Psychiatrists and Judges Form a New Team

For decades, public mental health care for the severely and persistently mentally ill (SPMI) has been in transition, from care in large state institutions to community-based care—overall, a badly needed transformation. Much has been written, however, about the unintended consequences that accompanied this reconfiguration of mental health care, particularly when community resources were inadequate to provide high-quality, alternative care.

In my column in the July 15 issue, I wrote about my experience in New York during the 1980s and 1990s in this regard. One of the consequences still very much with us is the transinstitutionalization of patients with SPMI into the correctional system. I gave a talk to a packed house at APA’s Institute on Psychiatric Services in Washington, D.C., in 1997, titled “Criminalization of the Mentally Ill,” where I presented some early statistics reflecting the dramatic increase in the number of patients brought by police either to emergency rooms or to jails, many of whom were then sentenced and placed in the correctional system.

A couple of years later, I was invited to give a talk at a conference hosted by the Broward County Office of the Public Defender in Fort Lauderdale, Fla., where I met Judge Ginger Lerner-Wren, the presiding judge of what I believe was the first mental health court in Florida. Her commitment to improving the education of the law enforcement, legal, and judicial systems about mental illness impressed me greatly, and this innovative model for judicial sensitivity for the specialized needs of those with SPMI in the correctional system has spread across the country.

There have been several recent articles in Psychiatric News describing the development of an important and growing new effort called the Judges’ Leadership Initiative (JLI). Founded in 2004, the JLI is led by Judge Steven Leifman, an associate administrative judge for Miami-Dade County, who has recently been appointed to serve as a member of the board of our newly restructured American Psychiatric Foundation (APF). Since its inception, the JLI has grown to involve almost 500 judges throughout the country.

I learned more about the JLI, and about its proposed new partnership with psychiatry, at APA’s recent Institute on Psychiatric Services in San Francisco. (The institute, by the way, was a terrific meeting with great attendance and a wonderful program. See coverage on pages 1, 5, 6, 12, and 13) A discussion group was chaired by Fred Osher and co-chaired by Steve Leifman, titled “Collaborating With Judicial Partners: The Psychiatric Leadership Group on Criminal Justice.” Fred serves as the director of health systems and services policy at the Council of State Governments Justice Center, and he provided an overview of current challenges to meet the needs of the millions of individuals who are incarcerated or in some sort of correctional oversight supervision. He reviewed the growth of mental health courts and the importance of their success in returning individuals with mental illness from prison and jail settings back into the community and into treatment. It is estimated that the number of individuals with SPMI in the criminal justice system is three to six times the number in the general U.S. population. Steve reported that on any given day, about 550,000 individuals with SPMI are incarcerated, and 900,000 are on probation or under community legal control. He referred to the Dade County jail as the largest psychiatric facility in the county. For the last 10 years in Miami-Dade, however, they have made good headway by building training programs for law enforcement officers and correctional officers. For example, they have trained more than 3,300 police and are now expanding to train other groups, such as air marshals.

Steve then described, to a lively and interested audience, the developing project jointly sponsored by the JLI and the APF to form a partnership between the judicial group and a new psychiatric leadership group (Psychiatric News, September 16). The goal of this new National Leadership Campaign by Psychiatrists and Judges will be to reduce the overrepresentation of individuals with SPMI in the criminal justice system. These are among its objectives:

• Developing an improved standard of care and access to care for individuals with SPMI involved in the criminal justice system by developing and disseminating training for psychiatrists.

• Developing program models that improve access to care and reduce unnecessary criminal justice involvement for individuals with SPMI by developing and disseminating training for judges.

• Planning for the promotion of collaboration and leadership development between psychiatrists and judges by continuing and building upon the cross-system dialogue through the two leadership groups.

In addition to Fred Osher, APA psychiatrists who have been involved in this effort include Stephanie LeMelle, Mark Munetz, Wes Sowers, Marcia Goin, and Annelle Primm.

A pilot training program (Psychiatric News, December 17, 2010) was organized by the JLI and held in Illinois, facilitated by Justice Kathryn Zenoff, an appel late court judge in that state; the training involved 62 judges and was highly successful. Since that time, at least six other states have requested the training. In addition, under the leadership of Paul Burke, the APF has received a grant (Psychiatric News, September 16) to work with Judge Leifman and a group of organizations in Florida to develop, pilot, and evaluate an essential system of care for individuals with serious mental illness who come into contact with the criminal justice system. The goal is to create a national model that can be replicated throughout the United States. There was a great deal of enthusiasm in the audience about these new programs, with many volunteers expressing interest in participating.

I’d like to say that this progressive attitude has turned the tide and that appropriate care is now being provided to the majority of individuals with mental illness who are incarcerated, but, alas, we’re not there yet. Sad to say that in my city of Houston, as in Miami, there is an often-heard and uncontested assertion that the largest mental health facility in the city is the county jail. But it’s easier to be hopeful and even optimistic, as we learn about the growing efforts of the mental health courts and of the new National Leadership Campaign by Psychiatrists and Judges. We are indebted to Judge Leifman for his strong advocacy and leadership in this effort, and I’m pleased to add that he has been selected to present the Award for Patient Advocacy Lecture at APA’s 2012 annual meeting in Philadelphia. Plan to attend!