Stephen Eide joins City Journal associate editor Seth Barron to discuss how America’s health-care system fails the mentally ill, and the steps that cities and states are taking to keep the mentally ill out of jail and get them into treatment.

Urban areas have seen a disturbing rise in street disorder and homelessness over the last decade. Unfortunately, many of the street homeless suffer from serious mental illnesses, such as schizophrenia and bipolar disorder. Despite federal spending of about $150 billion annually on mental illness programs, individuals with the most severe diagnoses are often thrown into a repeating cycle of jail stays, homelessness, and hospitalizations.

In response, many states and cities are developing their own methods to keep the severely mentally ill out of jail. Launched in 2000, Miami-Dade County’s Criminal Mental Health Project is one of the nation’s most admired and successful of these programs.

Audio Transcript

Seth Barron: We're back with another edition of 10 blocks. This is your host, Seth Barron, associate editor of City Journal. People in big cities around the country regularly encounter individuals who are clearly troubled and often seriously mentally ill. Despite decades of work and attention to the issue, our society has not yet come up with an effective way to treat the mentally ill in a humane manner. In fact, many of these people wind up getting arrested, either for minor or serious crimes and then cycle in and out of the jail system, which has become the nation's de facto mental health treatment facility. I'm joined now by Steven, I'd senior fellow at the Manhattan Institute and Contributing Editor to City Journal. He writes frequently on the intersecting issues of mental illness and homelessness, and has a piece in the current issue of City Journal entitled "Keeping the Mentally Ill Out of Jail." Hi Steve. Thanks for joining us.

Stephen Eide: Hey Seth, so nice of you to have me on.

Seth Barron: So Steve, why is this a problem? Why aren't the mentally ill in mental hospitals?

Stephen Eide: Well, that's the way that we used to do it. When we talk about the public mental health care system, what the government does to help them mentally ill, it used to do that in only one way. Up until the 1950s, we ran these massive mental asylums, mental institutions that house hundreds of thousands of people. For various reasons, we decided to phase that system out, through a process known as deinstitutionalization. So now for the most part, we try to treat mentally ill, even people with serious mental illnesses such as schizophrenia, bipolar, depression, in the community, and outpatient for forms of treatment as much as possible. That has meant a somewhat fragmented system of delivery for mental health care. And oftentimes people have difficulty accessing the treatment that they need for their particular condition. And one of the reasons why we know that this approach does not work very well, why we regularly debate how to reform mental health care is the large numbers of mentally ill people in jails and prisons. In fact, in every state, the largest mental health facility, inpatient mental health facility you could say, is a jail which has a larger patient load than the than the largest state mental hospital at this point. So, this is a problem. In various ways, we try to address this rate of high levels of mental illness amongst our incarcerated population.

Seth Barron: Yeah. But what's the problem with sending these people to jail if they've committed a crime? Are you in favor of an insanity defense?

Stephen Eide: Yes, but for most part, when we talk about the very large population mentally ill behind bars, we're not talking about people who are guilty by reason of insanity. That's a real sliver. And we're really talking about jails, places where people go after they've been arrested before their case has been processed, before their offense, has been adjudicated. The idea I think is that most of these people are there because they're sick, not because they're criminals. Many of them are picked up for low level offenses, nonviolent offenses, and had they received proper treatment, they wouldn't be there, but because they're not receiving treatment, that's where they wind up and many of them as many kind of journalistic exposes show, such as a series of the Virginia pilot newspaper last year, their condition tends to worsen while they're behind bars.

Seth Barron: I see. So what is the scope of this problem? I mean, what percentage of people in jail are mentally ill? How often do they get arrested?

Stephen Eide: The seriously mentally ill are about four to five percent of the adult population, but there's somewhere around 20 percent of the jail population. So they're disproportionately represented in the jails.

Seth Barron: And I take it, there's not a lot of treatment for them in the jails.

Stephen Eide: Well that depends, there are certainly many good people who work in the criminal justice system who are psychiatrists who try to provide treatment. Some states do a better job than others, but I don't think anyone thinks that this is an ideal scenario, that people think that this is really a cause that we lack of proper mental health care system. We shouldn't think of more ways to deliver better mental health care behind bars.

Seth Barron: Well, in your latest article for City Journal, "Keeping the Mentally Ill out of Jail," you profile a program in Miami that you seem to think is doing a good job. Can you describe this program to our listeners?

Stephen Eide: Yes. This program is called the Criminal Mental Health Project. It is in Miami-Dade County. It began in 2000 and it was designed by and is still run by a judge named Steve Lifeman. He's the county judge in Florida. It's an alternative to incarceration program or a jail diversion program. The idea is to identify people who have recently been arrested for a low level offense and misdemeanor or a nonviolent felony and put them in a treatment program instead of leaving them in jail. And so long as they comply with the terms of that treatment program, after a certain period of time, their charges are dropped and they're allowed to continue to remain in the community as opposed to being sent deeper and deeper into the criminal justice system where their illness is likely to be exacerbated.

Seth Barron: So what's an example of the type of crime and how would this then be... I mean, I, assume this doesn't work for murderers.

Stephen Eide: No, it's a certain type of person. These would not be very serious offenses. They would not be violent offenses, but it could be something as serious as let's say trespassing or something, or low level theft or something. And so in some cases when a seriously mentally ill person gets picked up for something like that, they get in jail, they stay in jail, maybe they get beat up while they're in jail. Maybe they have some sort of altercation with the corrections officers, maybe more offenses pile up. That's what I mean by getting kind of sucked deeper and deeper into the system. So instead of allowing that to happen, you divert them away from jail. This is to provide an alternative to incarceration.

Seth Barron: Oh, okay. I see. Now what about a drug addiction? I mean, is that considered an illness, a mental illness in the sense that you're talking about?

Stephen Eide: Well, the problems of untreated mental illness, substance abuse, there's a lot of overlap between them. A lot of mentally ill people have substance abuse problems. In this particular program, around 70 percent of the participants in this program have some sort of substance abuse problem, and that would be part of the treatment program when they are put into the community and monitored as far as the progress of their treatment program goes, one component of that treatment program would be treating for their substance abuse issue in addition to their kind of underlying mental disorder.

Seth Barron: So what kind of outcomes has this Miami program demonstrated? Is it working? Is it portable? Could we adopted in New York City or could San Francisco take it up, for instance?

Stephen Eide: This is a successful program. Hundreds of people have come through it and been able to even have their charges dropped and been able to live safely in the community. This is, you know, New York does have its own set of alternative to incarceration program. This program, I thought was worth profiling because it's unusually well known, high profile. New York is often said to have one of the most robust sets of alternative to incarceration programs and other similar programs called a mental health court where it's a problem solving court for people with mental illness. Similar idea. Basically what you need, and I talk about this in my article for some sort of alternative to incarceration program to work with the mentally ill, you need to have a social services system and New York City, in Miami-Dade county are places where there is, you know, a relatively robust social service sector that provides treatment programs that you can put people in. States that regardless of what their attitude is towards, like letting you know, criminal offenders out on the streets without having their charters adjudicated, if they don't have mental health programs that they could put people into, it's not going to work as well for them.

Seth Barron: New York City has put a lot of money into treating people who have mental illness and trying to get their mental health straight. We have a program called Thrive Nyc. Are you familiar with this program and does that overlap with the type of program that Miami is doing?

Stephen Eide: Thrive NYC is a very different type of program than in the Criminal Mental Health Project in Miami-Dade. Miami-Dade's Criminal Mental Health Project is strictly for seriously mentally ill offenders. It's only for the seriously mentally ill. Thrive NYC pitches itself as a comprehensive mental health program that's for everybody regardless of the severity of their mental disorder.

Seth Barron: So is that less effective or it's a different type of program?

Stephen Eide: Well, it's certainly different type of program. I think it's less effective and it's not going to end up doing very much for the problem of serious mental illness, which really requires a special type of approach. I mean, I think it's an open question, what the government's responsibility is, what kind of public sector policy response we need towards problems such as anxiety, mild depression. Maybe that's the government's responsibility, maybe it isn't. It's untreated schizophrenia, somebody on the streets because they're, you know, they burned all their bridges with friends and family, they've been rattling in throughout the system of jails, homeless shelters and the streets because of their untreated schizophrenia. Anybody would agree that that is a governmental responsibility. And I think one lesson from the criminal mental health project is that you really need a specially tailored response to that kind of program. If you're just going to kind of loop it into a larger mental health push, it's just going to get kind of lost and is not going to receive the kind of special attention and care that it needs. It's a unique policy challenge, untreated serious mental illness.

Seth Barron: What about, we have something called Kendra's Law in New York City, assisted outpatient treatment, I believe is it's called, and I understand that they have in a lot of places. Is AOT, or Kendra's Law, is that similar to what's happening in Miami or how effective is that and how widely used is it?

Stephen Eide: Kendra's Law and the Criminal Mental Health Project could both be seen as alternatives to institutionalized inpatient psychiatric care. These are both programs that allow people to live in the community that are alternatives to hospitalizing them, which a lot of mentally ill people don't want to do. They don't want to go to the hospital. So they're both kind of bent forms of community services. The main differences that Kendra's Law, you're talking about people who may have had run ins with the law in the past but are not currently, you know, dealing with any charges, they're not currently in jail. It's a preventative program because you think that this is someone who, because of his history, because he's not complying with medication, if he isn't put in this program, he's likely to wind up in jail, but he's not currently facing jail time. Whereas the Criminal Mental Health Project, you are talking to you about people for whom jail or even prison time could be imminent if you don't provide this diversionary alternative.

Seth Barron: So, in terms of where, you know, the practitioners and social workers and psychiatrists and people like this judge who are concerned about it, where do they think things are going? Are we going to reopen mental hospitals to institutionalize people? Are we going to rely more on a psychotropic medications to keep them stable? How are we going to coerce people to take their medicine? I mean, this raises so many important questions about liberty and security. I can't even understand how we're going to deal with this. So where are we headed?

Stephen Eide: We're most, conventionally speaking, we're kind of still headed on the same route we've been on for many, many years. There is not a serious push underway now to reopen mental institutions, to re-institutionalized everybody. There are a lot of people, myself included, think that we've reduced our inpatient psychiatric bed count way too far, that that's a pendulum that's swung way too far in the opposite direction, but all of us support worthy outpatient treatment programs. These things like Kendra's Law, alternatives to incarceration, these are programs that certainly did not exist in the asylum era because we were forced to develop them because of deinstitutionalization and as a result of them, if we were to kind of build back our bed count to some degree, it wouldn't have to be anywhere near as large as it was in the old days because we do have strong, worthy alternatives to inpatient hospitalization like we didn't have back then and no one would talk about like defunding Kendra's Law or the Criminal Mental Health Project because they wanted do things a different way. I mean, these are really impressive, admired programs that, in fact we could talk about expanding them to some degree.

Seth Barron: Steve, thanks so much for joining us. Don't forget to check out Steve Eide's work on our website,, where you can read his excellent piece, "Keeping the Mentally Ill Out of Jail." It will be going up soon. We would also love to hear your comments about today's episode on twitter at City Journal. Lastly, if you like our show and want to hear more, please leave ratings and reviews on itunes. Thanks for listening and thanks, Steve for joining us.

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