Clergy: Contact Rev. Peter Laarman if you would like to add your name to this urgent request from the ACLU: firstname.lastname@example.org
The Honorable Mike Antonovich
Los Angeles County Board of Supervisors
500 W Temple Street
Los Angeles, CA 90012
Dear Supervisor Antonovich,
We are well aware of, and appreciate, your longstanding efforts to figure out effective and humane ways to help people with mental illness in Los Angeles County, many of whom are also homeless and have co-occurring drug addiction. We believe that there are many areas where we can agree on both the goal of helping people with mental illness and the best means to achieve it.
The Vanir report and the contemporaneous debate about both what new jail construction is appropriate for Los Angeles County and what alternatives might be better for people with mental illness provides an opportunity to work together for further diversion of the mentally ill out of jail and into treatment that will improve their lives as well benefitting public safety and the taxpayers.
Unfortunately, the Vanir report basically ignores need for, as well as the effectiveness and feasibility of, diversion. This failure is compounded by a most serious omission in the report – the report does not account for the administrative and operational costs of its proposed treatment jail.
Vanir concedes that crime is going down in Los Angeles. (Last year, the Sheriff reported that violent crime is down 29.09% in 5 years with a 45.45% drop in the rate of homicide and a 30.69% drop in burglary.) Moreover, studies show that the population of people with mental illness has remained constant over the last few years. But Vanir nonetheless expects an increase the number of mentally ill people incarcerated. Specifically, the report states that DMH estimates that there will be a 50% increase in the need for mental health services in the jails. This enormous projected rise is hard to square with both crime and mental health population projections.
Vanir’s report states that increase is partly attributable to “[d]ecreases in available treatment resources in the community including several acute psychiatric hospital closures.” Report at p. 8. This conclusion is highly questionable: it conflates “available treatment resources in the community,” with “acute psychiatric hospitals.” California may be consolidating acute psychiatric hospitals, but those are places for people with very severe and intractable mental health problems. The majority of people with mental health related diagnoses in Los Angeles County jails would not be subject to care in acute psychiatric hospitals and would be better served in community treatment settings specializing in mental health treatment.
Additionally, under the Mental Health Services Act, the Affordable Care Act (ACA) and Medi-Cal expansion, a significant number of Los Angeles residents with mental illness, including homeless people, will have more access to care in the community, not less. By contrast, even with the implementation of the ACA, federal funds will not be available to pay for the medical or mental health treatment of inmates in the County jail, even if they are otherwise Medi-Cal eligible. Finally, there are bills currently pending in the legislature, SB 364 and SB 585, that would increase the availability of community treatment resources throughout California. See “Editorial: Steinberg plan for mental health has real merit,” Sacramento Bee, May 11, 2013.
Vanir is recommending that the County spend more than a billion dollars in new jail construction in part on the ground that the County will be cutting spending to community mental health programs. But the decision whether to cut or expand those programs is within the County’s control. And, expanding those programs would unquestionably reduce the scope of necessary new jail construction, lower the need for jail mental health treatment, as well as providing better mental health outcomes, and thus less future criminal activity by people with mental illness.
Problems with the underlying assumptions regarding projected capacity needs are further compounded by Vanir’s omission of the costs of running the new jails it is proposing. We know those costs are likely to be very high. For example in 2011, the Vera Institute of Justice’s report on LA County Jail Crowding concluded that, based on 2007-08 data , the cost of housing for a male inmate is $95 per night and $145 per night for female inmates. However, Vera estimated that a mentally ill male inmate costs the County about $195 per night in housing and treatment costs, or almost $72,000 per year, and about $245 per night or almost $90,000 per year for a female inmate with mental illness. Over the long term, those operation and treatment costs will dwarf the projected construction cost for the consolidated treatment facility Vanir is proposing.
In short, the Vanir report omits important data that is necessary for the Board and the taxpayers to make an informed choice on the appropriate mixture of options, including treatment in jail or in the community.
Rationales for Diversion
We understand that there are and will continue to be people with mental illness who need to be incarcerated for public safety reasons. Thus, there may well be a need for a new facility devoted to the treatment of people with mental illness., particularly if the County tears down Men’s Central Jail. But, we believe that the facility proposed by Vanir is far too large and far too expensive.
However, there is strong support among both mental health professionals and law enforcement officials that jails and prisons should not be housing and attempting to treat a significant percentage of people with mental illness, as is currently the case in Los Angeles.
Diversion Provides Important Public Safety and Therapeutic Benefits
Jail is not a therapeutic environment. No mentally ill person goes there to get well. People with mental illness are treated and restrained to reduce their symptoms while they are incarcerated, an approach that is not consistent with improved mental health outcomes There is a strong consensus among mental health professionals that treatment for mentally ill people is most effective when delivered in the community, not jail or prison. See, e.g., H. Richard Lamb, M.D.; Linda E. Weinberger, Ph.D.; Jeffrey S. Marsh, M.D.; Bruce H. Gross, J.D., Ph.D., “Treatment Prospects for People With Severe Mental Illness in an Urban County Jail,” Psychiatric Services, 2007; Jennifer S. Bard, “Re-Arranging Deck Chairs on the Titanic: Why the Incarceration of Individuals with Serious Mental Illness Violates Public Health, Ethical, and Constitutional Principles and Therefore Cannot Be Made Right by Piecemeal Change,” 5 Hous. J. Health L. & Pol’y 1, 6 (2005); Lovell D, Gagliardi GJ, Peterson PD, “Recidivism and use of services among people with mental illness after release from prison,” Psychiatric Services 53:1290—1296, 2002; Torrey EF, Stieber J, Ezekiel J, et al, “Criminalizing the seriously mentally ill: the abuse of jails as mental hospitals.” Washington, DC, Public Citizen Health Research Group, 1992.
Law enforcement officials have also recognized the downside of making jails and prisons the community’s de facto treatment facility for people with mental illness. See Mary Zdanowicz, J.D, “Mental Health Policies Are Cause for Alarm in the Corrections Community,” Sheriff Magazine, January-February, 2007. They have also recognized that certain people with mental illness who would not voluntarily seek out the treatment they need because they do not recognize the severity of their illness will accept necessary treatment when incarceration is the alternative to entering treatment. See id. (noting prospect of jail time can be effective leverage to make persons with severe mental illness enter and adhere to treatment).
On average, people with mental illness who are incarcerated experience more and worse exacerbations in their mental illness, become more resistant to treatment, and leave jail with a much worse disability and prognosis. They also tend to have shockingly high levels of recidivism, in large part because jail is not a proper environment for good treatment, and their condition worsens while in jail. We know that “[i]n the Los Angeles County Jail, 90 percent of mentally ill inmates are repeat offenders, with 31 percent having been incarcerated ten or more times.” E. Fuller Torrey, M.D., et al., “More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States”, at 7, May, 2010 .
By contrast, research comparing the recidivism rates of those people with mental illness charged with criminal offenses who are diverted into treatment programs compared to those who incarcerated consistently show significantly better results, which makes the community safer. See, e.g., Henry Steadman, et al., “Effect of Mental Health Courts on Arrests and Jail Days: A Multisite Study,” (2010) see also Superior Court of California County of Orange, “Collaborative Courts 2012 Annual Report,” , at page (2012). Therefore, in terms of cost/benefit analysis, it is always more expensive and less effective to build jail beds for people with mental illness than provide community treatment.
Additional factors also weigh heavily in favor of diverting persons with mental illness out of jails and into community treatment. First, inmates with mental illness suffer far higher rates of physical and sexual abuse from both other inmates and guards than do inmates who are not mentally ill. See, e.g., US Department of Justice, Bureau of Justice Statistics, “Sexual Victimization in Prisons and Jails Reported by Inmates, 2011–12,” at page 7.
The abuse of the mentally ill is not just a general problem in jails and prisons across the nation; it has plagued the Los Angeles County jails for years. In 1997, the United States Department of Justice found that “[i]nmates [in the LA County jails] who are mentally ill or housed in mental health housing are subject to an unacceptably high risk of physical abuse and other mistreatment at the hands of other inmates and custodial staff.” Letter from Civil Rights Division, USDOJ, to Los Angeles County Executive, “CRIPA Investigation of Mental Health Services in the Los Angeles County Jail,” p. 18-19 (1997) (emphasis added). In 2008, Dr. Terry Kupers, an expert on persons with mental illness in jails, concluded that force in the Los Angeles County jails was disproportionately directed at inmates with mental illness. Dr. Terry Kupers, “Report on Mental Health Issues in the LA County Jails,” at page 41 (2008). In 2011, Sheriff Baca corroborated Dr. Kupers’s finding, conceding that use of force in the jails was disproportionately focused on the mentally ill. Jack Leonard and Robert Faturechi, “L. A. County jailers more likely to use force on mentally ill inmates,” Los Angeles Times, Jan. 11, 2012. Just last year, a report by the USDOJ’s Bureau of Justice Statistics reported that Twin Towers – the facility where most of the inmates with mental illness are housed — was one of the jails that had the highest level of inmate-on-inmate sexual abuse in the United States. See “Sexual Victimization in Prisons and Jails,” at page 12.
Second, mentally ill inmates commit suicide at extremely high rates. See, e.g., E. Fuller Torrey, et al., “More Mentally Ill Persons Are In Jail And Prisons than Hospitals: A Survey of the States,” (2010), at page 10) Simply put, diverting persons with mental illness from the jails into community treatment will save lives.
Diversion Will Save the County Significant Sums of Money
As stated, it is very expensive to house and treat a mentally ill person in Los Angeles County jail. The costs of psychotropic medications alone are astronomical. The County pays the costs of those medications while someone is in jail; the State or the Federal government will pay for all reasonable treatment costs, including medications, when a person is in community-based treatment, but not when they are incarcerated.
There are a significant number of programs in Los Angeles that provide mental health treatment as well as providing or arranging for housing and other services. The barrier to diversion is not that there are no existing services. What must be done is arrange for the identification of appropriate candidates for diversion, link them to services, and ensure they are enrolled in benefits programs such as Social Security Disability and Medi-Cal.
Only if there are no other benefits programs to cover the necessary housing and treatment would the County have to ensure that funding is available for treatment and housing. But, the costs of community treatment and housing are far lower than housing and treating the mentally ill in jail. Even if the County paid for the mental health treatment and housing for people with mental illness diverted from the jails, it would cost taxpayers less than building an enormous new jail and then paying the operating and treatment costs for running that jail.
In addition, as explained above, expanding diversion will provide significant long-term benefits in reduced recidivism among the mentally ill. Although we do not have a precise figure for the recidivism rates among people with mental illness, we do have good evidence that the recidivism rate is awful. See E. Fuller Torrey, M.D., et al., “More Mentally Ill People Are in Jails “ supra, at page 7. By contrast, there is substantial research showing that mental health diversion programs are very effective in reducing recidivism. See Steadman, et al., “Effect of Mental Health Courts,” and “Collaborative Courts 2012 Annual Report,” supra page 4.
There Are Good Models for Diversion in Other Jurisdictions, and Pieces of a Diversion Program Already Exist in Los Angeles
Some of the pieces of an effective diversion program are already in place in Los Angeles, and successful models of mental health diversion – none of which Vanir even mentions in its report – exist in other jurisdictions. For example, the new Los Angeles City Attorney is very interested in reviving Project HALO, a program designed to divert homeless people with mental illness out of jail and into housing and community treatment. The Superior Courts also have methods of identifying mentally ill people who would be good candidates for diversion. What is needed for real diversion is for the County to provide appropriate funds to cover the housing and treatment, where Medi-Cal expansion, HUD grants, and other sources will not pay for them. But, to the extent that there are not other sources of funding, having the County fund community treatment would be far less expensive than funding the construction of jail beds, and jail and mental health operations.
We would like to work with you and other members of the Board in two ways. First, we would appreciate your leadership on a pilot diversion project. As we said above, the City Attorney is interested in reviving Project HALO. The ACLU and the Integrated Recovery Network are already seeking private funds sufficient to ensure treatment for at least 100 people who are homeless, mentally ill and arrested on a misdemeanor charges that would subject them to prosecution by the City Attorney. The private funds will pay for a research study that will track two groups of people who are identified through Project HALO as appropriate for diversion. One group will receive treatment. The other similarly situated group will, unfortunately, go to jail because there are insufficient funds to provide housing and treatment for everyone identified as appropriate for diversion. The study will compare recidivism rates between the two groups and also the public costs, e.g., jail housing and treatment, emergency room visits for the groups to determine the true amount of public savings from diversion and treatment, compared to sending members of the same population to jail, thus allowing for an evidence-based assessment of Project HALO.
Second, we encourage you to oppose construction of the massive new mental illness treatment jail, at the very least until the results of the pilot project are in. We believe that pilot project will establish without a doubt that many people with mental illness can be safely diverted from the County jails into community treatment, and that doing so will benefit them, public safety and the taxpayers of Los Angeles County. While a new and modest sized treatment facility consistent with your motion to address services of those mentally ill people who are charged with violent or sexual crimes is probably necessary, we are confident that the pilot project will show that what Vanir proposes is too large, too expensive, and bad criminal justice policy.
Los Angeles County should not be building jail mental health beds to accommodate a projected 50% increase in the subpopulation of prisoners with mental illness. Instead, we should working together to keep most of those people out of jail, and that includes putting some of the huge amount of money projected in the Vanir Repot into funding community mental health treatment options for defendants with mental illness and those with co-occurring substance abuse problems.
Cc: Anna Pembidjian, Justice Deputy
 The only exception to the so-called prisoner exception under Medi-Cal is for medical or mental health treatment provided to a prisoner who leaves the jail for 24 or more hours to receive treatment.