Skip navigation

Presidents Task Force on 21st Century Policing, Bazelon Center, 2015

Download original document:
Brief thumbnail
This text is machine-read, and may contain errors. Check the original document to verify accuracy.
The Judge David L. 

for Mental Health Law 



Nikki Heidepriem, Chair
Heidepriem & Associates, LLC

March 12, 2015

Anita L. Allen
U. of Pennsylvania Law School
David B. Apatoff
Arnold & Porter

President’s Task Force on 21st Century Policing
Office of Community Oriented Policing Services
U.S. Department of Justice
145 N Street, N.E. 11th Floor
Washington, DC 20530
Via Email To:

Samuel R. Bagenstos
University of Michigan Law School
Dana Bazelon
Defender Assoc. of Philadelphia
Eileen A. Bazelon
Department of Psychiatry, Drexel
Robert A. Burt
Yale Law School

Dear Co-Chairs Ramsey and Robinson, and Members of the Task Force:

Jacqueline Dryfoos
New York, NY

The Judge David L. Bazelon Center for Mental Health Law is a national public
interest organization, founded in 1972 to advance the rights of individuals with
mental illness or an intellectual disability. Among other priorities, we seek
implementation and enforcement of the Americans with Disabilities Act’s
guarantees of non-discrimination and reasonable accommodation. The Center
has long worked for the diversion of people with mental illness from the
criminal justice system and for safer police practices. We applaud your work
promoting better policing practices and fostering collaboration between law
enforcement and communities. We would welcome the opportunity to talk to
you about the resources law enforcement and other public agencies require to
ensure safe and non-discriminatory policing for people with mental illness.

Kenneth R. Feinberg
Feinberg Rozen, LLP
Howard H. Goldman, MD
U. of Maryland School of Medicine
Jennifer A. Gundlach
Hofstra School of Law
Stephen J. Morse
U. of Pennsylvania Law School
Margaret E. O’Kane
Joseph G. Perpich
JG Perpich, LLC
Harvey Rosenthal

Law enforcement’s role in responding to individuals with mental illness has
increased over the last several decades, as more people with such disabilities
are living and receiving services in the community. Community mental health
systems lack the resources they need and, as a result, many individuals with
mental illness are homeless or unemployed, circumstances that correlate with
encounters with police.1 Individuals with mental illness have higher rates of
arrest than the general population, and the rate of arrest among public mental
health service recipients is “roughly 4.5 times higher than those observed in the
general population.”2

Elyn R. Saks
USC Gould School of Law
Martin Tolchin
Washington, DC
Sally Zinman
Berkeley, CA
Miriam Bazelon Knox
Mary Jane England
Regis College

It is especially concerning that people with mental illness are
disproportionately injured or killed in encounters with the police.3 Moreover,

Martha L. Minow
Harvard Law School
H. Rutherford Turnbull
Beach Center for Family & Disability
Robert Bernstein, PhD
Affiliations for informational purposes only 


Steven K. Hoge, et al., Outpatient Services for the Mentally Ill Involved in the Criminal Justice
System, American Psychiatric Association Task Force Report (Oct. 2009) at 11-12, available at
William H. Fisher, et al., Risk of Arrest Among Public Mental Health Services Recipients and
the General Public, 62 Psychiatric Services 62 (Jan. 2011) at 67, available at
Rachael Bale & Alex Emslie, More Than Half of Those Killed by San Francisco Police are
Mentally Ill, KQED News (Sept. 30, 2014), available at; Kelley Bouchard, Across Nation,

1101	15th	St.	NW,	Suite	1212,	Washington,	DC	20005	|	Phone:	202‐467‐5730	|	

25% of inmates in local prisons and jails have a mental illness;4 and 17% of inmates have a
serious mental illness.5
These are grim statistics. But the situation is not hopeless. Police departments across the country
are implementing modifications to traditional policing practices that can increase the safety of
officers and of people with mental illness during police encounters.6 To be truly successful,
though, strategies such as enhanced police training and mobile crisis teams must be coupled with
community-based mental health and addiction services—those that help individuals with mental
illness avoid police encounters in the first place and those that help reduce the risk of recidivism
upon release from police custody or incarceration. We were pleased to see that the Task Force’s
interim report contained several recommendations for increasing the use of some of the
successful practices we discuss below, but we urge the commission to make more specific
recommendations on several points.7
1. Strategies to Protect Officers and Better Serve Individuals with Mental Illness
During Police Encounters
Police are increasingly responding to calls relating to individuals in mental health crisis who
have committed no violent act or crime.8 With proper training, the risk to both officers and the
individual in crisis can be greatly reduced. Among the modifications officers can make to their
practices when interacting with people in mental health crisis is the use of Crisis Intervention
Teams (CITs) and of the skills officers learn in “CIT training.” CITs consist of officers with
specialized training in de-escalation techniques, who safely and effectively respond to situations
involving people in mental health crisis.9 Officers who are not part of a CIT can receive CIT
training on these same techniques. CIT training gives officers the knowledge they need to connect
Unsettling Acceptance when Mentally Ill in Crisis are Killed, Portland Press Herald (Dec. 9, 2012), available at; Tux
Turkel, When Police Pull the Trigger in Crisis, the Mentally Ill Often are the Ones Being Shot, Portland Press
Herald (Dec. 8, 2012), available at
The New Asylums Frequently Asked Questions, PBS Frontline, available at The most recent Bureau of Justice Statistics study
estimated that the United States inmate population with mental illness (defined as a clinical diagnosis or treatment
by mental health professional) was higher: 56% of inmates in state prisons and 45% of inmates in federal prisons.
See Doris James & Lauren Glaze, Mental Health Problems of Prison and Jail Inmates, U.S. Dep’t of Justice (Sept.
2006) at 1, available at
Alex M. Blandford & Fred C. Ocher, A Checklist for Implementing Evidence-Based Practices and Programs for
Justice-Involved Adults with Behavioral Health Disorders, SAMHSA Gains Center for Behavior Health and Justice
Transformation (Aug. 2012) at 1, available at For a definition of “serious mental illness,” see Federal Register Vol. 58 No. 96 at
29422-29425 (May 20, 1993).
Title II of the Americans with Disabilities Act requires that state and local governments make reasonable
modifications to their programs for individuals with disabilities. See 28 C.F.R. § 35.130(b)(7); cf.
42 U.S.C. § 12182(b)(2)(A)(ii) (defining discrimination for purposes of Title III of the ADA to include the “failure
to make reasonable modifications”).
Although our comments are focused on individuals with mental illness, individuals with intellectual disabilities
face similar challenges. See, e.g., “Suspects with developmental disabilities & the criminal justice system,” The
ARC of New Jersey, available at (noting that
between 2-10% of offenders and at least 25,000 individuals in prison have intellectual disabilities).
Fernanda Santos & Erica Goode, Police Confront Rising Number of Mentally Ill Suspects, New York Times (Apr.
2, 2014), available at
Randolph Dupont, et al., Crisis Intervention Team Core Elements, The University of Memphis School of Urban
Affairs and Public Policy, Department of Criminology and Criminal Justice CIT Center, (2007) at 3, 5, available at


people in crisis with the public mental health system, rather than channeling them into the
criminal justice system.10
The results of properly-implemented CITs and CIT training for officers are dramatic: increased
officer safety, improved outcomes for people with mental illness, increased confidence for
responding officers, and cost savings. CIT-trained officers in Memphis—where the first CIT was
developed in 1988—are “more likely to indicate that they [are] well prepared in situations
involving people with mental illnesses,” view their non-CIT trained colleagues as less capable of
successfully responding to such situations, and are “more likely to rate the mental health system
as being helpful.”11 In Georgia and Indiana, CIT-trained officers demonstrated greater knowledge
of mental illness and how to appropriately respond to symptoms of mental illness; as a result, they
used less-aggressive policing techniques with people with mental illness and had “improved
rapport-building skills, de-escalation abilities, and communication between officers and . . .
[individuals with mental illness] and their family members, as well as better outcomes . . . in
terms of referrals to mental health services.”12 The use of CITs and CIT training for officers is
also associated with less use of “high-intensity police units” such as SWAT teams, and there is a
“lower rate of officer injuries” among police departments with CITs and officers who have
undergone CIT training.13 According to the National Alliance on Mental Illness (NAMI), which
provides CIT training to many police officers around the country, the introduction of CIT-trained
officers has resulted in an 80% reduction in officer injuries when responding to situations
involving a person in mental health crisis.14
By teaching officers how to better interact with people with mental health illness and avoid
channeling them into the criminal justice system, CIT training also results in lower arrest rates
and thus reduces burdens on criminal justice systems. The Memphis CIT program has shown
significant savings for that city’s criminal justice system by shifting costs to the mental health
system, where such costs belong and public resources are more efficiently invested.15 Research on
the Louisville, Kentucky CIT program shows that an annual investment of $150,000 in CIT
training for police officers has saved over $1 million per year for both the criminal justice and
mental health systems, mostly in deferred hospitalizations and reduced inpatient referrals from
Although there are over 400 CITs17 in forty-six states,18 most states do not require the forty-hour
training that is considered standard for police officer CIT training.19 A review of thirty-seven
states shows that most require eight or fewer hours of CIT training, and Hawaii and others have

Id. at 5
Michael T. Compton, et al., A Comprehensive Review of Extant Research on Crisis Intervention Team (CIT)
Programs, The Journal of the American Academy of Psychiatry and the Law (2008) at 49, available at
Id. at 50.
Id. at 52.
Megan Pauly, How Police Officers Are (or Aren’t) Trained in Mental Health, The Atlantic (Oct. 11, 2013),
available at
Id. at 52.
Peggy El-Mallakh, et al., Costs and Savings Associated with Implementation of a Police Crisis Intervention Team,
Southern Medical Journal (2014), available at
A Comprehensive Review of Extant Research on Crisis Intervention Team (CIT) Programs, supra note 11 at 48.
Crisis Intervention Team Map, The University of Memphis School of Urban Affairs and Public Policy,
Department of Criminology and Criminal Justice CIT Center, available at
How Police Officers Are (or Aren’t) Trained in Mental Health, supra note 14.


no mental health training requirement despite having a registered CIT program.20 Police
departments report that it is primarily a lack of funding that prevents them from investing more in
CIT training.21
CITs and CIT training are not the only methods proven to improve outcomes in encounters
between people with mental illness and law enforcement. Mobile Crisis Teams (“MCTs”)
arrange for one or more highly-trained mental health treatment providers—psychiatric nurses,
social workers, or paraprofessionals—to accompany an officer responding to a mental health
crisis. MCTs are on-call and can be deployed as needed to help officers assess a situation, or
meet with individuals without a law enforcement presence. MCTs use a variety of
interventions to de-escalate crises and connect people with the public mental health system.22
Depending on the jurisdiction, MCTs can be called by police dispatchers or even social
workers or family members, and they often facilitate rapid treatment and transportation to
hospitals or other mental health providers.23 The results can be dramatic: a survey of mobile
crisis teams in DeKalb County, Georgia found that their use prevents hospitalization 55% of the
time compared to only 28% for typical police interventions.24 The same study found that mobile
crisis teams cost 23% less than traditional police involvement and hospitalizations.25
Both mental health professionals and the United States Department of Justice have embraced the
use of CITs and MCTs. Based on research and experience, the American Psychiatric Association
and the American Psychological Association have declared that CITs improve “officers’
familiarity and comfort with the mental health system” and mobile crisis teams are “effective at
de-escalating police interactions with individuals with mental illness,” leading to better outcomes
for individuals with mental illness.26 A 2012 settlement the DOJ reached with Portland, Oregon
required substantial investments in CITs and mobile crisis services.27 The City agreed to invest
additional resources in its existing officer CIT training by requiring that all officers receive a
minimum of forty hours of training before assuming independent patrol or call-response duties; it
also agreed to create a Memphis-style CIT, with an initial size of 60-80 volunteer officers,
depending on demand for CIT services.28 In addition, the city committed to expanding its mobile
crisis services so that each precinct had a Mobile Crisis Team consisting of an officer and a
mental health professional.29
Some funding from the federal government is available for these services. The Bureau of Justice
Assistance, a component of the Office of Justice Programs at the U.S. Department of Justice that
administers the Justice and Mental Health Collaboration Program (JMHCP), provides funding to

Mobile Crisis Teams, New York City Dep’t of Health and Mental Hygiene, available at
Id.; H. Richard Lamb, et al., The Police and Mental Health, Psychiatric Services 1266 (2002) at 1269, available at
Roger Scott, Evaluation of a Mobile Crisis Program: Effectiveness, Efficiency, and Consumer Satisfaction, 51
Psychiatric Services 9 (Sept. 2000) at 1153-6, available at
See Brief of American Psychiatric Association, American Psychological Association, et al. at 30, 32, City and
County of San Francisco, California v. Teresa Sheehan, No. 13-1412 (S. Ct. Feb. 17, 2015), available at
See Settlement Agreement, United States v. City of Portland, Civil Action No. 12-2265 (D. Or. Dec. 17, 2012).
Id. at 37-38.
Id. at 40.


projects designed to “increasing public safety through innovative cross-system collaboration for
individuals with mental illness who come into contact with the criminal justice system.”30 This
grant program has been used to fund CIT training and to develop and maintain statewide
implementation efforts.31 Medicaid funding, at least 50% of which is federal, can be used to pay
for the activities of the mental health professionals who participate on MCTs, although a national
survey identified only 12 states using Medicaid to cover mobile crisis services.32 The
Administration has also allocated money to mental health first aid programs through the “Now is
the Time Initiative.”33 There are several states that also directly fund CIT training.34

Nevertheless, CIT training and MCTs are in short supply. Funding for these fundamentally
necessary trainings and services should be expanded.
2. Strategies to Reduce Encounters Between Police and People with Mental Illness:
Expanding Community-Based Mental Health Services
CITs and MCTs are important, but they seek to improve outcomes when a crisis occurs. We must
devote resources to expanding community mental health services that prevent mental health
crises from occurring in the first place and provide appropriate—non-forensic—responses when
they do, including diversion from the criminal justice system.
There is a broad consensus in the mental health community about how to achieve these goals.
Mental health crisis services including MCTs based in and operated by the mental health system
(vs. law enforcement agencies), Assertive Community Treatment (“ACT”), and supportive
housing are key evidence-based approaches to preventing mental health crises and responding
safely and appropriately when they do occur.
Mental health crisis services include mental health MCTs,35 crisis walk-in centers, crisis
respite apartments, and crisis hotlines, and can help prevent police encounters from occurring
in the first place. Crisis walk-in centers allow individuals who are having a mental health
crisis to receive an immediate assessment and diagnosis for treatment as well as planning and
referrals for ongoing treatment.36 Crisis respite facilities provide temporary living space and
supports during a mental health crisis; they are often staffed with peers who have lived

See Justice and Mental Health Collaboration Program (JMHCP), U.S. Department of Justice, Office of Justice
Programs, Bureau of Justice Assistance (2015), available at The Bureau of Justice Assistance is also funding a
report summarizing how some states have utilized JMHCP funds to increase usage of CIT and mobile crisis teams.
See Melissa Reuland, Laura Draper, and Blake Norton, Statewide Law Enforcement/ Mental Health Efforts:
Strategies to Support and Sustain Local Initiative, Council of State Governments Justice Center (Dec., 2012)
available at
See Reuland, et al., supra note 30, at fn.11.
Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies, Substance Abuse and Mental Health
Services Administration (SAMHSA) (2014) at 16 (listing Arizona, Connecticut, Delaware, Florida, Hawaii,
Mississippi, North Carolina, New Jersey, New Mexico, Oklahoma, Vermont, and Wisconsin as states in which
Medicaid funding is available), available at
“Now is the Time” Project AWARE State Educational Agency Grants, SAMHSA (2014), available at
Id. at 6-9. See also Crisis Intervention Team Grant Program Guidelines and Application Instructions for Projects
Starting June 1, 2009, The Commonwealth of Virginia, Department of Criminal Justice Services (2009), available
See Mobile Crisis Teams, supra notes 22 and 23 and the corresponding text. MCTs that are operated by and
within the mental health system do not include law enforcement officers.
See, e.g., Walk-In Crisis and Psychiatric Aftercare, North Carolina Dep’t of Health and Human Services,
available at


experience with mental illness.37 Crisis hotlines provide support services and referrals via
telephone and text message.38 Mental health MCTs travel to the person in crisis. In most
instances, they both allay the crisis and arrange for needed treatment.
Assertive Community Treatment (ACT) teams are comprised of mental health specialists—
psychiatrists, nurses, social workers, and others—working in a coordinated fashion to help
people with serious mental illness live independently and avoid crises.39 ACT teams are mobile,
provide services in the home and in other community settings where people spend time, and are
available twenty-four hours a day, seven days a week.40 ACT teams help people access mental
health care, maintain stable housing, secure and maintain employment, become part of a
community, manage physical health, and develop other recovery skills.41
Supportive housing, another critical service that reduces homelessness and improves mental
health outcomes,42 provides an individual with rental assistance to move in to their own
apartment or home while making available a wide range of “wraparound” services that support
recovery, engagement in community life and successful tenancy.43 ACT teams or similar support
staff work with residents in supportive housing to provide a flexible array of services.44 There are
no preconditions to participating in supportive housing (such as treatment compliance), the
housing is permanent and affordable, and residents have the rights and responsibilities of
These approaches work.46 A recent survey of evidence of the effectiveness of mental health

The Key Assistance Report Focus on Peer-Run Crisis Respite Services, National Mental Health Consumers’ SelfHelp Clearinghouse, available at
Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies, SAMHSA (2014) at 11-12, available
A Way Forward: Diverting People with Mental Illness from Inhumane and Expensive Jails into Community-Based
Treatment that Works, ACLU of Southern California and the Bazelon Center for Mental Health Law (2014) at 4,
available at
Id. The Substance Abuse and Mental Health Services Administration provides an Evidence-Based Practices Kit
on ACT teams. See
A Way Forward, supra note 39 at 4.
Id. See also Housing First, Pathways to Housing, available at
A Way Forward, supra note 39 at 4.
Supportive Housing: The Most Effective and Integrated Housing for People with Mental Disabilities, The Bazelon
Center for Mental Health Law, available at The Substance Abuse and Mental
Health Services Administration provides an Evidence-Based Practices Kit on supportive housing. See
Another key service is supported employment, which helps people with mental illness find and keep employment,
and provide supports as needed, including skills training, benefits counseling, and job coaching. See generally and Higher rates of
unemployment among people with serious mental illness impact the disproportionate arrest and incarceration rates
among this population, making supported employment another key approach to improving mental health outcomes
and preventing unnecessary police interactions. See Employment Status of the Civilian Population by Sex, Age, and
Disability Status, Not Seasonally Adjusted, United States Dep’t of Labor Bureau of Labor Statistics (2015),
available at (showing that the February 2015 unemployment rate for
individuals with disabilities is 11.9%, versus 5.9% for people without disabilities); Eric Gould, et al., Crime Rates
and Local Labor Market Opportunities in the United States: 1979-1997, The Review of Economics and Standards
(1997), available at; see also Steven Raphael and
Rudolf Winter-Ebmer, Identifying the Effect of Unemployment on Crime, Journal of Law and Economics (2001),


crisis services found that crisis walk-in centers, peer-run crisis respites, and crisis hotlines
provide effective care, with greater consumer satisfaction than hospital care.47 ACT programs
have decreased participants’ days spent in jail over the course of a year by as much as 83%.48
Supportive housing reduces shelter use, hospitalizations, duration of hospital stays, and
incarceration.49 Pathways to Housing,50 a well-studied and widely-emulated provider of ACT
and supportive housing, has reduced prison episodes by 50%, shelter use by 88%, hospitalization
episodes by 71%, and crisis response episodes by 71% percent among its participants.51
The Department of Justice has incorporated these services into a series of settlements with cities
and states in its cases enforcing the United States Supreme Court’s landmark decision in
Olmstead v. L.C.,52 in which the Court affirmed that the needless institutionalization of people
with disabilities is a form of discrimination prohibited by the Americans with Disabilities Act. In
a 2010 DOJ settlement with Delaware, the state agreed to create mental health MCTs that could
“reach someone anywhere in the state within one hour,” ACT teams, and supportive housing
vouchers.53 In a 2010 DOJ settlement with Georgia, the state agreed to create ACT teams, mental
health MCTs, and supportive housing.54 And in a 2012 settlement with North Carolina, the state
agreed to create additional supportive housing slots, ACT teams, and crisis services including
mental health MCTs, walk-in crisis clinics, and a twenty-four hour crisis telephone line.55 In a
2014 settlement with New Hampshire, the state agreed to create a crisis system that included
mental health MCTs and crisis apartments with peer staff and clinical staff, as well as expand
ACT and supportive housing services.56
Not only do these community-based services work, they save money. In one year, Georgia
experienced a net cost savings of $1.1 million in reduced hospitalizations, fewer arrests and
available at; Deborah R. Becker, et. al, Converting Day Treatment Centers to
Supported Employment Programs in Rhode Island, 52 Psychiatric Services 3 (Mar. 2001) at 351, available at
_Island.pdf (finding that a Rhode Island supported employment program resulted in employment rates as high as
56.7%, compared to 19.5% for individuals in a day treatment program). By helping people with mental health
disabilities obtain jobs, states and localities help reduce homelessness and give people a productive way to fill their
day. The Substance Abuse and Mental Health Services Administration provides an Evidence-Based Practices Kit on
supported employment. See
Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies, supra note 32, at 8-14.
J. Steven Lamberti et al., Forensic Assertive Community Treatment: Preventing Incarceration of Adults with
Severe Mental Illness, 55 Psychiatric Services 11 (Nov. 2004) at 1285-1293, 1289, available at
Dennis P. Culhane et al., Public Service Reductions Associated with Placement of Homeless Persons with Severe
Mental Illness in Supportive Housing, 13 Housing Policy Debate 107 (2002) at 137-138, available at
More information available at
Evaluation of Pathways to Housing PA, Fairmont Ventures, Inc. (Jan. 2011), available at content/themes/pathways/assets/uploads/PTHPA-ProgramEvaluation.pdf; see also
Ronda Eisenberg & Sam Tsemberis, Pathways to Housing: Supported Housing for Street-Dwelling Homeless
Individuals, 51 Psychiatric Services 4 (Apr. 2000) at 487, available at
527 U.S. 582 (1999).
Settlement Agreement, United States v. Delaware, Civil Action No. 11-591 (D. Del. July 6, 2011), available at
Settlement Agreement at 12-13, 18-19, 29, United States v. Georgia, Civil Action No. 10-249 (N.D. Ga. Oct. 19,
2010), available at
Settlement Agreement at 4, 9, 11, United States v. North Carolina, Civil Action No. 12-557 (E.D.N.C. Aug. 13,
2012), available at
Settlement Agreement, United States v. New Hampshire, Civil Action No. 12-53 (D. N.H. Feb. 12, 2014),
available at


decreased jail time among ACT recipients.57 Numerous studies have shown that expanding
supportive housing saves states significant money by reducing shelter use, hospitalizations,
duration of hospital stays, and incarceration.58 A survey of community crisis services such as
mobile crisis services and crisis respites found that these services produced cost savings.59
In addition, Medicaid funding is available to cover the costs of these services for individuals who
are Medicaid eligible.60 This is a growing group, especially among adults with serious mental
illness, because states that have adopted the Medicaid expansion may cover all of these services
at largely federal expense for numerous people who were previously uninsured and ineligible for
Despite the substantial benefits of these services and the Medicaid financing available to pay for
them, these services are largely unavailable to those who need them. In 2012, state mental health
authorities reported that only 2% of individuals served received ACT services and only 2.6%
received supportive housing services.62
These services need to be expanded, and we urge the Task Force to recommend that additional
federal funding be allocated to support these services.


Forensic Assertive Community Treatment: First Year in Review, Georgia Rehabilitation Outreach, Inc., July 1,
2004 ‐ June 30, 2005 3 (2006), available at
See, e.g., Dennis P. Culhane, et al., Public Service Reductions Associated with Placement of Homeless Persons
with Severe Mental Illness in Supportive Housing, 13 Housing Policy Debate 107 (2002), available at (supportive housing participants used
an average of $16,282 less in services per year, and the cost of providing supportive housing was approximately the
same as the cost of having individuals remain homeless); Fairmount Ventures, Inc., Evaluation of Pathways to
Housing PA, supra note 51 (supportive housing reduced participants’ shelter episodes by 88%, hospitalization
episodes by 71%, crisis response center episodes by 71%, and prison system episodes by 50%, and cost
approximately $28,000 annually per person, compared to $56,600 for programs housing chronically homeless
people and $41,000 for residential drug and alcohol programs for homeless people with mental illnesses); Robert
Bernstein, Fourth Report of the Court Monitor on Progress Toward Compliance with the Settlement Agreement:
U.S. v. State of Delaware (Sept. 2013), available at (net annual savings per
person between $96,000 and $276,000 when state psychiatric hospital residents, many with protracted stays, moved
to supportive housing; hospital readmission rate for this high-risk group was about half of that of all individuals with
serious mental illness in the state).
Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies, supra note 32, at 14-15.
Take Advantage of New Opportunities to Expand Medicaid Under the Affordable Care Act, The Bazelon Center
for Mental Health Law (July 2012), available at
The Medicaid Expansion gives states an enhanced reimbursement rate (100% until 2016, after which a minimum
90%) for all newly eligible individuals, anyone whose annual income is less than 139% of the federal poverty level.
States must create Medicaid expansion plans that cover, at a minimum, the mandatory traditional Medicaid services
and the essential health benefits. States can also chose to align these expansion plans with the state’s traditional
Medicaid plan, simplifying administration. Regardless of what states cover in their Medicaid expansion plans,
individuals with serious mental illness are among those considered “medically frail” and thus can choose to receive
traditional Medicaid services. The state will still receive the increased reimbursement rate for the newly eligible. See
When Opportunity Knocks: How The Affordable Care Act Can Help States Develop Supported Housing for People
with Mental Illness, The Bazelon Center for Mental Health Law (2014), available at
2012 CMHS Uniform Reporting System Output Tables, Substance Abuse and Mental Health Service
Administration, (2012), available at


3. Strategies for Justice-Involved Individuals: Diverting Individuals with Mental Illness
from Jail and Reducing Recidivism
For individuals who are swept up in the criminal justice system as a result of mental illness,
appropriate services are needed that focus on diverting them from jail and supporting them in the
community after release (if they are incarcerated), to prevent cycling in and out of jail and
The same services that help prevent involvement with the criminal justice system in the first
place, like MCTs, ACT teams, and supportive housing, are key components of effective
diversion programs. They also help individuals with mental illness avoid committing new
Miami-Dade County mounted a major effort to divert people with mental illness from detention
in its jail. Among other approaches, the County invested more in ACT and supportive housing
services. As a result, misdemeanor recidivism has been reduced from 75% to 20%.64 The same
program has reduced felony recidivism to just 6%.65 A study of a San Francisco diversion
program showed an 84% percent drop in the likelihood of re-arrest for program graduates.66
The Nathaniel Project in New York City, which relies on ACT and supportive housing, has
demonstrated a “70% reduction in arrests over a two-year period among program participants.”67
Chicago’s Thresholds’ Justice Program, which offers ACT and supportive housing, has shown an
“89% reduction in arrest, an 86% reduction in jail time, and a 76% reduction in
hospitalizations.”68 In King County, Washington, a Forensic ACT program serving adults with
serious mental illness who have extensive criminal histories has demonstrated a 45% reduction
in jail and prison bookings among participants, who have “significantly decreased their amount
of time institutionalized” in jails, prisons, and hospitals.69


Diverting people from incarceration and reducing recidivism through community-based services can also lead to
substantial savings for states and local governments. Localities with limited budgets spend disproportionate funds
jailing individuals with mental illness. The Los Angeles County Jails, the Rikers Island Correctional Facility in New
York City, and the Cook County Jail in Chicago have become the three largest psychiatric institutions in the nation.
See A Way Forward, supra note 39 at 6. In Los Angeles County, for example, it costs $38,000 per year to jail an
inmate without a mental illness, but it costs $48,500 to house an inmate with a mental illness; the average length of
stay in jail is just eighteen days for a person without a mental illness compared to forty-three days for a person with
a mental illness. See id. at 8. Just to cover psychiatric medications for inmates, Los Angeles County spends $10
million per year—and because the recipients are inmates, Medicaid dollars are not available to cover these costs. See
id. at 3, 8.
Id. at 7.
Id. at 5.


Without effective programs like those described above, reported rates of recidivism for
individuals with serious mental illness are alarmingly high—from 54% among individuals with
severe mental illness in Philadelphia,70 to 80% in California,71 to 95% in Los Angeles.72
In addition to the right set of services, both diversion efforts and efforts to prevent recidivism
require collaboration between the mental health and the criminal justice systems. For example,
mental health service providers must have notice of individuals with mental illness being
released from jails and prisons. In addition, the two systems must collaborate to ensure that
inmates who are being released have ready access to Veterans benefits, Medicaid, and Social
Security disability benefits upon release.73
4. Conclusion
The shortage of training and effective community-based services is a fundamental problem in
our law enforcement and public mental health systems, and it can lead to tragic consequences.
There are concrete steps that can be taken to improve the situation. As we initially mentioned, we
think that the Task Force’s interim report included some excellent recommendations, but we urge
the Task Force to include the following specific recommendations in its final report to the
Crisis Point Practices and Services:
We support Recommendation 5.6 of the Task Force’s interim report that Crisis
Intervention Team (CIT) training should be made a part of both basic recruit and
in-service officer training. We also support the Task Force’s recommendation that
Congress provide additional funding to ensure that there is sufficient capacity.
We also support Recommendation 4.3 and agree that “multidisciplinary,
community team approaches for planning, implementing, and responding to crisis
situations with complex causal factors” is a fundamentally important practice. In
the mental health context, this includes ensuring that Mobile Crisis Teams are
available to respond to individuals in mental health crises.
We would add to this recommendation that:
1. The federal government should provide clear guidance and technical
assistance to states about how to use Medicaid funding for Mobile Crisis


Study finds higher rates of jail recidivism among people with co-occurring severe mental illness and substance
use disorders, Case Western Reserve University (2012), available at
Council on Mentally Ill Offenders, California Department of Corrections and Rehabilitation, available at
A Way Forward, supra note 39 at 7.
Alex Blandford & Fred Osher, Guidelines for Successful Transition of People with Behavioral Health Disorders
from Jail and Prison, SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation and the Council
of State Governments Justice Center (Nov. 2013) at 3, available at


2. States should ensure that there are both law enforcement-based and mental
health system-based Mobile Crisis Teams available on a statewide basis
and in sufficient numbers to respond to mental health crises.
Strategies to Reduce Encounters Between Police and People with Mental Illness:
We appreciate that the Task Force made the Overreaching Recommendation 0.2
that “[t]he President should promote programs that take a comprehensive and
inclusive look at community based initiatives that address the core issues of
poverty, education, health, and safety [. . .] the justice system alone cannot solve
many of the underlying conditions that give rise to crime. It will be through
partnerships across sectors and at every level of government that we will find the
effective and legitimate long-term solutions to ensuring public safety.” This is
especially true for people with mental illness, many of whom do not have access
to the services they need to avoid encounters with the police.
We urge the Task Force to add to its final report the recommendation that states
expand access to services proven to decrease encounters with law enforcement
including mental health crisis services, ACT teams, and supportive housing.
Strategies for Justice-Involved Individuals:
The same services that are so successful upstream are also an important part of
appropriate downstream diversion and are necessary to prevent recidivism. We
urge the Task Force to add these additional recommendations to its final report:
1. States should ensure that there are diversion programs that include mental
health crisis services, ACT teams and supportive housing.
2. In order to prevent recidivism, states must also provide these services as
part of reentry programs for individuals who are transitioning back into
the community after incarceration. As the Interim Report notes at
Recommendation 4.6, law enforcement agencies should involve their
communities in re-entry programs for adults leaving prisons and jails. This
reentry period is crucial and all agencies involved in this process should
enter into memorandums of understanding that address how inmates who
are being released can apply for services, the response time for
determinations, and how to ensure ready access to Veterans benefits,
Medicaid, and Social Security disability income upon release from prison
or jail.
3. The federal government and Congress must work to ensure there is
sufficient funding for States to implement the recommendations above.
Only by adequately funding and expanding community mental health services can we
dramatically improve outcomes for both police officers and people with mental illness. We urge
the Task Force to consider the information we have provided as it finalizes its recommendations
to the President. Thank you for taking the time to review our recommendations, and please
contact us if we can provide more information.


Robert Bernstein, Ph.D.
President and CEO