit"
misdemeanants would be diverted from the criminal justice system to the hospital, with the
charges against them dismissed -- all within a few days. Implementing this recommendation
might require spending more money on 730 exams than is currently allocated; however, it
would be money efficiently spent because it would save the cost of extended incarceration
and repeated court dates.
Make ATI Programs an Option for People with Mental Illness114
Formal ATI programs can, and should, include the mentally ill.
People with mental illness have less access to formal ATI programs than other offenders.
This is not the result of any intentional policy, but merely the product of a great gap between
the ATI community and the mental health community. This gap can be bridged by integrating
mental health services into existing ATI programs and using the expertise of both
communities to create new programs that understand both how to provide services to the
mentally ill and how to create successful alternatives to incarceration.
1. Develop ATI programs for the mentally ill.
The staff of New York City's existing ATI programs have many years of expertise in
supervising and serving people diverted from the criminal justice system. However, they do
not know very much about mental health or how to supervise and serve offenders with
mental illness. One cost-effective approach to diverting defendants with mental illness,
including those charged with felonies, would be to expand the expertise of existing ATI
programs into the area of mental health. This could be done by funding specialized mental
health training and staff to enhance established ATI programs and permit them to develop
specialized services for offenders with mental illness.
Given the large numbers of people with serious mental illness being sentenced to jail and
prison, and the unique needs of this population, it may also be necessary to establish one or
more new ATI programs specifically for people with serious mental illness. Such programs
could draw upon and combine the expertise of New York City's mental health treatment and
ATI communities.

C. Continuum of Care
Build Links Between Jail and Community Treatment Providers
The lack of information-sharing between jail-based and community-based mental health
services should be remedied by development of a comprehensive management information
system linking community- and jail-based treatment providers. Early negotiations to develop
such a system in New York City are underway. We support this effort, with the caveat that
such a system must be conservative in how much information it shares and who has access to
the information. It must, under no circumstances, be used to disseminate information
detrimental to defendants' rights. If implemented with scrupulous attention to confidentiality
and the rights of the accused, this system could bridge many of the gaps in the continuum of
care.
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Following are two simple and quick ways to ameliorate the breakdown in the continuum of
care that currently occurs when a mentally ill person involved in community mental health
services is arrested. One involves community mental health workers "reaching in" to the
criminal justice system; the other is for jail-based mental health workers to "reach out" to
community providers. Ideally, these strategies should happen simultaneously.
1. Teach community mental health workers to track clients in the criminal justice system.
Community mental health workers trying to provide a continuum of care for their arrested
clients encounter great difficulty in navigating the criminal justice system and understanding
its complexities. Many of these workers are inexperienced and have no professional training;
most jobs working with the homeless or the mentally ill in New York City require only a
bachelor's degree and pay in the low 20s. These workers have an essential role in creating a
continuum of care for people with mental illness moving in and out of the criminal justice
system, but they lack the tools needed to play this role effectively. At a time when people
with mental illness, particularly the homeless mentally ill, are increasingly likely to encounter
the criminal justice system, it makes sense to offer training about this system, especially about
how to contact jail-based treatment providers, to all workers serving people with mental
illness.
2. Create mechanisms to connect jail-based mental health services to the community.
It should be easy for a community mental health service provider to make contact with a
client's jail-based mental health worker. Instead, it is often a frustrating process, where the
jail-based workers very rarely instigate the contact, and do not necessarily respond when the
community program contacts them. This could be changed by an adjustment in the policies of
jail-based mental health services. Jail mental health staff should ask every new patient for a
detailed treatment history and should have the patient sign a limited release of information
form permitting community programs to release information about the patient's diagnosis and
medications.
The jail-based mental health provider should contact every known recent treatment provider,
fax the release and make every effort to obtain this information. Jail-based mental health
services should also make communicating with outside treatment providers an integral part of
both treatment and discharge planning procedures. Implementing this recommendation would
be a nearly cost-free way of ensuring a continuum of care and improving the efficacy of jailbased treatment.

D. Discharge Planning
Both inpatient and outpatient mental health service providers in the community are required
by New York statutes or regulations, and by professional standards, to provide discharge
planning to every patient leaving their program. The reasons for this are clear: Severe and
chronic mental illness is rarely "cured," and a patient leaving a hospital or outpatient program
needs assistance in accessing ongoing services. As jail and prison staff take on the role of
mental health treatment provider, they should offer the same discharge planning services
patients would receive from community service providers. The following are
recommendations about how effective discharge planning practices can be incorporated into
New York's corrections systems.
Link Inmates with Services Before Release
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People with mental illness should leave jail/prison with essential services already in
place.
The goal of discharge planning is to create a smooth transition into the community. The days
and weeks immediately following the release of a person with mental illness from jail or
prison are critical: The ex-inmate's actions and access to resources during this time are likely
to determine whether the individual will succeed or fail in the community. The following
recommendations illustrate how pre-release planning can help guide vulnerable people with
mental illness through this difficult transition.
1. Provide pre-discharge discharge planning to all mentally ill jail and prison inmates.
All jail and prison inmates with mental illness should receive comprehensive pre-release
counseling including referral and aggressive linkage with mental health services, benefits,
shelter and housing. Because of the complex and demanding nature of discharge planning
tasks, the ratio of discharge planners to clients should be low, with no worker having more
than 20 active cases at one time. There should be enough discharge planners in every jail and
prison to serve every inmate receiving on-going psychiatric treatment. Discharge planners
should have professional qualifications, adequate supervision and resources, and should
receive extensive initial and on-going training in engaging clients and accessing community
resources.
Every person with mental illness leaving jail or prison should have safe housing (or at least
shelter) arranged, a clear plan for how to get on-going psychiatric treatment including a
supply of medication and an upcoming appointment, and an application for benefits at least
pending. Inmates with mental illness should also, by the time of their release, have been
referred to and accepted by a social service provider able to meet their need for case
management and crisis intervention services. Many people with mental illness leaving jail or
prison fall through the cracks without ever reaching the program to which they may have
worked hard to be admitted; all seriously mentally ill people leaving jail or prison and going
to a shelter or supportive housing should be physically transported to their
destination. Discharge planners, and the goverment agencies they work for, should view the
successful reintegration of their clients into the community following release as their
responsibility.
Jail detainees released from court. Pre-trial detainees with mental illness are often released
directly from court because of changes in bail status or as a result of a dismissal or other
disposition of their case. They leave the courtroom with neither medications nor discharge
planning, without even the few possessions they had with them when they were arrested. For
this population, there should be a "drop-in" office at the court where they can receive on-thespot advice about how to obtain mental health services, benefits, shelter and housing. Such a
service, while no substitute for real discharge planning, would be far better than what the
current system offers: nothing at all.
State prisoners. The physical remoteness of many state prisons from New York City creates
a huge barrier to adequate discharge planning for state prisoners with mental illness who are
returning to the city. Community supportive housing programs, which may be reluctant to
accept ex-offenders, are far less likely to do so without the benefit of a face-to-face interview.
Prisoners being released from state prisons have no way to develop relationships with New
York City mental health service providers prior to their release.
This barrier to adequate discharge planning could be removed by the Department of
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Correctional Services transferring state prisoners with serious mental illness who are from the
city to state prisons which are in or near the city six months prior to release for discharge
planning purposes. There are two prisons and a number of work-release facilities with access
to mental health services in New York City where these inmates could be housed. An even
better idea would be to develop one or more specialized pre-release centers for state prisoners
with mental illness on the grounds of down-sized state psychiatric hospitals. New York City
houses several state psychiatric hospitals, all of which have been significantly down-sized in
recent years. Down-sizing has left vacant former hospital buildings which, with little capital
investment, could provide adequate security for inmates nearing release.
Discharge planners at city-based facilities could help inmates with mental illness apply for
housing, benefits and supportive services. An interim measure could be to use video
conferencing to facilitate interviews, but this is no replacement for in-person interviews and
the greater efficacy of a discharge planner who is local. Transferring prisoners with mental
illness to New York City would also permit a community service provider to escort the
releasee directly to housing.
Ensure Immediate Access to Essential Services Following Release
45 days without access to medication and services is a recipe for disaster.
If offenders with mental illness are to leave jail or prison and be successful in the community,
we must find ways to provide them with treatment and shelter immediately. An individual
who is sleeping under a bridge or lost in the shuffle of a city intake shelter, facing a 45-day
wait to get benefits and insurance, has no chance of success.
1. Provide immediate access to medications and treatment.
Every person receiving mental health services while incarcerated should leave jail or prison
with a scheduled appointment to see a community mental health service provider. The
provider should be fully apprised, by the corrections-based mental health service provider, of
all relevant information about the patient's treatment needs.
Every person receiving psychiatric medications while incarcerated should receive a onemonth supply of the needed medication at the time of release, except in cases where the
corrections-based mental health service provider has good reason to think that the patient may
endanger himself by mis-administering the medication. In such a case, the patient and the
medication should be sent to a shelter or housing provider with the capacity to dispense the
medication.
For recent releasees who find themselves without necessary medications before they have the
benefits to pay for a new supply, there must be another payer. Expansion of the Prescription
Medication Service already developed to support the NYC-LINK program could solve this
problem.
2. Expedite benefit approval/recertification.
One of the greatest obstacles to mentally ill releasees maintaining their psychiatric stability
and staying out of trouble is the 45-day delay in benefit eligibility following release from
incarceration. In order for people with mental illness leaving jail and prison to have any real
chance of successfully reintegrating into society, this gap must be closed. The New York
City Human Resources Administration (HRA) has the power to provide on-the-spot
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Medicaid and cash assistance to applicants with "immediate needs," but under the current
system these requests are dealt with in an informal and cumbersome manner. Nearly all
seriously mentally ill people leaving jail or prison have "immediate needs"; these needs could
be addressed through creation of HRA post-release "emergency" centers where released
inmates could go with a referral from a jail or prison discharge planner and get cash and a
temporary Medicaid card on the spot.
3. Refer ex-offenders with mental illness to supportive housing or shelter programs.
Homeless mentally ill people leaving jail and prison and returning to New York City
generally go to the city's Department of Homeless Services (DHS) shelter system. Jail- and
prison-based discharge planning staff should work with every inmate with a mental illness to
try to find the person permanent supportive housing prior to release. Where this effort is
unsuccessful, however, there needs to be a connection between jails and prisons and the
shelter system. Unfortunate as it is to discharge anyone to a shelter, where such a discharge is
unavoidable, it should be handled in a way that creates some continuum of care.
This continuum could be created by DHS providing specialized shelter beds that offer
intensive mental health services to people with mental illness recently released from
correctional facilities. These beds should be in settings that provide structure and support
without replicating the experience of being incarcerated. In the absence of such specialized
services, however, it should be possible for jail- or prison-based discharge planners to refer
clients with mental illness directly to one of DHS's mental health "program shelters."
Program shelters are specialized shelters for mentally ill homeless people where supportive
case management services are provided and the goal is to move clients to permanent
supportive housing. Referral from jail or prison to a DHS shelter should include the
correctional facility sending all relevant information regarding the inmate's treatment needs to
the shelter-based mental health service provider prior to the inmate's release.
4. Create specialized mental health parole/probation programs with low caseloads.
People with mental illnesses create specific challenges for parole and probation officers.
These challenges could be much better met by designating specialized officers who are
trained in mental health and assigned smaller caseloads. Specialized probation and parole
officers could play a key role in helping people with mental illness access the services
necessary to succeed in the community and avoid re-offending.
New York City-based parole offices have recently agreed to create specialized caseloads for
parolees with mental illness. This is a very promising step toward assisting ex-offenders with
mental illness. It is essential, however, in order to improve the current system, that "mental
health parole officers" receive specialized training in mental health services, a mandate to
assist parolees in accessing those services, and small enough caseloads so that they have time
to assist individuals in a comprehensive and compassionate manner. New York City's
Department of Probation currently has no specialized officers with mental health caseloads.

IV. CONCLUSION
People with mental illness in the criminal justice system are a large and growing population
with enormous, complex needs. Instead of treating them, we prosecute them. We must
reverse this trend now not only because it is the right and humanitarian thing to do, but also
because our current practices spin people ever faster through the revolving door -- from the
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community to jail to the community to the hospital, out again and then back to jail -- and
needlessly waste precious taxpayer dollars. We need to stop serving this population
reluctantly and haphazardly, in precincts, court pens, emergency rooms, jails and prisons, and
offer them, instead, comprehensive community-based services that will stop the revolving
door.
The solutions to these problems are clear. They are not necessarily expensive or difficult to
implement. Many merely require a recognition of the inefficiencies of the current system, the
programs and services that are available, and a desire to integrate our criminal justice and
mental health systems in sensible ways. We need mechanisms to divert people with mental
illness at every stage of the criminal justice system. We need ATI and enhanced community
mental health programs that can accommodate people with mental illness diverted from the
criminal justice system. We need discharge planning for all jail and prison inmates with
mental illness and programs that will assist people as they return to the community.
People with mental illness caught up in the criminal justice system are part of our
communities. Our present system is failing to retrieve these many desperate lives and failing
equally to spend available money judiciously. Decency and fiscal responsibility call for the
changes outlined here. New York City and State could become leaders in addressing this
growing national problem and assisting society's most vulnerable citizens. It is our hope that
this report and these recommendations will persuade policymakers to follow this sensible and
humane path.
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