Whether it is for loitering over and over again in a hotel lobby or stealing from a local shop, offenders with mental health problems are finding themselves behind bars for their behavior instead of in treatment.

The rising number of mentally ill offenders coming through the doors of correctional facilities is old news to many in the criminal justice system. But as agencies have become more vocal about the problem, funding and support has started to float towards local communities in an effort to help address it.

In the last year alone, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) has provided grants to a number of communities across the country to help divert mentally ill offenders out of local jails and into treatment. Funding for mental health courts, where offenders can be directed by judges toward treatment instead of incarceration, has also surfaced.

"What we are interested in is stopping the revolving door for [these] inmates and getting them adequate care. Most of the folks with mental illness are there on misdemeanor charges and many [of those] could be prevented," said Fred Osher, Director of the Center for Behavioral Health, Justice and Public Policy at the University of Maryland.

These new grants and the increased attention have finally started to make a dent in the problem, but in the process agencies need to be careful about how and where these offenders are receiving services.

"It is easy to come up with models for diversion, but diversion to what? There needs to be adequate partners in the community, otherwise we speed up the revolving door," said Osher.

Those following diversion trends warn that while programming will address some of the issues, and has done quite well in some jurisdictions, the entire community mental health system must be ready and able to manage the needs of the population.

Involving Many in Diversion

Diversion programs have taken many faces in the community from mental health courts to diversion into community mental health treatment to a team approach to providing services. Many of the successful ones have taken a broad approach to the issue by involving multiple community stakeholders in the solution. The ultimate goal is to reduce the number of mentally ill offenders being housed in the correctional setting by providing treatment.

One example is the Mental Health Diversion Program in Jefferson County, Kentucky, which has been in operation since 1989.

The program first began as a county-funded endeavor, then was picked up by the local corrections budget and is currently operated under contract with a community mental health agency called Seven Counties Services.

According to Jim Burch, a licensed psychological associate and administrator for the Mental Health Diversion Review Program at Seven Counties, the program operates with a staff person in the local jail, helping to identify offenders who could benefit from diversion and treatment, and a court liaison who finesses an agreement between the defense and the prosecution in court to divert the offender to treatment.

Then, if the judge agrees, the offender is required to follow a treatment plan or risk re-incarceration.

"We go by the criteria of being diagnosed with a serious mental illness such as schizophrenia, bipolar disorder or major depression with chronicity. That rules out a lot of folks," said Burch.

Primarily the offenses committed by these offenders are low-level, but some non-violent felony offenses are accepted. A volunteer board of people involved in the mental health field reviews the cases chosen for the program monthly.

While the services provided to these offenders are primarily mental health related, those who work with the offenders understand that this population has many other needs that must be addressed.

Those needs include housing and the re-instatement of SSI benefits.

"One of the problems community-resource wise is often, if someone has been in jail for a while, they have lost their housing and they may have to go to a shelter," Burch said. He added that the difficulty is compounded by the scarcity of beds designated for people with mental illness. There are less than 30 beds in the community for men and none for women, he said.

Another complication is the short time span that the agency has to find housing for an offender who often needs housing right away after a judge has signed off on the treatment plan.

Seven Counties also keeps on top of other needs the offenders may present with, such as substance abuse treatment, and makes referrals to those services as well.

Because of the program's presence in the jail, Burch said, offenders who have not been identified for the diversion program when they are incarcerated often come to the offices after release for assistance and referrals.

"A lot of them do want help and don't want to repeat the cycle," he said.

And they have been getting it.

In the last year the program screened 714 potential clients and served 204. Burch said the agency estimates that by diverting those offenders it saved the county jail more than 19,000 jail days, based on the sentences those offenders would have served. At a cost of $53 per day, the savings is around $1 million.

Success has also come to programs that focus on different set of mentally ill offenders -- those who risk being incarcerated in a state's prison system because they have been charged with felonies.

Nathaniel Project Makes a Mark

In 2000, the Center for Alternative Sentencing and Employment Services (CASES) in New York City began targeting this population, which it felt was being ignored by the system and the community.

CASES officials say that many other diversion programs focus on offenders committing misdemeanor crimes, leaving those who had committed more serious offenses to sit behind bars.

"Programs are afraid of taking on felony level offenders because of the politics. Folks who have a serious mental illness need a lot of case services and case management. There is a concern both because of the politics and because federal funding is denied to violent felons, [and] you close yourself off to a lot of [that]," said Sarah Bryer, Chief Policy and Planning Officer for CASES.

Bryer said that CASES was able to start a program that specifically worked with this population in part because of its solid reputation in the court system, where these offenders are diverted to mental health services.

"We have been working in the courts for more than 30 years. We have trust built up and they know we are reliable. We tell the truth, we give accurate and timely reports to the courts and the judiciary knew they could trust us. And, we knew that we would have no program unless they gave us clients," said Bryer.

CASES decided to start with this population and build a solid reputation for the program before it went after funding. The idea was that if CASES could show success with this population, it would not have to compromise its goals and work with misdemeanor offenders - which often garner more program support because the risk is lower to the community.

"The biggest obstacles to the program are in the community. Community programs didn't want to take our clients. [Often] diversion programs sometimes don't link that gap," said Anne Marie Lawson, Coordinator of the Nathaniel Project at CASES.

The goal for CASES was to ensure that the clientele it was working with had programs to go to and resources to access without displacing any others in the community who need mental health care.

"It's about making a space for your clientele rather than adding more people to the pool to compete against each other," she said.

This formula seems to have worked as the positive results from those participating in the Nathaniel Project have highlighted. In public safety, the number of arrests dropped from 101 in the year prior to the program to seven. At six months, the project had an 88 percent retention rate and an 80 percent retention rate over two years. As for treatment, 100 percent of participants are engaged in services and in housing, after one year, 79 percent of participants had permanent housing.

But while separate programs are notching successes in their belts, some say that the problems will not truly be addressed until society as a whole takes them on, not just the courts, criminal justice or community mental health systems.

A Societal Issue

According to Margaret Severson, Professor at the University of Kansas, a former jail administrator of mental health programs and a court expert in jail mental health, this broader issue is one that has not often been addressed by diversion programs, and should be.

Severson said that some diversion programs, mental health courts in particular, can actually create more competition in the community for these services.

"What we know for certain is there have been no new services created [in the community] as a result of these mental health courts," she said. "It's a complex situation. While the idea is good and it is good to think creatively, if we don't create services, then the jail becomes the primary service provider."

According to Severson, an already overloaded community mental health provider faced with serving a client who is court-ordered to the program versus taking a client who walks through the door, will be forced to send the one without the court order elsewhere or back to the street.

Severson said this is a tragedy in two ways, one because it may not resolve the problems for the criminal justice system and, two, because it simply shouldn't happen to those with mental illness.

"What is happening to mental health and community mental heath is abominable. We wouldn't dream of doing this to people with physical illnesses. We wouldn't say 'Figure it out yourself.' Nor would we incarcerate them based on their disease," Severson said.

Severson suggests that the issue be dealt with on a societal level where the government steps in to take on the issue in a systemic way.

"The most recent literature on stigma suggests that we actually acknowledge certain kinds of mental illness and people are able to talk about it and feel okay about thinking about people being on medication. But, when it comes to working with them or living next door, I'm not sure we can say people are getting it until we get beyond these stereotypes," Severson said.

She said there needs to be a "reckoning" in our communities that people with mental illness deserve treatment and have a right to live in the community, not be locked up in jail.

So, how does this happen? Severson suggests that if public health agencies and federal, state and local governments begin to work on the issue together, then real progress can be made.

A few first steps have already been made such as when the U.S. Surgeon General produced reports in 1999 and 2001 about the extent of mental illness in our nation's communities.

"He really brought to focus the fact that we have a widely diverse population that brings with it different traditions and practices and those things need to be fully developed and integrated into assessment and intervention and follow-up procedures," Severson said.

When specifically addressing problems that jails face with this population, Severson said a link should be made to these findings.

"In jails we are talking about people who are of ethnic and racial minorities. We have to think about it as not a one-size-fits-all deal. People in the south may have some cultural  things they bring with them to the jails and that may mean they are treated differently. The courts can't [address] that; it's not the courts bailiwick," Severson said.

Some agencies, like SAMSHA, have made this connection at least in providing funds and assistance to corrections agencies that are motivated to change their situations.

Centers of Assistance and Support

As grant money for diversion programs has become available, so has technical assistance to those grantees and other criminal justice agencies seeking help related to diversion.

The TAPA Center for Jail Diversion was funded through SAMSHA as a coordinating site for its jail diversion grantees, but it also provides information to any agency about diversion trends.

According to Melanie Shaw, Project Associate for the TAPA Center, the funds being made available to these communities are designed to help local communities improve services for the mentally ill population coming in a jail's front door.

The programs typically are split between two types: pre-booking and post-booking and each program sets its own eligibility criteria for offender participation.

"The goal of the program is to expand these communities' capacity and it may well be the services were not as accessible before hand, but they are using the funds to make the services available [now]," said Shaw.

Other centers have also been tapped to become a part of the solution. The Center for Behavioral Health, Justice and Public Policy at the University of Maryland, for example, has been charged with creating a brief jail mental health screen to help agencies better identify those offenders needing diversion more quickly.

According to Osher, director of the center, currently there is no standardization among jail mental health screening tools, but there should be.

"Everyone comes through the jail door, so there's a real opportunity to identify people with serious mental illness. Now, it's haphazard how people are doing that," Osher said.

He hopes that the screening tool, which is being developed through a grant from the National Institute of Justice, will become a measure that is approved for all jails to use in the future.

With these efforts in motion, including increased funding for programs, agencies will be making a difference in their local communities. What they also need to keep in mind, however, are the larger policy issues that should change as well.

"We have to start thinking about policy. Diversion cannot be programs [only]. These have to be philosophies we talk about [where] we say we want to support the idea that people with mental illnesses are treated fairly and that there are a range of interventions for them, including the jail," said Severson.

Resources:

TAPA Center - http://www.tapacenter.org

CASES - http://www.cases,org

Mental Health Diversion Program, Jefferson County, Ky. - 502-589-8926

Margaret Severson - mseverson@ku.edu

Center for Behavioral Health, Justice and Public Policy - http://www.umaryland.edu/behavioraljustice/